In 2004 I interviewed Eva, a transgender former prostitute in Oaxaca, Mexico. She was an attractive 28-year-old with long brunette hair, stylish black glasses, and simple but chic clothes. She told me that her father had kicked her out of the family home after realizing that his son perceived himself as a woman, and his mother had accepted this. On the streets, Eva had begun to drink heavily and experiment with drugs. She quickly fell into sex work to survive, joining a world shared by other transgender youth. In the years that followed, many of her friends left for Mexico City, where life was hard, and some were HIV-positive when they returned. By then, several years had passed. Eva had left the sex trade and remade her life, eventually getting a job and finding a home. She continued to go out with her friends, but none of them drank. When her mother became ill, Eva brought her into her own home and took care of her. And she was HIV-negative.
 Mayan community midwives from the Lake Atitlán region of Guatemala, after finishing a workshop on preventing mother-to-child HIV transmission. (By Evan Abramson for the Children Affected by AIDS Foundation) |
Eva likely avoided becoming infected, in part, because of the regular health exams for sex workers mandated by the municipal authorities; she also had the benefit of living in a culture in which intravenous drug use is rare. Her story reflects the relative success of public health in Latin America, a success that ought to give us cause for hope when we consider the future of the AIDS pandemic in the region. For this reason, the International AIDS Conference, meeting for the first time in Latin America in Mexico City in August, should be the most optimistic gathering since 1996, when researchers announced the development of triple therapy, a combination of drugs that represented the first effective treatment for the disease.
In November 2007, the United Nations reduced the estimated global number of people infected with the virus from 39.5 million to 33.2 million.1 Well-done epidemiological studies have also shown that infection rates are lower than had been feared in both China and India, and in some nations where the epidemic has seemed the most desperate, such as Haiti, the prevalence may be decreasing. Whichever candidate wins the White House in November, it seems possible that President Bush’s original $15 billion commitment to the President’s Emergency Plan for an AIDS Response (PEPFAR) could be increased to $50 billion for the next five years. There are now such large investments being made to treat AIDS in developing countries that some have begun to question whether part of the money would not be better spent on other priorities, like basic health care and clean water.2 Combined with the political victory that Brazil and other developing nations won by asserting their right to produce generic drugs against HIV, both developing nations and international grantors now view treatment in poor countries as feasible.
True, a vaccine remains elusive, and political disasters from South Africa to Russia allow HIV to flourish. But after years in which despair and denial sapped hope, it now seems that humanity could reshape HIV’s future. While the trend may be positive, the pandemic is the sum of diverse sub-epidemics, so it is hard to speak of a single experience of the disease. No place better illustrates the fractured nature of the epidemic than Latin America, which Marcos Cueto and others have described as having a “mosaic of infection.” To study the AIDS pandemic, I traveled widely in Latin America. I toured the sanatoriums of Cuba and talked with people living with the virus from Havana to Cienfuegos. In Oaxaca, Mexico, I spoke with gay leaders, political activists, doctors, and government employees, and in São Paulo, Brazil, I interviewed crack addicts, intravenous drug users, drug traffickers, NGO members, doctors, and government officials.
Overall, I was struck by the extent to which a disease spread by the most personal of behaviors is shaped by public policy. Mysteriously, one country in Latin America may have a high rate of infection, while its neighbor—with the same language, culture, religion, and history—does not. Why has HIV circled around the Caribbean Sea and Atlantic Coast, striking nations as diverse as Haiti, Honduras, and Guyana, while passing over others? Furthermore, how is it that Latin America has largely avoided the disaster of Southern Africa, despite its own struggles with poverty and inequality? How has democratization affected the epidemic in Latin America? How does development shape a nation’s experience of HIV? What trends might predict the epidemic’s future or suggest how to fight this enemy? To answer these questions, we must examine the epidemic’s complexity by describing its course in different subregions.
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The fact that the first reported cases of HIV occurred in the United States meant that in the early 1980s, people in Latin America associated the disease with what they thought of as the moral failings of their northern neighbor. Various doctors and other health “experts” in the region opined that because the United States had much more drug use and homosexuality, the epidemic could not arrive in Latin America. Mexicans, some argued, had stronger immune systems because they were frequently exposed to germs, while the Andes supposedly formed a geographic barrier that would shield Chile from this northern plague. In Brazil, journalists wrote that the first case of AIDS proved that their country was “sophisticated” enough to have the disease, which oddly recast northern immorality as linked with modernity.4
But this association of HIV/AIDS with northern development and moral decadence changed as the Centers for Disease Control and Prevention announced the discovery of heterosexual cases of HIV among Haitian men. AIDS first appeared in Haiti and the United States at virtually the same moment in the 1970s, although this would not be recognized until years after the disease was described as a distinct syndrome in 1981. This recognition came too late to stop doctors and authors in the United States from speculating that Haiti had introduced the disease to the Americas. Major medical journals published letters and articles speculating that voodoo rites might have infected people and wondered if Haiti’s water supply was so contaminated that it permitted the virus’s spread.5 Unsurprisingly, this fed hysteria in the United States, further fueled by the equation of HIV with poverty and blackness. Haitian immigrants in the United States suffered terrible discrimination, while Haiti’s tourism industry collapsed. This experience shaped subsequent discussions of HIV’s history, as epidemiologists tried to determine whether HIV flowed from the United States to Haiti or vice versa. The most recent study of HIV’s molecular biology suggests that perhaps Haiti did first receive the virus, as the island’s close ties to Africa in the 1960s and 1970s might suggest.6But because of this sad history, the question remains painful and political.
The United States was not the only nation where fear led to a problematic response to the virus. Cuba responded quickly to the virus’s appearance, with such steps as the mandatory testing of the blood supply and the destruction of all imported blood. On the one hand, these measures prevented the disaster that swept over hemophiliacs in the United States. On the other, the government began mass-testing the entire population, which undermined individual human rights. Like the appearance of the virus in Haiti, any discussion of Cuba’s HIV/AIDS policy is inevitably politicized. If the measure of success is preventing the social disaster that swept over its Caribbean neighbors, as the Cubans suggest, then the nation’s policy might appear successful. On the other hand, given Cuba’s high literacy rate, ubiquitous health care system, and public information resources, the virus might have been contained without violating individual rights. Today, Cuba’s experience of HIV seems much more like that of other nations, with the state emphasizing prevention and treatment rather than quarantine.
In the late 1980s and early 1990s, as Julie Margot Feinsilver’s work suggests, Cuba’s leaders viewed themselves as being in a health competition with the United States; the disease represented an opportunity to prove the superiority of their society.7 Within a decade, almost the entire population of the island had been tested for the virus. HIV-positive Cubans were confined for life to sanatoriums, where they received a salary, many services, good food, and the necessary medicines. But they were separated from their loved ones.
This policy contained the virus—Cuba may have the lowest prevalence of HIV in the hemisphere—but it also led to the self-injection movement. Between 1989 and 1992, more than 200 Cuban youths deliberately injected themselves with HIV-infected blood. While in some cases they wanted to join their HIV-positive spouses in the sanatoriums, the majority were young men known as roqueros, members of a subculture that adored U.S. rock music and rejected the Cuban state. Many may have believed that a vaccine would be soon found, while others wanted the food, television, and leisure to be found in the sanatoriums. For most, it was also an act of futile rebellion.8
After Cuba’s economic crisis of 1992, the rising power of the international gay movement, together with the media coverage of the roqueros, forced the Cuban government to stop confining HIV-positive people to the sanatoriums. The self-injection movement faded. By the time I visited Cuba in 2004, most people who recently tested positive would enter the sanatoriums for only a few weeks to receive a health evaluation and education. The government has produced drugs for effective therapy since 2001, largely inspired by the Brazilian example, and HIV mortality rates in Cuba have plummeted.
Brazil has had much more impact on global HIV/AIDS policy than its Caribbean counterpart. The nation’s early history with HIV/AIDS was marred by the same discrimination and lack of will that characterized many other nations’ responses. The return to democracy in 1985 created a space for civil organizations to flourish, but it was not until the discovery of highly active antiretroviral therapy (HART) in 1996 that Brazil decided to make medications available to all HIV-positive citizens. Until then, it had appeared that there would be two epidemics: one in Northern nations, where patients might pay $15,000 a year for treatment, and a second epidemic in the Global South, where only a small minority could afford the medicines. Brazil declared that the right to life for HIV-positive people outweighed the patent rights of drug companies and threatened to produce generic drugs if the pharmaceutical companies didn’t lower their prices. Other countries considered such a policy, but Brazil stood out because of the size of its national pharmaceutical industry, which gave it the technical capacity to produce the drugs.
International pharmaceutical companies responded by asking the U.S. government to invoke clauses in the World Trade Organization’s agreement, which would prevent nations like Brazil and India from producing generics. An immense political struggle ensued between the U.S. government and some pharmaceutical corporations, on the one hand, and developing nations and international nongovernmental organizations (NGOs) on the other. In the end, Brazil and its allies (both other developing countries and international NGOS) won. This success changed the terms of the debate about fighting HIV globally, by proving that it is possible to provide universal treatment in developing countries. The policy may ultimately have saved money, because fewer people enter hospitals for expensive end-of-life care and more people now know their HIV status.
Unfortunately, not all nations in Africa and Latin America are following this policy. South Africa has had the resources to make these medications available, but the government has lacked the will to do so. In Central America, Mexico, and some other Latin American nations, HIV-positive people or the government might pay $2,000 for a year’s treatment, well above prices in Brazil or some countries in Africa, where it might cost $160. In principle, the Mexican government provides medication—but not the necessary tests—for free, but not all HIV-positive people receive treatment. If the United States were to use its influence to further reduce the cost of these medications, and to support the infrastructure to deliver them, it could reshape the future of the roughly 2 million people living with HIV in Latin America and the Caribbean.
In Spanish-speaking South America, each country’s position in the drug trade has shaped the epidemic. In the United States and Europe, it is common to think of Andean countries as cocaine producers that export their product to the developed world. But there is now a significant market for cocaine and other drugs in Argentina and Brazil, which has shaped the region’s HIV epidemic. In cocaine-producing nations like Colombia, Bolivia, Peru, and Ecuador, there are not generally large numbers of drug users, the prevalence of HIV is lower, and the epidemic is less diverse, since it tends to be more concentrated in young gay men. For example, HIV-positive people in Argentina are 170 times more likely to be drug users than their counterparts in Bolivia.9 In Colombia, ongoing violence makes it hard to trace the virus’s spread in the countryside. There is no question that fighting and fear hamper AIDS outreach efforts and leaves internal refugees vulnerable to sexual exploitation.
Countries that neither produce nor consume massive quantities of drugs—such as Chile and Venezuela—tend to have a lower prevalence of HIV compared to those with significant drug markets, which tend to have epidemics that affect more communities and have a higher HIV prevalence. In 2005 I interviewed drug addicts in a São Paulo favela and found that most used crack cocaine. Small groups of addicts hid in the long grass and smoked it in pipes made from broken car antennas. These pipes were themselves an HIV-transmission risk, because they left the users’ mouths burned and cut. The NGO leaders I met who worked in these communities—some of them crack users themselves—had shifted their efforts from drug use prevention to harm reduction. The drug’s hold on peoples’ lives seemed too strong to make going sober the only goal. The challenge is similar in Argentina, where drug use blossomed after the end of the military dictatorship. In these nations, HIV and the drug trade will have to be addressed holistically.
Mexico, which has a lower HIV prevalence rate than the United States, has enjoyed notable successes in its efforts to address the epidemic. There are a number of reasons for this, including the fact that intravenous drug use is uncommon, and the sex trade is regulated in most states and municipalities. Sexual transmission accounts for perhaps 90% of HIV cases in Mexico, mostly among men who have sex with men. But the situation is changing, and more women are now HIV-positive. In the early years, HIV was concentrated in the nation’s capital and in the border areas in the north. Now it is spreading to small towns in rural areas, where young men, many of whom are indigenous, are migrating to the United States in large numbers. They often have a low level of schooling, and Spanish may be their second language. They follow well-established pathways to the United States, where they often do not have any family, but do have more income than at any point in their lives. They are stressed and find a nation with different sexual customs. Away from the small communities of their birth, some men experiment with drugs and sex, and a fraction become infected with HIV. Sadly, the migrants are stigmatized, both in the United States and in Mexico, which, combined with their mobility, makes it hard to conduct outreach campaigns with this population. One can imagine the situation of a young housewife in the Mixtec Alta of Mexico’s Oaxaca state, whose husband returns for a saint’s day celebration after a six-month absence. It would be hard to discuss safe sex on the first night. At the start of 2003, 11 sex workers, 208 housewives, and 263 migrants, “of whom only seven were women,” had tested positive for the virus in Oaxaca.10
Despite Mexico’s success containing the virus, the concern remains that the country still may see rates of HIV similar to those in some of its southern neighbors, given the many similarities between these regions. The history of HIV in the seven countries of Central America seems to have been shaped by the warfare in the region during the 1980s. Some nations, like Belize and Costa Rica, escaped the fighting, while El Salvador, Guatemala, and Nicaragua witnessed sustained violence. Paradoxically, the fighting seems to have slowed the spread of HIV in some nations, which has been witnessed in other nations as well, including Angola and Mozambique.11 Panama and Belize, two countries that escaped the fighting, have the highest rates of HIV in Central America.
One question frequently raised is whether the sad and wasteful Contra war of the 1980s may explain the relatively high rate of HIV in Honduras early in the epidemic, perhaps because the virus was introduced by U.S. military personnel or by Contra fighters. But the geography of the epidemic does not seem to match this hypothesis. From the start, Honduras’s epidemic focused on the two main cities of San Pedro Sula and Tegucigalpa, while the regions that hosted U.S. troops had much lower rates. Likewise, the location of the Contra camps did not match areas with a high prevalence of HIV. A careful study of repatriated Contra soldiers found only a handful infected with the virus. For this reason, Honduras’s early experience of the virus remains mysterious, especially given that Nicaragua’s rate has remained extremely low.
Central American nations are now collaborating to bring antiretroviral drugs to those who need them. Despite these efforts, costs still remain high, and only Costa Rica currently provides such medications to all HIV-positive citizens. In the long run, it probably makes sense to consider Central America’s epidemic in the same context as Mexico’s, given these populations’ high rate of mobility. Young, poorly educated men and women on their way to the United States pass through a series of transit points throughout Central America where they are vulnerable to exploitation. A small minority of migrant women fall victim to human traffickers, the sex trade, and demands for transactional sex. Because these transit points are documented, an outreach effort in these areas could have a broad impact.12 Given this migratory context, no country in this region can fight the epidemic in isolation; a truly hemispheric initiative is needed.
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 A giant pink condom covers the Buenos Aires obelisk, in an AIDS-awareness effort co-sponsored by the city government and a radio station in 2005. (By Guillermo Jones / Latinphoto.org) |
Latin America is home to many of the factors that might lead one to expect HIV to flourish in the region: widespread poverty, gender inequality, hidden male homosexuality, an extensive sex trade, and often imperfect national health care systems. Yet, with the exception of Haiti, Guyana, and perhaps Honduras, it has been spared a generalized epidemic. Why? First, it might be good to exclude some hypotheses that seem insufficient. One argument might be that Latin America has not experienced the level of sustained warfare that many African nations have. But as we have seen, warfare in some cases has the paradoxical effect of dampening the spread of the virus. Similarly, there is no clear connection between the spread of the virus and poverty or globalization. On the surface, it might seem that the lower level of poverty in Latin America, compared with Africa, might explain why the region has been more successful in facing HIV. It is true that one cannot discuss the virus’s course without discussing international political economy, from structural adjustment programs to chronic indebtedness, which hampers the state’s ability to respond to HIV. But some extremely poor countries in Latin America, like Bolivia and Nicaragua, have low rates of HIV, while some wealthier ones, like Argentina, have significantly higher rates. An exclusive focus on poverty may in fact distract from other issues that shape the spread of the virus—patriarchy, gender inequality, and racial and economic discrimination.
I would suggest that Latin America has escaped a generalized epidemic of HIV in most countries for four reasons. First, the virus arrived in Latin America later than in Central and Eastern Africa, where the first cases appeared in the 1960s, which allowed more time for Latin American governments to clean up the blood supply, educate the public, and create a plan. Much of Africa—with the exception of the continent’s southern region—did not have this opportunity. Second, one has to consider the role of migration, a key force in driving the spread of HIV all over the world. Certainly there has been extensive migration from Mexico and Central America to the United States, but migration has been less important than in Southeast Asia and Southern Africa. Still, the danger remains that without precautions a similar disaster may be repeated in Mexico and Central America. Third, for all of their weaknesses, most Latin American nations had the state capacity to respond to the epidemic. As the work of Andrew Price-Smith has shown, stronger states are more effectively able to address the spread of HIV.13 Even relatively poor nations, like Cuba, were generally able to create a plan to mobilize their public health infrastructure and educate their people. Key states in Asia (Myanmar and Cambodia), as well as in Africa (Democratic Republic of the Congo and Zimbabwe), proved less capable.
Lastly, the virus arrived in Latin America just as sweeping political changes came to the region. From 1983, when the Argentine military government collapsed, to 1990, when Pinochet left power in Chile, one authoritarian regime after another fell to popular protest and political exhaustion (though there were exceptions: Peru under Fujimori, Mexico until 2000). Democracy alone is not enough to slow HIV, as South Africa has proved, but most of Latin America saw a proliferation of grassroots activism dedicated to everything from gay rights to women’s issues. In country after country the popular protests of activists, often supported with funds from international NGOs, led to key policy changes, from enforcing human rights provisions to making free treatment available. In sum, HIV would have had far more devastating consequences if it had not been for the flowering of civil society that accompanied regional democratization. Moreover, the region has both the resources and the capacity to continue expanding treatment and care, while also safeguarding human rights.
Shawn Smallman is the author of The AIDS Pandemic in Latin America (University of North Carolina Press, 2007). He is Vice-Provost for Instruction and Dean of Undergraduate Studies at Portland State University in Oregon.
1. “Fact Sheet: Revised Estimates,” UNAIDS, November 2007. Accessed from data.unaids.org/pub/EPISlides/2007/071118_epi_revisions_factsheet_en.pdf.
2. Laurie Garret, “Do No Harm: The Global Health Challenge,” Foreign Affairs 86, no. 1 (January–February 2007): 14–38.
3. Marcos Cueto, Culpa e coraje: Historia de las políticas sobre el VIH/SIDA en Perú (Lima: Consorcio de Investigación Económica y Social, 2001), 16.
4. For a fuller discussion with references, see Shawn Smallman, The AIDS Pandemic in Latin America (University of North Carolina Press, 2007), 12–13.
5. Ibid., 24.
6. M. Thomas P. Gilbert, Andrew Rambaut, Gabriela Wlasiuk, Thomas J. Spira, Arthur E. Pitchenik, and Michael Worobey, “The Emergence of HIV/AIDS in the Americas and Beyond,” Proceedings of the National Academy of Sciences of the United States 104, no. 47 (November 20, 2007): 18566–570.
7. Julie Margot Feinsilver, Healing the Masses: Cuban Health Politics at Home and Abroad (University of California Press, 1993), 22, 56.
8. Smallman, 50–57.
9. Pan American Health Organization and the World Health Organization, AIDS Surveillance in the Americas, Biannual Report, 2002 (Pan American Health Organization, 2002), 7–8.
10. Alejandro Villegas, “Afecta SIDA en mayor grado a amas de casa y migrantes,” El Tiempo (Oaxaca, Mexico), April 24, 2003.
11. Laurie Garrett, “The Lessons of HIV/AIDS,” Foreign Affairs 84, no. 4 (July–August 2005): 57.
12. Mario N. Bronfman, René Leyva, Mirka J. Negroni, and Celina M. Rueda, “Mobile Populations and HIV/AIDS in Central America: Research in Action,” AIDS 16, no. 3 (December 2002): 42–49.
13. Andrew Price-Smith, Steven Tauber, and Anand Bhat, “State Capacity and HIV Incidence Reduction in the Developing World: Preliminary Evidence,” Seton Hall Journal of Diplomacy and International Relations 5, no. 2 (summer–fall 2002): 149–150.
