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HIV & AIDS in Latin America
The current situation
Latin American countries have been affected by HIV and AIDS in different ways, and to different extents. Despite many differences between the epidemics of individual countries, high levels of poverty, migration, homophobia and HIV-related discrimination are apparent throughout the region, and these factors present common barriers to overcoming the crisis.2
In this page, we use the term Latin America to refer to the countries of South and Central America, excluding Suriname, Guyana, French Guyana and the Caribbean islands, which we discuss in our HIV & AIDS in the Caribbean page. AVERT.org also has an individual country page about AIDS in Brazil.
The scale of Latin America’s HIV epidemics
Although HIV prevalence in Latin American countries is relatively low compared to the rates found in many parts of Africa, the number of people affected is still substantial. No country in the region has experienced a significant drop in HIV prevalence; most global regions have experienced declines in new HIV infections between 2001 and 2011, but it has remained constant in Latin America.3 4 As well as affecting millions of people’s lives, HIV and AIDS have had widespread social and economic implications for Latin American countries.5
More than half of Latin Americans living with HIV reside in the region’s four largest countries: Brazil, Colombia, Mexico and Argentina. Brazil is home to 490,000 people living with HIV – more than any other Latin American country – but due to the large size of its population, this equates to a relatively low HIV prevalence of 0.3 percent. The most severe epidemics are found in smaller countries such as Belize, Guyana and Suriname, which have an HIV prevalence of 2.3 percent, 1.1 percent and 1.0 percent respectively.6 The majority of countries in the region have prevalence rates of less than 1 percent, but the prevalence among specific groups, such as men who have sex with men and sex workers, is often very high. For more figures, see our Latin America Statistics Page.
Key affected groups
Men who have sex with men
Men who have sex with men (MSM) account for a key share of HIV infections in Latin America.7 This problem is largely hidden, since homophobia and ‘machismo’ culture are common throughout the region and sex between men is highly stigmatised. The extent of HIV infection among MSM is downplayed in many countries, and prevention campaigns often neglect this group.
An example is Guatemala, where critics have disputed the government’s claim that the country’s HIV epidemic is primarily heterosexual. Activists within the country argue that the official statistics, which attribute around 15 percent of HIV infections to MSM, do not reflect the reality of Guatemala’s epidemic. Some claim that the real figure is closer to 40 percent.8 As one civil society worker explained, MSM are often hesitant to reveal how they became infected and many are mistakenly classed as heterosexual:
“Annual spending estimates… confirm that many Latin American countries make little effort to provide AIDS-related services that address the needs of men who have sex with men.”
“Unless he’s a total queen, a man will always be [counted as] heterosexual. Plus, people don’t want to be recognised [as homosexual]”.Ruben Mayorga, civil society worker, Guatemala City9
On the other hand, other Latin American countries – such as Mexico and Peru - openly acknowledge that their epidemics are primarily driven by MSM. In Mexico, the government has appointed Jorge Saavedra, an openly gay, HIV positive man, as head of its leading AIDS agency, which has helped the country to make significant progress in addressing the problem. Among other initiatives, Saavedra has helped to launch a provocative anti-homophobia campaign.10 In Peru, a large amount of research is being conducted relating to HIV and MSM. The country is now recognised by researchers around the world as an important base for studies of HIV infection among this group.
“It’s a very concentrated epidemic, and we have a very good relationship with the community.”Jorge Sanchez, Peruvian epidemiologist11
Overall 0.4 percent of Peruvian adults are living with HIV, but HIV prevalence is much among MSM at 12 percent.12
For the most part, the epidemic among MSM in Peru has not spread to other segments of the population, but there is a risk that this will soon occur. As is the case in other Latin American countries, large numbers of MSM in Peru do not identify themselves as homosexuals, and have sex with women as well as men. MSM therefore form a ‘bridge’ population - rising rates of infection among this group are likely to aggravate the spread of HIV among the heterosexual population.13 In both Colombia and Ecuador, it has been reported that a large number of women with HIV have been infected by their husbands or regular partners who have acquired infection through sex with another man.14
HIV transmission between sex workers and their clients is recognised as a major factor in the spread of HIV in several Latin American countries. The extent to which sex workers are affected varies between areas – one study of different countries, which looked at brothel-based sex workers, found HIV prevalence rates ranging from 0 percent to 6.3 percent .15 However, higher rates are found among street-based sex workers, who are harder to reach with HIV prevention services. In Guatemala, for instance, surveillance suggests that 15 percent of street-based sex workers are living with HIV.16 Similarly, in surveys of sex workers in Brazil, HIV prevalence was found to be 4.9 percent, compared to a national prevalence of 0.3 percent.17 Since condom use is often low among regular sexual partners, male clients of sex workers may pass on HIV to their wives and girlfriends once infected.
Injecting drug users
Drug use is common in many Latin America countries. A number of Southern Cone countries (those found in the southernmost area of South America,) have shifted from dictatorships to democracies in recent history, and this goes some way towards explaining the rise in drug use - for some people, liberation led to experimentation, as one Argentinian explained to reporters:
“Around 1986 there was a tremendous fascination, especially among intellectual circles, with intravenous drugs. People wanted to try everything, and I think it was in some way a result, a legacy, of the military dictatorship because during the dictatorship you couldn’t do anything”18
In Argentina, injecting drug use has been a major driving factor behind the spread of HIV, with 49.7 percent of IDUs living with HIV; this figure is 48 percent in Brazil.19 Cocaine and heroin are the most commonly injected drugs, with cocaine users facing the greatest risk of HIV infection because they inject more frequently than heroin users.20
Harm reduction programmes, including needle exchanges, have been implemented in Brazil and are thought to have contributed to declining HIV prevalence rates among injecting drug users in several Brazilian cities.21 22 Some harm reduction activities have also been carried out in Argentinean cities. In general, though, Argentina lacks harm reduction programmes at national, state and local level.23 This is despite a severe HIV epidemic among injecting drug users – one study carried out in Buenos Aires, for instance, found an HIV prevalence rate of 44 percent among this group.24 Other Latin American countries face severe restrictions in carrying out programmes of this kind, due to restrictive laws and a lack of political support.25
In several Southern Cone countries, ‘pasta base’ or ‘paco’ – a form of cocaine, which is smoked – has become extremely popular in recent years, both among poorer populations and the middle-classes.26 Although the rise in popularity of pasta base has generally had negative health implications, there is evidence to suggest that some drug users have started smoking cocaine in this form instead of injecting it. While there is currently little solid evidence, this may be reducing the level of needle-sharing in the region, thereby reducing the number of people becoming infected with HIV through injecting drug use.27 28
In other countries, such as Bolivia, Peru and Ecuador, the spread of HIV through injecting drug use has been limited in scope. In Chile, data are scarce, and in Venezuela the role of injecting drug use in the HIV epidemic is negligible. However, the availability of heroin is increasing in these countries, which may lead to a change in the situation in coming years.29
Migration occurs on a large scale throughout Latin America. Patterns of migration have been particularly well documented in Central America, where civil conflicts and political conditions in the past created a high degree of movement between countries that continues today. International migration, particularly between Mexico and the United States, is also increasingly common.30 Although it was not well documented in previous years, studies have now established that the movement of people is linked with the spread of HIV in Latin America.
Several factors may put migrants in this region at a high risk of HIV infection: poverty, violence, few available health services, increased risk-taking, rape, loneliness, and contact with large numbers of sex workers. In some cases, migrants themselves are sex workers, or resort to sex work while travelling in order to survive.31 In one Mexican study, less than 20 percent of male migrants reported having used condoms, and 8 percent of the women surveyed said they had been raped.32
As migration increases, the epidemics of individual countries are becoming less well defined, and the problems surrounding the crisis in each country are merging.
Different countries, different problems
Latin America is a vast region – in some ways it is misleading to talk about the ‘Latin American epidemic’, because of the scale of the lands, cultures and populations involved. Although there are many close links and similarities between countries, it should be recognised that HIV and AIDS in Latin America is not a homogeneous problem, and that each country faces a unique situation. Below are some examples of the problems faced in particular countries.
A violent civil conflict between left-wing guerilla groups and right-wing paramilitaries has raged for decades in Colombia, causing suffering on a huge scale. Economic decline, violence, murder and drug trafficking are just some of the results of the fighting.
Gay men, who are more heavily affected by Colombia’s HIV/AIDS epidemic than any other group, have faced violent oppression from both sides of the conflict. Armed groups have also capitalised on the social fears that surround HIV and have victimised HIV positive people; in one incident, the AUC (the United Self-Defence Forces of Colombia, the country’s most powerful paramilitary force) demanded that all HIV positive people in Barrancabermeja abandon the city within twenty-four hours.33 The AUC has also been responsible for oppressing gay men. In one reported example, a young gay man was forced to walk around his neighbourhood naked with a sign reading “I am gay” tied to his neck.34
On the other side of the political divide, FARC (the Revolutionary Armed Forces of Colombia) is known to have forced residents of areas they control to take HIV tests. At least one activist who spoke out about this policy was forced to flee the country following death threats.35
The stigma and discrimination created by these groups is stopping people from talking about HIV, reducing awareness and therefore putting more people at risk. It is also hindering HIV prevention programmes, and campaigns to support and provide treatment for those who are already living with HIV.
As well as fuelling stigma, the civil conflict has also displaced an extremely large number of people within Colombia, and caused many to migrate to neighbouring countries.36 Since migrants may face a higher risk of HIV infection, this high level of movement could be having an effect on the epidemic.
In Honduras, where HIV is mainly spread through heterosexual sex, a severe epidemic has developed among communities of Garifuna – descendents of Nigerian slaves, who have maintained their culture in the country for over two hundred years. Widespread poverty, poor access to health care and the popularity of myths about HIV are some of the factors putting Garifuna communities at risk of HIV infection.
Already highly stigmatised as a minority group, Garifuna now face added prejudice as a result of HIV.
“If you go to the street and ask the people about AIDS, many of them think ‘AIDS, it’s not in my house – it’s in the house of the Garifuna” Sergio Flores, doctor, La Ceiba37
Honduras has a large population of people living with HIV and the high prevalence among the Garifuna community is only part of the problem. But there is a risk that the stigma surrounding this group will create a ‘somebody else’s problem’ attitude, where members of the general population falsely believe that they are not at risk of becoming infected with HIV.
In Guatemala, the sizeable Mayan population is another example of a stigmatised group that may face increased risk of HIV infection. Mayans generally have a lower socio-economic status than other Guatemalans, meaning that they have less access to health care services. Many Mayan communities have trouble speaking Spanish (the most commonly used language in the country), which also makes it hard for HIV prevention campaigns to get through to them.
Although the spread of HIV among Mayans has not been fully evaluated, the results of a small-scale study carried out in one clinic suggest that Mayans may be three times more vulnerable to HIV than other members of the population.38
Indigenous communities in Guatemala have particularly been overlooked by HIV prevention programmes which need to be more accessible, culturally appropriate and tailored to their specific health beliefs. Rising HIV and AIDS rates have been reported amongst such communities. If their vulnerability to HIV is not seriously addressed, misinformation and cultural taboos will continue to increase the risk of contagion.39
Nicaragua is proportionally less affected by HIV/AIDS than any other country in Central America, with 0.2 percent of the adult population living with HIV.40 However, there is currently potential for a more severe epidemic. One major issue is the stigma surrounding condom use.41 Negative attitudes towards condoms may discourage young people from using them, even though many are aware of the protection that condoms can provide. One study of adolescents that had been sexually active in the previous three months suggested that only 21 percent had used a condom, despite the fact that most knew that condoms could prevent HIV.42
HIV testing in Nicaragua is also a concern, as there are currently insufficient voluntary counselling and testing services.43 There is only one central laboratory with government authorisation, and this laboratory processes all HIV tests. This can cause delays of up to 3 months before individuals receive confirmation of their HIV status.44 Such a long wait for results causes a lot of anxiety for the individuals concerned, and may dissuade people from accessing testing in the first place.
HIV prevention in Latin America
Overall, HIV prevention efforts in Latin America have been small-scale, slow, and largely dependent upon non-governmental organisations and international programmes.45 This is partly due to poverty and a shortage of resources throughout the region, but lack of political leadership and will has also played a role.
At the same time, several countries have put a lot of time and effort into raising awareness about HIV, promoting condom use and encouraging testing, among other schemes. Some of these interventions have been enormously successful, and have helped to reduce HIV incidence among certain groups in particular areas. Despite the overall picture, in terms of individual prevention campaigns Latin America has some of the strongest and most creative programmes found anywhere in the world.
Many of the most effective prevention efforts have taken place in Brazil, where civil society groups and non-governmental organisations have helped to fight the stigma surrounding AIDS and to raise awareness about the subject. The government itself has vigorously promoted condom use, through media campaigns and advertisements. They have also given away large numbers of free condoms, distributing 25 million at the 2006 pre-Lenten festival (held annually in Rio de Janeiro) alone.46 HIV prevention efforts have focused on high-risk groups such as sex workers and men who have sex with men, and attempts have been made to reduce the stigma that these groups face. Needle exchanges have also been opened in many areas, which has helped to reduce the HIV prevalence among injecting drug users.47
Across Latin America, governments have used television, radio, billboards and posters as means of raising awareness about AIDS. Various messages have been promoted by these campaigns, including condom promotion and anti-discrimination messages. In many cases, though, these messages are not getting through. Young people in particular are often more likely to respond to folk wisdom and inaccurate information circulated by their peers than to these adverts. Sex education in schools can help young people to protect themselves, but recent reports suggest that the subject is absent in many Latin American schools, and inadequate where it is available.48
Some of the most impressive prevention campaigns in the region have been carried out through outreach work, which takes anti-HIV messages directly to the people at risk. In Tijuana, Mexico, a mobile health clinic travels to areas of the city that health workers usually avoid, providing HIV testing and clean syringes to injecting drug users.49 In Mexico City, a former sex worker runs an initiative that provides counselling and HIV testing services to sex workers. Along with her son, she also sits in her car overseeing sex worker’s transactions and transporting them to ensure that they have security at work.50 In Belize, a government program called Youth for the Future works with gang members in an attempt to link violence reduction with HIV/AIDS education. Gang members are provided with information and free condoms, both on the street and at the organisation’s resource centre.51
Although they are no doubt making a large impact in the areas in which they are carried out, these outreach schemes are only small-scale. On a wider scale, most countries still need to expand harm-reduction programmes for injecting drug users, raise a greater level of awareness about HIV, tackle the stigma surrounding AIDS, improve testing facilities and encourage more people to use condoms, among other things. For the most part, governments have neglected high infection rates among vulnerable groups, and rising rates among the general population.
“[Latin American countries] are far behind when it comes to prevention for highly vulnerable populations like men who have sex with men and injecting drug users. My conclusion is it looks easier for a government to deal with treatment than prevention.”Luiz Loures, Brazilian epidemiologist52
HIV treatment in Latin America
Since highly active antiretroviral therapy (HAART) became available to treat HIV in the late 1990s, the distribution of this treatment across the Latin American region has been impressive. It is estimated that, as a result of combination antiretroviral therapy, people living with HIV in the Latin American region have gained some 834,000 years of life between 2002 and 2006.53 In 2011, an estimated 68 percent of those needing antiretroviral therapy in Latin America were receiving it.54
Brazil has led the way in terms of ARV provision, with an internationally renowned treatment campaign. Since 1996, the government has made treatment provision a priority, and has made aggressive efforts to drive down drug prices. Under Brazil’s policy, all people with advanced HIV infection are eligible for ARVs through the public health system. This has improved the health of thousands of people living with HIV, and allowed them to live relatively normal, healthy lives. It has been reported that deaths from AIDS and HIV-related hospitalisations in Brazil have fallen by 50 percent and 70-80 percent respectively since 1997.55
Treatment coverage is also high in Argentina, Chile, Costa Rica, Mexico, Panama and Venezuela.
Stigma and discrimination in Latin America
“Is AIDS a big problem in Chile?” people often ask me, to which the only possible response is yes: If you get AIDS in Chile, it is a big problem.”
HIV/AIDS is not confined to groups such as gay men, injecting drug users or sex workers - in Latin America or elsewhere. Yet people continue to associate the epidemic with these groups, which are already highly stigmatised by people who have moral objections to their lifestyles.
Additionally, HIV carries its own stigma. Since HIV and AIDS directly affect less than 1 percent of the population in most Latin American countries, the epidemic has a low visibility and many people are ignorant or fearful of HIV and AIDS. Many people are unclear about the ways in which HIV can be transmitted, and mistakenly believe that everyday contact with an HIV positive person will put them at risk.
“[His family] fed him in the same plate ever, and like that, he had his own cup, glass, fork, knife, spoon, you get the idea, he was isolated by his own family. His razors where always trashed, and his tooth brush too, also, no one was ever taking care of his pills... One week before he died, in the middle of a discussion because of he having AIDS he was thrown out of his house by his older sister... he died alone.” Lover of an HIV positive man in Honduras56
The following examples further illustrate how prejudice has caused immense suffering for people living with HIV in Latin America:
- In Peru, soccer player Eduardo Esidio was removed from the University Sports Club professional team when it was discovered that he was HIV positive. The club’s directors argued that if he was allowed to stay, he might be a health risk to other players.57
- In Costa Rica, officials tried to transfer a teacher from a small-town school when it was found that he was HIV positive. The transfer was eventually stopped, but only after protests from citizen groups forced the Ministry of Education to intervene.58
- In Mexico, there have been numerous cases of HIV-related discrimination involving health-care workers. HIV tests are sometimes applied to those who are perceived to be at risk of infection without their consent, and patients who test positive are often isolated from other patients in a hospital.59
- In Brazil, the results of a study published in 2006 indicate that children living with HIV in SÃ£o Paulo face a high level of stigma as they grow up.60
These are just a few examples of HIV-related discrimination, but situations such as these occur on a regular basis in Latin America. This is a major barrier to the fight against AIDS, partly because fear of stigma often prevents people from accessing testing and treatment. Discrimination also stops people from talking openly about HIV and AIDS, which leads to a climate of silence in which people are unaware that they may be at risk. On top of these factors, the prejudice that HIV positive people face also causes them a great deal of suffering on a personal level, at a time when they are already dealing with the burden of being infected.
“Although there is a law against it, my husband, who is dead now, was fired when they found out he was sick. My relatives refused to take us in, my daughter and I, because we are [HIV] carriers”Peruvian woman marching on World AIDS Day61
Some Latin American countries have taken steps to address the problem of stigma and discrimination, mainly through media campaigns to raise awareness about HIV and AIDS. The Pan-American Health Organization have campaigned to reduce discrimination against sexual minorities and people living with HIV in the provision of services. Peru, Columbia, Brazil and Mexico have recently launched new actions plans, strategies and guides to raise awareness among health providers and government officials of the importance of non-discrimination on the basis of sex, race, religion, sexual orientation and HIV status.62 HIV positive people themselves have also done a great deal to fight this problem, forming citizen groups and standing up to discrimination through protests and campaigns. Governments must continue to support these groups, and expand their own anti-stigma efforts.
The future of HIV and AIDS in Latin America
HIV/AIDS in Latin America is sometimes referred to as a ‘hidden’ crisis: awareness is low, governments have been relatively inactive, surveillance of those affected is sometimes unreliable and stigma has stopped people from conducting open and frank debate about the problem. This is not just an issue within Latin America though – the international community has also overlooked the region. In the face of a more severe situation in Africa, rapidly rising infection rates in Asia and higher profile epidemics in richer parts of the world, Latin America has often been neglected.
While it is understandable that more attention has been devoted to other areas that have been worse affected, many have been frustrated by the lack of notice given to Latin America’s epidemics. The tendency of some people to compare Latin America’s AIDS problem with those of other regions is also a point of contention for AIDS activists in the region:
“The suggestion that the region has somehow been ‘luckier’ than others is reprehensible. “Is AIDS a big problem in Chile?” people often ask me, to which the only possible response is yes: If you get AIDS in Chile, it is a big problem… Examining successes and obstacles to future progress is far more useful than ranking human tragedy on a scale”Tim Frasca, author and AIDS activist in Chile63
The region is gradually gaining more notice from the international community though, largely due to the success that has been achieved in providing treatment. As well as continuing to provide ARVs and care for people living with HIV, prevention schemes now need to be improved. Efforts to tackle stigma and discrimination must run parallel to these programmes, because prevention is likely to be ineffective while the fear and ignorance surrounding AIDS is so widespread.
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