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The number of Latin Americans with HIV/AIDS who receive medical attention through state programmes and who have access to adequate treatment is growing, but many are still out of the loop. What must be done to remedy the situation?

By Diego Cevallos*

MEXICO CITY - Hugo Estrada, 43, has been HIV-positive for the last five years and says he is content with his life. He has studied at the graduate level, he has access to antiretroviral medications, timely medical treatment as well as psychological support. Furthermore, he receives a disability pension and he has strong family support.

Estrada's case might be considered normal in an industrialised country, but in Latin America, where there are 1.4 million people with HIV/AIDS - 130,000 who became infected this year - he is the exception.

"I am among the privileged," acknowledges Estrada. His good fortune, he says, is linked to having state social security benefits and a university education, but is largely due to his leadership in the Mexican organisation known as the National Front of People with HIV/AIDS.

"I can't think about a future in the long term, but with the time I have left and the prospects for new medications, I will always put up a fight," he says.

A volunteer nurse tends to an AIDS patient at the Mexican Foundation for Combating AIDS. /Photo credit: Sergio Dorantes.

Activists defending the rights of people who are HIV-positive recognise that notable progress has been made in Latin America as far as access to medical attention. This has much to do with the discovery of new drugs, particularly the antiretrovirals that have transformed AIDS from a killer into a chronic disease because they destroy HIV or prevent the virus from multiplying. Nevertheless, there are still many infected individuals who are excluded from health services and who are marginalized from society. Many HIV-positive Latin Americans are from poor communities where education levels are relatively low, which generally means they lack the awareness to demand the treatments that are available. Often, if they do obtain the services, they are unable to maintain the discipline required for taking the AIDS drugs.

When it comes to AIDS, the problem is "not only individual, but also social," says Marclei Guimaraes, a Brazilian sociologist who is HIV positive. "Among those with low incomes, adherence to treatment programmes is low. Not for lack of motivation, but because of objective social conditions," he adds.

In countries like the United States, where medical attention for HIV/AIDS patients is generally of very high quality, the national health expenditure is 4,180 dollars per capita. In contrast, the average in Latin America is 349 dollars per capita, according to the United Nations Development Programme.

"We can't compare ourselves to a rich country. In Latin America, there are few countries that offer medical attention like that available in the United States," said Mexican activist Estrada.

But there has been some progress. In Venezuela, where the Supreme Court of Justice declared last April that all Venezuelans with HIV/AIDS shall receive medical attention, including antiretroviral drugs, the number of people receiving treatment for AIDS skyrocketed from 2,000 late last year to 10,000 in 2001. However, some 62,000 Venezuelans, in a national population of 23 million, are believed to be HIV positive.

In Brazil, meanwhile, there are 105,000 HIV/AIDS patients receiving free health services from the state, and the number rises by 15,000 to 20,000 each year. But an estimated half-million more are HIV positive, and few of them are aware of it.

The Portuguese-speaking nation of 162 million people stands out in Latin America for its capacity to produce generic AIDS-fighting drugs. But this advantage has meant clashes with the big transnational pharmaceutical companies, which defend their drug patents tooth and nail.

"The success of the Brazilian programme is due to the government's early response to AIDS, the participation of civil society, and the defence - in the national and international spheres - of ensuring access to all the necessary medications," says Rosemeire Munhoz, assistant coordinator of the sexually transmitted disease programme at Brazil's Ministry of Health.

The new pharmaceutical Saquinavir is an HIV protease inhibitor. /Photo credit: Sergio Dorantes.

Of the AIDS drugs distributed in Brazil in 2000 - at a cost of 303 million dollars - 41 percent were produced by laboratories inside the country. Chile has also recorded progress in the AIDS fight. Today, the government can assure antiretroviral therapy for 81 percent of the 3,212 people holding prescriptions for the treatment - nearly double the percentage of coverage in previous years. An estimated 40,000 people in this country of 14.5 million are HIV-positive. According to Cynthia Morales, with the Defence Council of the State, the Chilean government should establish the goal of providing all AIDS patients with the best medical attention possible. She adds, however, that if it fails to do so, it would not be breaking any law. That attitude, here and elsewhere, has come under fire from non-governmental organisations. AIDS activists throughout the region assert that the government should -without exception - provide treatment for all people with HIV/AIDS.

The expansion of health coverage in Chile was achieved largely as a result of negotiations between the government and five pharmaceutical companies, which brought drug prices down by an average of 50 percent, says Gloria Berrios, an official at the National AIDS Commission. In Mexico, the state provides antiretroviral drugs for approximately 20,000 people, or 85 percent of Mexicans with the disease, according to Carlos Magis, head of research at the National Centre for the Prevention and Control of HIV/AIDS. But activists say the true percentage is much lower because of the under-reporting of cases. They calculate that some 120,000 people are infected with the virus in Mexico, a nation of approximately 100 million people. Furthermore, there are 4,400 Mexicans with AIDS who do not have social security benefits. Their only possibility for obtaining antiretroviral drugs is through a special government-run programme, but it can only cover 2,000 patients. If an HIV-positive Mexican requires medical attention and has no insurance, he or she has to wait until someone abandons the programme or dies, says activist Estrada. "The only alternative may be to shut yourself away at home and wait for death," he adds.

AZT is a well-known antiretroviral drugs. It is a reverse transcriptase inhibitor of HIV. /Photo credit: Sergio Dorantes

In Mexico, Brazil, Chile and Venezuela, state support is vital for the HIV-positive population because treatment in the private sector would cost each patient 700 to 1,000 dollars a month, a sum that is far out of reach for most people.

Though the governments of Latin America still need to do much more, the situation for HIV/AIDS patients in the past was even more complicated.

Improving the quality and quantity of medical services has cost a great deal of effort and many lives, agree activists and governments alike.

In 1998, Anthony García and two fellow Chileans infected with HIV petitioned their country's justice authorities to obligate the government to provide them with antiretroviral medications. The Chilean judges rejected the request, but the Inter-American Human Rights Court ruled in favour of the three petitioners. García today receives the drugs free from the government, but his two associates in the case died from AIDS-related causes during the legal battle for their cause. The changes in the fight against AIDS in Latin America are the result of the activism of the people with the disease, the mobilisation of local and international organisations, and the negotiations between governments and pharmaceutical companies - which have brought down drug costs by as much as 80 percent, as was the case of the Merck corporation in Mexico

It does not represent a comprehensive victory for the region, however. There are still relatively few people with HIV/AIDS who receive free medical treatment from the government like Estrada does in Mexico.

"Unfortunately, in this country (Mexico) and others, if you don't put on the pressure, if you don't yell and demand treatment, nothing happens. If you don't take action, you die," Estrada said.

Psychological support, regular laboratory tests, treatment and control of the opportunistic illnesses associated with AIDS are still scarce in most countries, say activists.

"The government's medical services are terrible and the medications never arrive on time. I have spent the last year asking for a new drug, but they just say I have to wait longer," says Humberto, a 35-year-old Mexican who is HIV-positive. He was fired from his job in the local media four years ago when he was diagnosed with virus.

Once a new AIDS drug becomes available in the industrialised countries, it is usually six months before it arrives in Mexico, a wait that can mean death for AIDS patients.

Arturo González, of Venezuela, says "there is still rejection and insensitivity, even among doctors, towards people with HIV/AIDS." But he says attitudes are changing "because now they know that we are ready to stand up for our rights."

On the economic front, experts point out that better medical attention for citizens with HIV/AIDS ultimately means fewer costs for the government. Just ask Brazil. There the distribution of the "cocktails" of AIDS drugs from 1995 to 1999 cut the mortality rate attributed to the disease in half. In the city of Sao Paulo alone, home to 21 percent of reported cases in Brazil, AIDS-related deaths fell 54 percent.

The antiretroviral treatments meant that HIV/AIDS patients became ill less often. From 1997 to 2000, hospitalisations linked to AIDS and its so-called opportunistic infections plunged 80 percent.

Overall, improved treatment for HIV/AIDS represented savings of 677 million dollars for the Brazilian government, reported health officials.

The governments of Latin America recognise the potential savings, but many argue that current economic problems limit their ability to take action. Still, several are promising that they will take all possible steps to improve the quality and expand the quantity of medical coverage for AIDS patients.

"Collective experience with HIV/AIDS has evolved to the point where it is now possible to state with confidence that it is technically, politically and financially feasible to contain HIV/AIDS and dramatically reduce its spread and impact," UN Secretary-General Kofi Annan has said.

But until all Latin Americans with HIV/AIDS receive comprehensive and high quality treatment like Mexico's Estrada, the "dramatic reduction" will remain a pending goal for most countries in the region.

* Mario Osava (Brazil), Gustavo González (Chile) and Andrés Cañizález (Venezuela) contributed to this article.