Abstract

“Crisis” is a phenomenon that is part of global and local policies with social, political, and economic repercussions. It is the context of this paper that aims to reflect on the Brazilian response to the HIV/AIDS epidemic. We examined the realms of this phenomenon, such as the review of the consensus on austerity policies, their impact and the construction of “anti-agendas” that hinder the narrative of human rights, gender, sexuality, and health and hamper HIV/AIDS prevention and care. Such a conservative move can be associated with censorship of specialized materials and the recent change of management in the structure of the Ministry of Health, the extinction of hundreds of participatory councils within the Executive Branch and the new National Policy on Drugs that replaces the guidance “harm reduction” with one of “abstinence”. All these phenomena revive an old concern, that is, that the “ideological virus” will outweigh the biological virus, exacerbating the situation of stigma and discrimination. Besides the neoliberal socioeconomic orientation that threatens the Brazilian state, such facts would affect the continuity of institutional responses to HIV/AIDS.

Key words
HIV/AIDS; Public policy; Crisis

Introduction

Over 900,000 HIV cases have been reported in Brazil since the beginning of the HIV/AIDS epidemic in the 1980s, and during this period, state HIV control policy has been built in different governments, albeit with different emphases¹1 Galvão J. Aids no Brasil: agenda de construção de uma epidemia. Rio de Janeiro, São Paulo: ABIA, Editora 34; 2000.^,22 Grangeiro A, Silva LL, Teixeira PR. Resposta à AIDS no Brasil: contribuições dos movimentos sociais e da reforma sanitária. Rev Panam Salud Pública 2009; 26(1):87-94.. This paper aims to reflect on the relationship between the current crisis and the Brazilian response to this epidemic. This crisis is polyphonic and marked by power struggles of the agents in a given field³3 Bourdieu P. Algumas propriedades dos campos. In: Bourdieu P. Questões de Sociologia. Rio de Janeiro: Marco Zero; 1983. p. 89-94., configuring itself as a multidimensional event with at least three interrelationships: social, political, and economic. One cannot ignore that it is based on global issues and local specificities.

From an economic viewpoint, we are witnessing one of the biggest cyclical crises in the capitalist accumulation process, aggravated by a multipolar and financial-speculative world. Time wise, we proposed 2013 as a point of significance for the crisis, when Brazil still supported positive socioeconomic indicators, despite inequalities. Non-regressive policies were subsequently undermined by the political crisis, resulting in the interruption of systematic poverty reduction and the further squeezing out of access to essential goods and services from which Brazil had been moving away.

At the same time, increasing mistrust in politics as a means of conflict resolution is being fostered. This movement is sustained – and exploited – from the constant dissemination of the patrimonialism of some agents of the Brazilian State, under the insignia of corruption, and has judicial and media support. The goal is to restore the hegemony of some groups in state organs and to make public policies and progressive social forces vulnerable. Finally, in the social sphere, we experience the (re) production of antagonisms and political affections of anger and fear, causing a symbolic crisis characterized by ruptures in interpersonal relationships and threats to otherness, which cloud the understanding of the dystopia we experience and how to address it.

In this scenario, the Unified Health System (SUS) was affected by fiscal austerity measures, highlighting the approval of an amendment to the constitution, namely, the EC-95, which froze investments in health and education for 20 years, generating accumulated losses and transforming the underfunding of the underfinanced system⁴4 Funcia F. Efeitos negativos da emenda constitucional 95/2016 sobre a execução orçamentária e financeira de 2017 do Ministério da Saúde. [acessado 2019 Mar 20]. Disponível em: https://www.cmb.org.br/cmb/index.php/noticias/2347-efeitos-negativos-da-emenda-constitucional-95-2016-sobre-a-execucao-orcamentaria-e-financeira-de-2017-do-ministerio-da-saude
https://www.cmb.org.br/cmb/index.php/not... . This contributes to the reduced supply of services, dismissal of professionals, supply blackouts and Science & Technology divestment, precisely when the population loses jobs and income and requires more social protection.

The Brazilian response to the HIV epidemic in the SUS context

We are in the fourth decade of the HIV epidemic, and the complexity of the realms involved has made it a metaphor of modern times, (re) updating this “epidemic of meanings”⁵5 Treichler P. Aids, Homophobia and Biomedical Discourse: an epidemic of signification. In: Crimp D, editor. Aids: Cultural Analysis, Cultural Ativism. Cambridge: MIT Press; 1988. p. 31-70.. The hegemonic narrative of the Brazilian HIV response was built from the 1980s onwards by a myriad of voices from civil society, health professionals, public officials, and artists around solidarity⁶6 Parker R. A Construção da Solidariedade: AIDS, Sexualidade e Política no Brasil. Rio de Janeiro: Abia, IMS-UERJ, Relume-Dumará; 1994.. It is an inclusive narrative, based on the recognition of diversity, state secularity, strengthened democracy, based on the SUS, with the guarantee of the right to prevention and care to people living with HIV/AIDS (PLWHA), and which began to materialize before the implementation of the SUS, and contributed to the process experienced in the country at that time and the health reform movement²2 Grangeiro A, Silva LL, Teixeira PR. Resposta à AIDS no Brasil: contribuições dos movimentos sociais e da reforma sanitária. Rev Panam Salud Pública 2009; 26(1):87-94..

Prevention policies were based on the partnership of governments with Non-Governmental Organizations (NGOs), highlighting the methodology of peer education, the production of official educational campaigns and various materials for specific populations, built in dialogue with the social movements¹1 Galvão J. Aids no Brasil: agenda de construção de uma epidemia. Rio de Janeiro, São Paulo: ABIA, Editora 34; 2000.^,77 Bastos C. Ciência, poder, acção: as respostas à Sida. Lisboa: Imprensa de Ciências Sociais; 2002.

8 Berkman A , Garcia J, Muñoz-Laboy M, Paiva V, Parker R. A critical analysis of the Brazilian response to HIV/AIDS: lessons learned for controlling and mitigating the epidemic in developing countries. Am J Public Health 2005; 95(7):1162-1172.

9 Szwarcwald CL, Castilho EA. A epidemia de HIV/AIDS no Brasil: três décadas. Cad Saude Publica 2011; 27(Supl. 1):S4-S5.^-1010 Parker R. O fim da aids? Rio de Janeiro: Abia; 2015.. The introduction of the concepts of “safer sex” and “harm reduction” were cornerstones to bring vulnerable subjects closer to caring for their health. A turning point in Brazilian politics arose in 1996, with the enactment of a law that ensured the universal distribution of combined therapy, helping to mitigate prejudice and the association of HIV with death. In the early years of the current decade, care and prevention actions from the technological incorporation and extending treatment to all people living with HIV stood out.

Crisis and HIV/AIDS

The Brazilian response to the HIV epidemic was one of the great achievements in the context of the SUS. The installed crisis, however, produces threats that already have repercussions on it and may have even more significant effects. For example, an established consensus is that austerity policies have deleterious impacts on infectious diseases, which scales up their coping¹¹11 Stuckler D, Basu S. A economia desumana: porque mata a austeridade. Lisboa: Editorial Bizâncio; 2014..

The role of SUS in ensuring the rights of PLWHA is unquestionable and supports access to free treatment achieved by the struggle of social movements associated with scientific evidence. This assurance is that health is an inalienable human right, as spelled out under the broad notion of social security in the 1988 Constitution. In contrast, weaker or decreased state social policies and the encouragement of its privatization implemented since the 2016 parliamentary coup¹²12 Löwy M. Da tragédia à farsa: o golpe de 2016 no Brasil. In: Jikings J, Doria K, Cleto M, organizadores. Porque gritamos Golpe? Para entender o impeachment e a Crise Política no Brasil, São Paulo: Boitempo; 2016. p. 61-67. – a process that ousted President-elect Dilma Rousseff – produce budgetary constraints to health policies and, in the case of HIV, reduce the possibilities for comprehensive care.

The challenges to confronting HIV/AIDS in Brazil are not restricted exclusively to the economic dimension. An important aspect from the “value agenda” viewpoint is noted: besides the exploitation of the political crisis, diffuse longings were fostered and “anti-agendas” were built to question categories such as “gender”, “sexual diversity” and “harm reduction”, historically central to HIV prevention in Brazil¹³13 Ayres JRCM. Práticas educativas e prevenção de HIV/Aids: lições aprendidas e desafios atuais. Interface (Botucatu) 2002; 6(11):11-24,^,1414 Paiva V. Sem mágicas soluções: a prevenção e o cuidado em HIV/ AIDS e o processo de emancipação psicossocial. Interface (Botucatu) 2002; 6(11):25-38.. The fight against “gender ideology” and the “school without a party” proposal have been promoting an inquisitorial hunt for internationally recognized theorists such as Paulo Freire and Judith Butler.

The 2018 two-round presidential election was held amid the increased crisis and was marked by a dispute over narratives. On the one hand, those of human rights characterized by increased access to education and state secularity, which had been consolidating the Brazilian response to HIV. On the other hand, far-right obscurantist discourses that forged, in collective representations, attacks on the platform of the leading progressive candidate – through a plethora of fictions through WhatsApp groups and other social networks, such as the emblematic “gay kit” and “penis-shaped bottle”¹⁵15 Almeida R. Bolsonaro Presidente: Conservadorismo, Evangelismo e a Crise Brasileira. Novos estud. CEBRAP 2019; 38(1):185-213.. Science itself was opposed to notions such as “family” and “good morals”, finding within the first echelon of elected government the support of anti-secular positions that lamented, for example, the loss of church space and creationism to the evolutionary theory.

Even in the institutional spaces for formulating and implementing already established policies, such as the Ministry of Health, questions about prevention and control of the epidemic were again raised after the elections. One example is the 2019¹⁶16 Brasil. Ministério da Saúde (MS). Prevenção ao HIV. Carnaval 2019. [acessado 2019 Mar 20]. Disponível em: http://portalarquivos.saude.gov.br/campanhas/usecamisinha/
http://portalarquivos.saude.gov.br/campa... Carnival Prevention Campaign that suppressed any reference to transgender people, gay men, and other men who have sex with men, mainly affected by the epidemic. Another example is the argument that sexuality can be seen as a subject to be addressed fundamentally in the family context¹⁷17 Folha de São Paulo. Política de prevenção a HIV não pode ofender as famílias, afirma novo ministro. [acessado 2019 Mar 20]. Disponível em: https://www1.folha.uol.com.br/cotidiano/2018/12/politica-de-prevencao-a-hiv-nao-pode-ofender-as-familias-afirma-novo-ministro.shtml
https://www1.folha.uol.com.br/cotidiano/... . In the recently published National Drug Policy, “harm reduction,” one of the cornerstones of HIV prevention work, is replaced by “abstinence,” a measure hailed by the most conservative mental health corporations¹⁸18 Associação Brasileira de Psiquiatria (ABP). Presidente da República assina Decreto que aprova a nova Política sobre Drogas. [acessado 2019 Mar 14]. Disponível em: https://www.abp.org.br/noticias/aprovacao-nova-pnad
https://www.abp.org.br/noticias/aprovaca... .

This conservative shift has also had the practical consequence, besides the debate on official platforms, of censoring specialized HIV/AIDS materials, such as a prevention booklet aimed at the transgender and transvestite population, and another aimed at adolescents¹⁹19 Folha de São Paulo. Ministério da Saúde retira do ar cartilha voltada para saúde do homem trans. [acessado 2019 Mar 14]. Disponível em: https://www1.folha.uol.com.br/cotidiano/2019/01/ministerio-da-saude-retira-do-ar-cartilha-voltada-para-saude-do-homens-trans.shtml
https://www1.folha.uol.com.br/cotidiano/... . Both materials were produced from expert consensus on the role of educational interventions in gender and sexuality and the fight against all kinds of discrimination in the greater adherence to prevention strategies²⁰20 Antunes MC1, Stall RD, Paiva V, Peres CA, Paul J, Hudes M, Hearst N. Evaluating an AIDS sexual risk reduction program for young adults in public night schools in São Paulo, Brazil. Aids 1997; 11(Supl. 1):121-127.

21 Paiva V, Pupo LR, Barboza R. O direito à prevenção e os desafios da redução da vulnerabilidade ao HIV no Brasil. Rev Saude Publica 2006; 40(Supl):109-119.

22 Ayres JRCM, Paiva V, França I Jr, Gravato N, Lacerda R, Della Negra M, Marques HH, Galano E, Lecussan P, Segurado AC, Silva MH. Vulnerability, human rights and comprehensive health care needs of young people living with HIV/Aids. Am J Public Health 2006; 96(6):1001-1006.

23 Edmundo K, Souza CM, Carvalho ML, Paiva V. Vulnerabilidade ao HIV em favela do Rio de Janeiro: impacto de uma intervenção territorial. Rev Saude Publica 2007; 41(Supl. 2):127-134.^-2424 Ferraz D, Paiva V. Sexo, direitos humanos e AIDS: uma análise das novas tecnologias de prevenção do HIV no contexto brasileiro. Rev. Bras. Epidemiol. 2015; 18(Supl. 1):89-103..

Besides the ensuing public debate – addressing issues such as sex and prevention – the Department of Sexually Transmitted Infections, HIV/AIDS and Viral Hepatitis at the Ministry of Health, as we knew it, was abolished²⁵25 Brasil. Secretaria Geral. Decreto nº 9.795, de 17 de maio de 2019. Aprova a Estrutura Regimental e o Quadro Demonstrativo dos Cargos em Comissão e das Funções de Confiança do Ministério da Saúde, remaneja cargos em comissão e funções de confiança, transforma funções de confiança e substitui cargos em comissão do Grupo-Direção e Assessoramento Superiores - DAS por Funções Comissionadas do Poder Executivo - FCPE. Diário Oficial da União 2019; 20 maio.. Even universal access to ARVs, which seemed unbreakable, may be under threat²⁶26 Associação Brasileira Interdisciplinar de AIDS (ABIA). Entenda o desmonte da resposta a AIDS no Brasil. [acessado 2019 Ago 28]. Disponível em: https://www.abiaids.org.br
https://www.abiaids.org.br... . One cannot neglect the consequences of all this to the health of PLWHA who need the right to ARVs to continue living – not dying – with HIV/AIDS.

Rather than retrieving elements that (re) feed what Herbert Daniel²⁷27 Daniel H. Vida antes da morte. São Paulo: Tipografia Jaboti; 1989. called “ideological virus”, referring to moral approaches to HIV that discriminate against PLWHA – which would already be highly damaging – these totems serve as a backdrop for implementing a neoliberal political-economic orientation that threatens the Brazilian state and, consequently, the country’s ability to continue implementing an effective response to the HIV epidemic.

Civil society participation was the target of attacks that led to the extinction of hundreds of participatory councils within the Executive Branch even in the face of protests by activists²⁸28 Instituto Brasileiro de Defesa do Consumidor (IDEC). Nota de repúdio à declaração de Bolsonaro sobre ativismo no Brasil. [acessado 2019 Mar 20]. Disponível em: https://idec.org.br/noticia/nota-de-repudio-declaracao-de-bolsonaro-sobre-ativismo-no-brasil-0
https://idec.org.br/noticia/nota-de-repu... . As we have seen, a socially-referenced science, the active participation of civil society and the incorporation of issues such as gender and sexuality have built an internationally recognized mix as a key to responding to the epidemic. Against this background, the anti-agendas that provided electoral triumph now threaten a state policy against all accumulated expertise on the role of information circulation and scientific and technological production in reducing vulnerability to HIV infection, illness and death^29,30. One cannot overlook that recent epidemiological data point to a significant increase in HIV infection among young people aged 15-24 years in the last two decades, and gay men and other men who have sex with men are the most affected³¹31 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de IST, HIV/Aids e Hepatites Virais. Boletim Epidemiológico Aids/IST. Brasília: MS; 2018..

Considering that one of the highlights of the epidemic during the turn of the century was its impoverishment, highlighting the incidence of social inequalities in new infections³²32 Bastos FI, Szwarcwald CL. AIDS e pauperização: principais conceitos e evidências empíricas. Cad Saude Publica 2000; 16(Supl. 1):65-76., constraining social security policies means frontally affecting the most vulnerable people living with HIV. This was the case, for example, of the suspended social security benefits and harsher criteria for granting them, which affected thousands of people, including many PLWHA. The social movement embarked on Bill 188/2017, which dispensed with the expert reevaluation of people retired for disability due to AIDS and who received a presidential veto, which was later overthrown by Parliament – which, despite the result, reveals new challenges to the lives of PLWHA, still marked by discrimination³³33 Senado Federal. Projeto de Lei do Senado nº 188, de 2017. [acessado 2019 Abr 14]. Disponível em: https://www25.senado.leg.br/web/atividade/materias/-/materia/129580/pdf
https://www25.senado.leg.br/web/atividad... .

The crisis and underfinancing of the SUS do not necessarily have “another” impact on HIV policy when we consider other social security areas but can serve as catalysts for consolidating civilizing setbacks such as legitimizing the end of drug dispensation and public services for the treatment of HIV and its co-infections. Such a move may threaten not only the enhancement of HIV policy but its very existence, and perhaps this is one of the unique realms of the repercussion of the crisis on HIV policy.

The Brazilian health reform legally and institutionally materialized in the SUS and was forged not only with a broad conception of health but also with democracy and human rights, traversing the shaping of participation policies and intersectoral care networks in a comprehensive perspective. Areas such as Mental Health and HIV/AIDS sharply reveal this perspective as they call for ethical-political positions of different social actors while at the same time being the focus of dispute, challenges, and innovations in health care.

While it is true that the establishment of the SUS was central in building a national response to the HIV epidemic, such response has enriched, albeit with tensions, ideals desired in the health reform struggle process, in part through broader strategies and fora than those of formal social control existing in the SUS. This is why the field of HIV, in the context of a crisis marked by uncertainty, helplessness, social hatred, conservatism, and minimal state role, is affected by the more general dismantling of the SUS, but also by its connections with issues such as gender, sexuality, and political activism. By having such a wide range of bridges, force lines can intervene uniquely, vigorously and early in this field towards its destruction, but it can also be one of the appropriate and vital fields to produce resistance for itself and the SUS.

Final considerations

This paper aimed to discuss possible implications of the current Brazilian crisis concerning the policy of coping with HIV/AIDS. This multi-dimensional crisis results from a combination of processes that have been taking place on a global (notably involving international capital, national states and capitalist democracies) and national scale (economic crisis and fiscal adjustment – affecting the lives of people – coupled with the (re) emergence of conservative forces and emergence of new political methods, and thinned social relationships materialized in the spread of hate and intolerance practices).

In this scenario, due to the symbolic and practical connections with the themes subject of disputes (in the field of gender, sexuality, human rights and political activism), the HIV/AIDS problem has the potential to be directly affected by the symbolic crisis, and the effect of the other realms of the crisis on the SUS. In fact, different events and initiatives – in the corporate and governmental field, inside and outside the SUS – have fiercely focused on aspects central to coping with HIV/AIDS, expanding the possibilities of stigma, prejudice, fear and violence, putting at risk the continuity of globally recognized actions and reducing the possibilities of adequate responses to the current profile of the epidemic in Brazil.

This situation also requires actors committed to citizenship and social justice to have a keen eye on the technical, political, and social construction of the Brazilian response to HIV and the singularities of the current situation, but also to establish new intervention strategies that take into account that the response to the epidemic cannot be restricted to biomedical confrontation and that the state should not be the only body involved, despite its strategic importance³⁴34 Birman J. A Physis da Saúde Coletiva. Physis 1991; 15(Supl. 1):11-16..

References

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