COVID-19 threatens HIV care continuity in Brazil
Authors: Joe Parkin Daniels
Journal: The Lancet HIV (2020)

A double-whammy of the pandemic and unsympathetic government threatens to undermine the HIV response in Brazil. Joe Parkin Daniels reports. Brazil's response to HIV/AIDS has long won plaudits. When infections surged in the 1990s, South America's largest country offered free and universal administration of antiretroviral therapy (ART) and leaned on pharmaceutical companies to lower drug prices. In another move that proved to be an example of behaviour modelling in the face of crisis, Brazil was among the first 40 countries to provide self-testing. The vast country, with a population of 209 million people, was seen as the standard-bearer for developing countries in their fight against HIV/AIDS. And yet that reputation is now threatened by two often intertwining forces: the COVID-19 pandemic, which continues to ravage the nation and wider region; and Jair Bolsonaro, the right-wing populist president who has made no secret of his scepticism towards science and his antipathy towards vulnerable population groups, including the LGBT+ community. “It is necessary to emphasise that the Brazilian response to HIV/AIDS was one of the greatest achievements in the context of the Unified Health System”, said Beto de Jesus, the country programme manager for Brazil at the AIDS Healthcare Foundation. “We were already experiencing a bedded-in crisis before the COVID-19 pandemic; with the conduct of the current government with cuts and freezes in the area of health, education, and social assistance, the situation is only sharpened. The pandemic has unveiled a dramatic situation!” Few countries or regions were prepared to deal with the arrival of COVID-19, although in Brazil—which like most of Latin America has huge inequality—the social, economic, and public health ramifications have been particularly pronounced. In 2018 (the latest year for which data are available), income inequality in the region's largest economy reached its highest rate since 2012, when the national statistics' series began. That disparity was laid bare when Cleonice Gonçalves, a domestic worker in an exclusive neighbourhood in Rio de Janeiro, died of COVID-19 in March, having probably caught the disease from her employer who had recently been abroad. By mid-September, Brazil had over 4 million confirmed cases of COVID-19, with over 125 000 deaths. Only the USA and India had more cases. While COVID-19 ravaged poor and vulnerable communities—particularly in the country's urban centres—many health experts saw similarities with the ongoing HIV/AIDS epidemic, which also exposed social fault lines. 920 000 people live with HIV in Brazil, according to data from UNAIDS, and key populations show higher rates: 30% prevalence among transgender people, 18·3% among gay men and other men who have sex with men, and 5·3% among sex workers. “40 years of responding to the HIV epidemic has taught us that community and human rights must be at the centre of any pandemic or public health response”, Claudia Velasquez (UNAIDS country director in Brazil) told The Lancet HIV. “This historic vulnerability to HIV in Brazil, which was already happening before the COVID-19 pandemic, is also strongly connected to other social determinants of health, such as structural racism, violence against the LGBTI+ population, and social and economic exclusion.” Prejudice against vulnerable populations, in particular LGBTI+ people, has hardly been reduced during Bolsonaro's tenure as president. The populist leader campaigned on a platform of social conservatism, often using flagrantly homophobic rhetoric, and has not mellowed in office. In July this year, the respected broadsheet Folha da São Paulo reported that Bolsonaro had mocked presidential staff members who wore protective face masks as “fairies”; previously, in December 2019, he attacked a journalist, saying “you have a terribly homosexual face”. The struggles of members of the LGBTI+ community living with HIV was chronicled in detail in the latest UNAIDS report, Rights in a Pandemic, which quoted a young Brazilian woman describing her experience in her parents' home. “Being a lesbian made them so disappointed in me that no matter what I do, it's never enough”, the woman is quoted as saying. “I feel like I'm watching my life go by through somebody else's eyes—because I'm not who they want me to be, but I also can't be myself when I'm in their house.” Velasquez told The Lancet HIV that the woman's story is indicative of a wider issue. “Women and lesbians are not part of key populations for the dynamic of the HIV epidemic in Brazil, but this statement also reflects the levels of vulnerabilities endured by LGBT+ populations, including gay men and men who have sex with men and transgender people, who are part of the key populations in the HIV dynamics and response.” Bolsonaro, who has sought to downplay the seriousness of COVID-19, has also shown little interest in tackling the HIV outbreak. Ongoing turbulence at the health ministry—Brazil went through two health ministers within a month at the start of the country's outbreak—mean that transactional politics often supplant thought-through policy. This follows more subtle attempts to undermine the country's HIV/AIDS response, such as the decision taken in May 2019 to roll the ministry's HIV/AIDS department into a broader, catch-all body: the Department of Chronic Conditions and Sexually Transmitted Infections. When that happened, staff were shifted between departments, leading to further disorganisation. Throughout last year, non-governmental organisations (NGOs) working in the field reported that the health ministry had censored or ceased distribution of materials relating to HIV prevention and treatment that had been published by previous administrators. ANAIDS, a collective of leading NGOs working on HIV/AIDS in Brazil, estimates that the country has seen a 30% reduction in services providing access to pre-exposure prophylaxis. HIV testing and CD4 monitoring have also been affected, and supply chains of medication and supplies continue to face interruptions. With the COVID-19 pandemic, the dysfunction has only escalated. In the summer months of May and June, as COVID-19 cases soared, Bolsonaro treated the pandemic as a problem that could be solved with tough rhetoric and a task force of military brass. The results were artificially low case counts and collapsed health infrastructure in some far-flung reaches of the country, such as the Amazonian city of Manaus. These measures were compounded by the practical difficulties for health workers and patients during a pandemic. “In terms of programmatic continuity, most government AIDS programmes (at the federal, state, and local levels) are working from home, which has slowed down and complicated everything in terms of the function of programmes”, said Richard Parker, the director of the Brazilian Interdisciplinary AIDS Association (or ABIA), a local NGO that has worked in Brazil since 1987. “Health services have of course been overwhelmed by COVID-19 cases, pulling staff from all other areas to help in the care and treatment of COVID-19.” The lack of leadership from Brasilia, the capital, has necessitated that civil society picks up the slack, although that effort too is hamstrung by the central government's hesitancy. The Ministry of Health announced last year that there would be new lines of support and calls for proposals to support NGOs in early 2020, “but once COVID-19 hit, everything seems to have been called off”, Parker said. “The funding calls that were supposed to happen in the first semester of 2020 still have not been issued, and we are now well into the second semester of the year.” Yet the importance of those NGOs during the pandemic is difficult to understate, according to Claudia Velasquez. “In Brazil, we have witnessed an important engagement of the civil society involved in the response to HIV, from their engagement and mobilisation for online surveys, to participation and implementation of virtual trainings and emergency solidarity projects for the distribution of basic food and hygiene supplies, as well as community-based distribution of antiretroviral drugs for those who were part of the vulnerable groups to COVID-19.” Some people living with HIV have organised protests, calling for the government to relax its rules on distributing ART. Typically, only 1 month's worth of drugs are handed out at once; because of the pandemic, people are asking for supplies that last 3 months. In a few locations across the country, local governments have agreed to supply up to 2 months' worth of medications. Other patients rely on NGOs. One of those is Marcia (a pseudonym), who is from a small city in the inland state of Minas Gerais. She normally travels to São Paulo to pick up her antiretrovirals and for medical tests and appointments, although due to lockdowns imposed by the local governments of Mines Gerais and São Paulo, she has been unable to do so. Marcia, now relies on a local NGO, Barong, to deliver her therapy. “Of course the biggest worry is that my treatment could be interrupted by the pandemic, something which Barong has helped with”, Marcia told The Lancet HIV. “Beyond that all we can do, everyone who is in my situation, is follow the recommendations of the Ministry of Health and the World Health Organisation.” Barong: reaching out to where things happen in BrazilWith Brazil's HIV/AIDS response beset by the ongoing COVID-19 pandemic and the antiscience approach from president Jair Bolsonaro, civil society organisations are picking up the slack, even as funds from international donors dwindle. The Barong Cultural Institute, formed in 1996 in São Paulo and working across 50 municipalities nationwide, has long sought to bring a holistic and non-judgmental approach to HIV/AIDS outreach in Brazil, as part of a wider strategy to promote sexual and reproductive health education. Full-Text PDF Brazil sustains HIV response during the COVID-19 pandemicBrazil is proud of its internationally recognised HIV programme, which was not discontinued or threatened because of the COVID-19 pandemic, as described in a Feature published in the December, 2020, issue of The Lancet HIV.1 Brazil has strongly criticised the Rights in a Pandemic report by UNAIDS because of inconsistent data and statistics. Full-Text PDF