Public Health, HIV Care and Prevention, Human Rights and Democracy at a Crossroad in Brazil

Abstract

On January 2019, Brazil’s new far-right president Jair Bolsonaro was sworn into office. Bolsonaro’s administration supports downsizing the Brazilian Unified Health System (SUS), while increasing the size of the private health sector. The new administration might leave millions of Brazilians without medical care, including hundreds of thousands of people living with HIV/AIDS. Bolsonaro’s administration, allied with a highly conservative Congress and sharp decreases in federal funding for public health, education and research, could jeopardize key health and human rights strategies focused on women, LGBTQ+ individuals, Indigenous populations, and people living with HIV/AIDS.

On 28 October 2018, Jair Bolsonaro, a far-right candidate, won the general presidential election with 55.13% of the popular vote [1]. The recently elected Brazilian president has endorsed the use of torture and strongly supports the military dictatorship that ruled Brazil from 1964 to 1985, a period when thousands of dissidents were tortured and killed in Brazil. According to Mr. Bolsonaro, “The only mistake of the Brazilian dictatorship was to torture but not kill”.

Before becoming president, Bolsonaro was already influencing key public health strategies, including those directly related to HIV care and prevention, in Brazil. In November 2018, Cuban authorities decided to withdraw the More Doctors Program (Programa Mais Médicos) from Brazil. [2] The partnership between Brazil and Cuba was created in 2013, mediated by the Pan American Health Organization (PAHO). The strategy was developed to foster preventive care and address Brazil’s sharp disparities in the distribution of physicians, concentrated in larger urbanized cities, to the detriment of the country’s less developed regions – several without a single doctor available [3]. However, Cuba withdrew thousands of doctors from the program after Jair Bolsonaro questioned their training and demanded changes in the contract. The program provided basic health services to around 60 million Brazilians from rural and hard to reach areas, including Indigenous communities. This initiative was pivotal in assuring proper delivery of HIV-treatment in hard to reach areas (e.g., Amazon bay), controlling epidemic levels of tuberculosis and dengue fever, promptly responding to outbreaks of Zika virus and malaria, and providing continuous primary health care for those with diabetes and other chronic conditions [2]. Over the five-year period, around 20,000 Cuban employees offered medical treatment in more than 3,600 municipalities (the majority with less than 20,000 inhabitants), with very successful results [4]. Cuban doctors were the only health professionals actively working in 75% of Brazil’s Indigenous communities. Previous attempts to hire Brazilian doctors to serve these small and hard to reach areas were unsuccessful, and many fear that millions of Brazilians will be left without any health care, including people living with HIV/AIDS [2].

The Brazilian Unified Health System (Sistema Único de Saúde – SUS) was established in 1988, with a new Constitution that established ‘health as a universal right and a State responsibility’. Brazil has the largest public health-system in the world, currently providing treatment and care for 150 million people. Around 75% of the Brazilian population relies exclusively on SUS as their only source of health care [5]. In 2018, around 580,000 people living with HIV/AIDS were receiving their antiretroviral drugs (ARVs) free of charge through SUS, and the majority of HIV-positive patients utilize SUS for their routine clinical and laboratory monitoring [6].

However, after 30 years of progress towards universal health coverage, SUS is facing a major threat - a package of austerity measures that includes freezing the health-care budget. The Constitutional Amendment 95 (EC 95/PEC 55/PEC 241) was passed in December 2016 and implemented in 2017, repealing the minimum federal expenditures on social protection and health, established by the 1988 Constitution. The amendment limited growth of federal expenditure on social protection and health, keeping spending levels adjusted for inflation over the next 20 years. The projected decline in the health budget will be around R$415 billion by 2036 [7]. In 2016, then federal deputy, Jair Bolsonaro, voted in support of Constitutional Amendment 95.

In a scenario of constant outbreaks of infectious diseases such as dengue fever, Zika virus and, most recently, measles, this new rule is a major public health concern. The legislation might leave millions of Brazilians without medical care, including hundreds of thousands of people living with HIV/AIDS. Simulations conducted by Davide Rasella and colleagues identified that the implementation of these fiscal austerity measures are likely to increase child morbidity and mortality within the next decade. Following the same path, the federal science budget is facing a 45% cut. Public education will also struggle with a similar budget decrease, while also struggling with highly conservative policies against sexual and gender diversity education [9].

According to Doniec and colleagues [10], current Brazilian health reforms include not only austerity measures, but also strategies to increase privatization and deregulation. President Bolsonaro appointed Luiz Henrique Mandetta as the new Ministry of Health. Mr. Mandetta was a congressman that voted in favor of PEC-95, and is currently being investigated for corruption and fraudulent bidding. Mandetta received thousands of dollars in campaign contributions from health insurance companies and was the president of a large health insurance company from 2001–2004. As the new Ministry of Health, Mr. Mandetta will probably continue the path to privatization and downsizing of the Brazilian SUS. The new government continues to support the increased offer of cheap and less regulated health plans, or ‘Planos Populares’. These plans provide fewer and lower quality health services than the ones already offered by SUS with high out-of-pocket costs [10].

While Jair Bolsonaro’s election represents an extreme shift to the far right, Brazil has been experiencing a steady growth of power concentrated in the so-called BBB block (standing for Bible, Beef and Bullets), comprised of highly conservative and religious fundamentalist politicians over the last decade. This shift has deeply influenced public policies addressing HIV/STIs and sexual and gender diversity education. In 2011, after protests from Evangelical legislators, former President Dilma Rousseff suspended the distribution of an educational kit that addressed gender, sexuality and human rights in public schools. In 2012, the Minister of Health censored an HIV prevention campaign targeting young homosexual men, a group with high HIV prevalence. In 2013, a campaign empowering female sex workers was also censored [11].

Following this path, Bolsonaros’ choice for Ministry of Education, Ricardo Vélez Rodríguez, fully supports the controversial project ‘Escola Sem Partido’ (“Schools Without Party”). The project promotes a conservative agenda that aims to prohibit discussion about gender identity, diversity, sex education and political debates. According to this project, teachers should be prohibited from encouraging students to participate in activism and should prioritize so-called ‘family values’. The project states that any debate and information about sexuality, gender issues and human rights should be solely discussed at home. This project is of great concern in a country where the vast majority of rape and sexual violence cases are perpetrated by male family members [12] yet women and girls lack access to safe and legal abortions [13]. ‘Escola sem partido’ follows the cancelation of a program that offered an e-learning course on gender, sexuality, and ethnic relations for teachers and school administrators in the public school system, in combination with activities targeting public school students. Mrs. Damares Alves, an evangelical pastor, was appointed for the new Ministry of Women, Family and Human Rights. The new ministry declined to add the LGBTQ+ community as a group explicitly protected by its mandate, adding that ‘diversity policies have threatened the Brazilian family’. Alves declared on her first day in office that “girls wear pink, and boys wear blue; girls will be princesses, and boys will be princes.” According to the new administration, “There will be no more ideological indoctrination of children and teenagers in Brazil.” Unfortunately Bolsonaro’s administration is directly opposing decades of scientific evidence that support sexuality, gender and human rights education as a core strategy to fight stigma, gender-based violence, while preventing HIV/STIs and unintended pregnancy among youth [14].

Compounding the problem, Mr Bolsonaro is well known for a long history of remarks against the LGBTQ+ community. He has said that he would rather his son die in an accident than be gay, has advocated that parents should beat being gay out of their children, and in 2013 proclaimed, “Yes, I am homophobic — and very proud of it.” Brazil has the highest LGBTQ+ homicide rate in the world, with at least 445 violent deaths reported in 2017. The country is the most dangerous for transgender and gender non-conforming people worldwide [15]. The election of Bolsonaro, allied with the most conservative Congress since the Brazilian dictatorship, could jeopardize key strategies that address LGBTQ+ rights in Brazil, including the development of strategies to decrease bullying, hate crimes and those that continue to support HIV prevention and care services for this highly affected population. The new administration represents a threat to established rights such as same-sex marriage, adoption by same-sex couples, and transgender rights for legal gender recognition.

Devastating consequences of these changes are already evident in Brazil. Jean Wyllys, Brazil’s first openly gay congressman who was elected for a third mandate, decided not to serve the new term. His decision was influenced by frequent death threats, which increased after the murder of Marielle Franco from the same party. In March 2018, Franco, another openly gay African American councilor from Rio de Janeiro was shot dead. Her crime remains unsolved. Jean Wyllys has been a frequent target of homophobic attacks from President Jair Bolsonaro. During Wyllys’ mandates, several strategies to promote human rights and protect LGBTQ+ rights were implemented and thousands of dollars allocated to fight stigma, discrimination and violence towards the population. It is uncertain if those initiatives will be continued.

Specific to HIV/AIDS care and prevention, several activists and public health professionals fear for the combined impact of an SUS downsize, increase of cheap and less regulated health insurances, allied with austerity measures and sharp decreases of funding. The Brazilian response to HIV/AIDS was once identified as a best model and a policy that should be followed by other low- and middle-income countries. However, this ‘best model’ has not been very successful in the last decade, with a median of 40,000 new cases and 12,000 AIDS-related deaths every year. According to recent estimates from the Brazilian Ministry of Health, in contrast with a worldwide downward trend, HIV cases in Brazil have increased - especially among young men who have sex with men [16]. According researchers Fernando Seffner and Richard Parker, “over the past 10 years, public policies in Brazil have increasingly been defined by a biomedical bias that has wasted the accumulated critical knowledge of key sectors of society that first responded to the epidemic: social movements” [17]. During the last decade, the Brazilian response to AIDS has been focused on biomedical strategies, while strategies focused on human rights and engagement of grassroots organizations, developed to fight stigma and discrimination, while promoting user-friendly services have been set aside [6]. Bolsonaro’s administration will have a strong and negative impact on the once socially inclusive, original and daring Brazilian response to HIV/AIDS.

It is estimated that around 850,000 people are living with HIV/AIDS in Brazil. All people living with HIV/AIDS are entitled to receive free treatment through SUS – including clinical and laboratory follow-up and antiretroviral drugs. However, in the current scenario of decreasing public health funds, the well-known Brazilian policy to provide free and universal HIV treatment might be threatened [16]. In a previous interview, Bolsonaro said that “those who have HIV should deal with it and exempt the government of this burden”. A possible lack of consistent access to quality HIV treatment and care could also foster HIV drug resistance, with catastrophic outcomes. In January 2019, Bolsonaro’s administration censored a manual addressing transgender mens’ health that included harm reduction strategies (e.g., need to avoid needle/syringe sharing while using hormones). According to the Ministry of Health, Mr. Mandetta, the HIV/AIDS policy should not “insult the family institution”. The manual was developed by a team of experts from the Brazilian National Department of Surveillance, Prevention and Control of Sexually Transmitted Diseases, HIV/AIDS and Viral Hepatitis (DDAHV), from Brazilian Ministry of Health. A few days later, DDAHV Director Adele Benzaken was exonerated from office. Dr. Benzaken was responsible for scaling up several key strategies, including Treatment as Prevention (TasP), PrEP (pre-exposure prophylaxis) and PEP (post-exposure prophylaxis) among key populations [16].

Brazil has been at the forefront of HIV treatment and prevention. It was the first low- and middle-income country to provide free highly active antiretroviral therapy in 1996, and the first to implement TasP, PrEP and PEP strategies. However, those strategies might be severely impacted by a highly conservative political scenario, funds constrains, lack of a human rights approach and proper dialogue and collaboration with social movements. Mr. Bolsonaro’s highly conservative administration, in conjunction with a sharp decrease in federal funding for public health, education and research, seems to be paving the way for a public health and human rights crisis.