HIV/AIDS, an “Introduction to International Studies” class lecture

I wrote a book, the AIDS Pandemic in Latin America, and have studied public policy and infectious disease for nearly twenty years. Here is a lecture that I wrote (around 2010?) for an “Introduction to International Studies” class. It would need to be updated now; it may also some references to my own experiences, which would need to be removed. But my hope is that it might prove a useful starting place for someone who wants to do a lecture on this topic in a similar class.

Shawn Smallman

HIV/AIDS

Terms:

clades

HIV 1-B

HIV 2

Retrovirus

Cameroon

 

Character of the Virus:

• HIV is not one virus but many
• The result of more than one introduction into humanity
• Two main forms: HIV-1; HIV-2
• Great diversity
• Difficult to create vaccine
• 10 year latency
• initial infection- blood/sex/mother daughter
• flu-like symptoms
• body holds the virus in check
• over time, the virus gradually erodes the immune system’s ability to defend the body
• the person dies of opportunistic infections
• there are different latency periods for different people: my Cuban experience
• medicines don’t work with everyone: my experience in the support group in Sao Paulo
• most people, the medications are effective
• recently realized: in a discordant couple medications prevent transmission in 98% of cases
• means that treatment is prevention
• heart-breaking: long argued that treatment was too expensive
• the only economical way to treat the virus was prevention
• proves to have been a flawed paradigm

History of HIV

• AIDS first recognized in 1981
• Far older
• Genetic tests in 1990s suggested that it could be as old as the 1880s
• Not older or it would have come to the Americas with the slave trade
• Recent work has given us much more insight
• Molecular geneticists have studied deviations in the virus’s genes to understand its origins
• Main form of the virus emerged in Southern Cameroon
• Then moved to Brazzaville –now Kinshasa- in the DRC
• First blood sample with the virus was taken there in 1959
• There were isolated cases in the 60s and 70s
• Norwegian sailor/Canadian mining engineer
• Document the existence of the virus
• The virus came to Haiti in the late 1970s
• About the same it first appeared in the U.S.
• Molecular testing now suggests that it came first to Haiti, most likely with Haitian professionals who had worked in the Congo after it attained independence
• The virus appeared in the U.S in the 1970s, first amongst injecting drug users in New Jersey and California
• Gay men- were the second wave
• Early association of the illness of the disease with drug use and homosexuality
• Shaped how the virus was seen
• People globally associated the virus with the U.S.- moral breakdown of U.S. society
• Many predictions throughout Latin America that the disease could not spread there
• Castro’s rhetoric; Mexico- people resistant to germs; Chile- the Andes an impenetrable shield
• Wasn’t until the mid 1980s that people realized that there was a heterosexual epidemic in Africa and Haiti
• Intense discrimination
• Haitians could not give blood
• SNL skit: “Bad Idea Jeans”
• Man forced to flee NE Brazil: squeezing fruit in the market

 

Medication

• Before 1996 there was little effective treatment
• Vancouver conference- announced that there was treatment but at a cost
• Looked like the world would have two epidemics: one northern and one southern
• Long struggle changed the terms of the debate
• Latin America key to this
• Part of the reason that I want to study region

 

Three Questions

• I had three main questions when I studied HIV/AIDS in Latin America
• Why was the epidemic so diverse despite the cultural unity of the region
• How could a disease spread by the most personal of behaviors be so impacted by INTL forces
• Why had LA avoided the disaster that swept over Africa

 

Brazil

• Brazil played a key role in changing the terms of the debate about providing free medications
• Early history of HIV in Brazil
• HIV associated with U.S.
• First cases appeared- Brazilian newspapers asked “Is Brazil sophisticated enough to have AIDS?” Almost a sense of pride
• Disease associated with urban, wealthy gay people.
• Democratization
• AIDS arrived around 1985, the same year that the military surrendered power in Brazil
• Decision to make drugs available
• Constitution: health a right
• Scale of struggle: generics
• September 11 attacks: US government debated breaking the patent on Cipro, in the aftermath of the anthrax attacks
• I believe about 5 people had died in those attacks
• Reaction of southern governments: we have millions dying, and you are fighting to keep us from breaking patents?
• Force went out from the fight
• George Bush Jr: committed to the fight against HIV
• Saved money: fewer people entering the system for end of life care
• Did so despite broad opposition: U.S; World Bank
• Why: democratization; national pride; Brazilian pragmatism and sexual openness; Brazilian wealth; size
• Anecdote: man who was having his mouth rebuilt
• This policy is now a means to assert their independence from the U.S. and Brazil’s stature on the global stage
• Brazil also a nation of 200 million people
• It is too big of a market for pharmaceutical companies to ignore, or for the U.S. to pressure
• Brazil’s economy is larger than that of Britain
• Extent to which it has change global thinking about HIV/AIDs
• Treatment and prevention are linked
• Can’t talk about the disease without discussing its social context
• Willingness to include sex workers in conversation
• My anecdote from brothel: level of ignorance among sex workers
• Anger in Brazil about restrictions on US aid: could not do anything seen to “promote” sex workers

 

Cuba and the Caribbean

• Association of AIDS with homosexuality and drug use in the U.S.
• Sign of moral breakdown
• Cuba saw itself as being in a health competition with the United States
• Strong response: mass-testing; quarantine/sanatoria
• a success in controlling the virus
• Cuba may have had the lowest HIV rate in the hemisphere
• Self-injection movement; the “rockers”
• Between 89-92 more than 200 people deliberately infected themselves.
• Mostly young men between the ages of 15 and 21
• The publicity about this made the government change its policy
• Now policy like that of other LA nations
• The government is producing triple anti-retroviral therapy, the “AIDS cocktail”
• Hard to get information
• My experience in the sanatoria trying to speak to someone with a government minder there
• Clear improvement: person who wanted clippers for his poodle
• Need to address homophobia

 

South America

• Importance of drugs
• Saw this in Brazil
• Low rates in producer countries
• High rates in consuming countries
• Talk about my experience interviewing crack and injecting drug users in Sao Paulo
• Don’t usually think of drugs being sold within SA
• Great market in Southern urban centers
• Shapes the epidemic of HIV in these areas, which are also urban, and associated with drugs
• In the producing countries: very low rates, generally among gay men
• Great disparity between the two regions in South America
• An HIV positive person in Argentina is a 170 more likely to be a drug user than in Bolivia
• Those S.A. countries that are neither producers nor consumers of drugs have a low rate of HIV
• For example, Chile has a relatively low rate of HIV infection

 

Central America and Mexico

• Rate of HIV relatively low in Mexico
• Less than in the U.S. and some C.A. countries
• In part because historically injecting drug use has been uncommon in Mexico
• About 90% of the cases of HIV transmission in Mexico are by means of sex
• Most cases still amongst gay men, although this is changing
• The same process of the feminization of the epidemic is happening in Mexico as in most of the world
• Rural character of epidemic in Mexico
• Originally urban, but it is now moving to the countryside
• A process that started along the border and has moved south
• Mexico lower rate historically than U.S. 
• Higher rate among housewives than sex workers in Oaxaca
• Migration: young men abroad; outside of small villages for the first time in their life; money; new opportunities; different sexual customs, a lot of stress; experimentation; then they return
• Have to be careful: migrants marginalized
• Newspaper coverage of them in Oaxaca terrible
• According to one account in the newspaper El Tiempo from February 2003:  “50% of women who go to the U.S. prostitute themselves” the headline
• There was no citation in the article for this information
• Complaints about migrants returning, getting drunk, driving
• Migrants are marginalized twice: once in the north, and again when they return
• Still, migration does affect the epidemic
• Tough for wives to talk about safe sex the first night that their husbands return from Chicago
• Strong discrimination
• Central America has multiple epidemics
• One problem: not all governments purchasing generics at a low price
• Might still cost $1,600 a year to provide treatment in some C.A. countries
• In Mexico, the medicines are free (in principle) but not the tests
• The people don’t always receive the medicines that they are promised
• Frente Comun’s findings in Oaxaca
• NGO shut down
• Great tragedy
• How do you do fieldwork in a region with 16 different languages, each of which may have different dialects?
• FC had largely solved this problem

 

Variables that impact the epidemic internationally

• What do we see when we look at the virus globally
• Huge disparities in the level of the virus in different communities
• First thing to notice: not a disease of the poor
• Bolivia and Nicaragua have the lowest rates of HIV infection in the Americas
• Very poor nations
• Argentina and Brazil: higher rates
• Level of economic development not enough to explain disparities in HIV levels
• War: also does not lead to higher HIV rates
• This was a common hypothesis early in the virus’ history
• Look at L.A.
• Countries most impacted by war have lower HIV rates
• Best example: Central America
• Nicaragua: profoundly impact by war in the 1980s
• Low level of HIV
• Honduras another example
• Spared the fighting that swept most of CA
• Highest level of HIV in C.A. ten years ago
• Angola provides another example
• Warfare closes borders and limits mobility
• Tends to undermine the spread of HIV
• What are important variables?
• Have to have some caution
• Global HIV levels highest in Southern Africa
• Swaziland: highest rate in the world, 26%
• Yet the virus came late to South Africa
• Took off in the 1990s
• So the rate of HIV can change quickly
• Africa suffered because it was where the virus began
• Wide-spread before anyone identified the virus and how it spread
• Legacy of colonialism also spread the virus
• In particular, the migration of men without their families into southern Africa
• If you were to identify one factor that spread the virus early in its history, I would argue that it was that
• Migration is key to understanding the virus
• Part of the reason that I worried about Mexico
• But you can also look at countries, such as Senegal, that have been as successful as the United States at containing the virus
• Regulation of sex work in Senegal: successful
• Also important to say that the disease cannot be understood outside of a social context
• A disease spread by the most personal of behaviors, which is shaped by international forces
• That what’s interesting to me: the ability of social change and public policy to fundamentally change how we view an illness and the progress of an epidemic

The epidemic in Southern Africa

• Return again to southern Africa
• Why the was the epidemic so bad there
• I would point to five factors
• One: democratization
• Where nations work with civil society, the epidemic tends to wane
• Much of the region not democratic at the time when HIV first appeared, with the exception of South Africa, which was headed by Nelson Mandela
• State capacity: many governments weak
• Timing: people did not fully understand the virus when it appeared
• Mismanagement: the government of S. Africa deliberately downplayed the virus
• Nelson Mandela overwhelmed with the legacy of apartheid
• Later said that not making HIV a top priority was his main mistake
• But the real problem was his successor Thabo Mbeki
• An HIV denialist
• Fought against making treatment available
• Had to be made to by the courts
•  This was in a country that did have the means to provide the medicines
• situation later changed
• but according to one study by Harvard Medical School, the government’s failure to make these medicines available led to the deaths of more than 300,000 South Africans
• that study is now relatively old
• sure that the number is much higher now
• democratization important to fighting the epidemic
• but it is not enough to stop the virus on its own
• there has to be a will in the government to fight it

Why was the epidemic less severe in Latin America?

• so why did LA avoid such a devastating epidemic?
• Emerged in LA. later
• People had time to react, unlike in Africa
• Emerged during democratization
• People advocated for care
• States had greater capacity
• Cuba: implemented quarantine
• Brazil: free treatment for all
• Most African states did not have the infrastructure at the time to have done that
• Migration important in LA
• But there were not movements within Latin America: say from South America to Mexico on the same scale of the movements in Southern Africa

Social Construction of a Disease

• the point that I am trying to make is about the malleability of diseases
• when HIV rates were so high in Honduras early in the epidemic, the WHO sent a team to study what was happening
• fear: there was a particularly aggressive form of the virus in the country
• not the case
• turns out that the epidemic spreads or declines based on public policy
• if I had to pick one variable to account for the spread of the disease: discrimination
• discrimination drives the sufferers underground
• fosters ignorance
• makes it difficult to implement policies that contain the virus
• in areas where civil society mobilizes to address the epidemic –such as Brazil- the trajectory of the epidemic can change very quickly
• migration: would be the second most important variable
• HIV- surprising because it defies easy answers
• Not simply a disease of poverty
• Does not always explode with warfare
• Much more subtle than that

 

The Future

• around 2000 the future still looked very bleak for the HIV/AIDS pandemic
• Now there are number of positive developments
• First person cured: bone marrow transplant for leukemia
• Not large-scale possibility
• But proof of principle
• In mice, they have altered stem cells to create a form of white blood cell that controls the virus
• If possible in humans: medication may no longer be need
• Work continues on a vaccine
• Now have a virus that is 35% successful
• Not enough to use commercially
• But they are studying the virus to see what antibodies were produced by the people who were protected
• For the first time, we can begin to see the correlates of immunity
• Creates a pathway to create vaccine
• More optimism in the field than I have seeb
• I’ve been following this virus for a long time