Sexuality Policy Watch

Understanding the dismantling of the AIDS response in Brazil

Rio de Janeiro, May 27th, 2019

Brazilian Interdisciplinary AIDS Association (ABIA)

After the justifications given by the Ministry of Health for the establishment of the new structure of the Department responsible for the response to the HIV/AIDS epidemic – among the measures is the renaming of the former Department of Surveillance, Prevention and Control of STIs, HIV/AIDS and Viral Hepatitis to the Department of Diseases of Chronic Conditions and IST (DDCCI) – ABIA publicly declares its assessment of the serious error of this action and demonstrates the mistakes made by Decree 9795 of May 17, 2019.

The new structure will NOT promote greater integration between the aggregated areas in the new Department. The pathologies gathered there (verminosis, together with viral infections – such as HIV and Hepatitis – and bacterial infections – such as gonorrhea, tuberculosis and leprosy) have significant differences in terms of forms of transmission, impact scales, population segments directly affected, social dynamics, indicators and epidemiological factors, among other issues. The social conditions of HIV and AIDS and verminosis, for example, are completely different. The HIV/AIDS epidemic particularly affects gay youth and transgender people, and the response requires an approach focused on combating stigma. On the other hand, verminosis particularly affects children and the response depends on a focused approach to basic sanitation.

Therefore, in the absence of common issues among the pathologies, there is a risk of fragmentation of the new Department. In addition to the possible dispute over resources, the addition of such disparate pathologies could compromise the production of epidemiological indicators and the efficiency of public health policy. The new Department may become a Babel tower in which there will be no dialogue between the different areas that compose it. This will NOT promote integration, as stated by the Ministry of Health, but rather, dilute resources and waste the expertise accumulated in each of these areas. Fragmentation may result in precarious responses to diseases that are already precarious.

It is also worth mentioning the mistake of the new management when it did away with the communication unit of the old Department, responsible until then for the autonomous development of communication strategies and campaigns, especially for prevention. These campaigns were one of the most important pillars in Brazil’s response to the HIV/AIDS epidemic and are equally fundamental for other STIs. What are the prevention strategies that will now ensure the reduction of HIV/AIDS infections and other STIs?

The Ministry of Health also announced that “the budget of the area has increased from US$427 million[i] in 2018 to US$553 million in 2019[ii]“. For ABIA, this data is inaccurate since this accounting increase to the Department’s budget occurred because of the incorporation of the budget for the purchase of drugs for Hepatitis C in the transition from 2018 to 2019. Last year, the Department’s budget was a little over US$427 million. With the increase of US$75 million in medicines for Hepatitis C, it reached US$503 million.  With the 2019 budget of US$503 million, we observed that the real increase was US$50 million[iii] and not US$126 million, as the Ministry said.

We also emphasize that the future of the purchase of medicines is a matter of great concern since the decree transfers to the Department of Pharmaceutical Assistance (DAF) the responsibility for the acquisition and distribution of all strategic inputs (Article 31), such as medicines. The DDCCI will only be responsible for “defining the programming of critical inputs” (article 38).  In this sense, the decree potentially weakens structures and functions related to the bidding, purchase, storage, and distribution of antiretroviral drugs. This means that the vast expertise developed in these fields by the technical staff of the former Department will be discarded, even though it has been essential to ensure significant reductions in drug prices over the years. In addition, it has been essential in managing distribution to patients, taking political positions on abuses committed by pharmaceutical companies, among other issues. Under DAF management, there is no guarantee that there will be the necessary flexibility for emergency purchases or the capacity for political articulation for more effective price negotiations or even a storage and distribution dynamic that is properly articulated with monitoring and epidemiological control.

It is also necessary to situate the potentially deleterious effects of Decree 9795 in relation to the broader health budget scenario. Due to the effect of Constitutional Amendment 95, which imposes the freezing of the available resources for application in health, the sector already loses US$2,137 billion in 2019. In addition, Ministry of Health Ordinance 3992/2017 imposed the end of the Single Unified Health System (SUS) financing blocks, hindering the maintenance and expansion of actions to prevent and assist the HIV/AIDS epidemic at the state and municipal levels.

The newly structured Ministry of Health also has short deadlines to present its budget proposal for 2020. In view of the new structure proposed for the Department, it is not clear how resources will be allocated for the response to HIV/AIDS, especially for the purchase of medicines, which is the most substantive component of this budget item.

We also regret that the Ministry of Health has not made any public response in relation to the criticisms presented by civil society on the lack of transparency and democratic rupture.  The changes announced by the decree emanate from a unilateral decision of the higher levels of the Ministry of Health that completely ignore the instances of participation and consultation that make up the institutional response to the epidemic and in which the decentralized levels of management and civil society participation. This decision-making procedure makes it clear that it is not a mere “technical adjustment”, but a clearly undemocratic measure.

Finally, ABIA points out that it is flagrant that this semantic change in the name of the Department aims to conceal HIV/AIDS, a terminology that since the 1980s has been synonymous in Brazil and in the world with citizen participation, the fight against inequalities, the protection of human rights and respect for diversity.  We recall that in the 1980s, in response to the outbreak of the epidemic, activists around the world adopted the slogan “silence = death” to give visibility to HIV/AIDS on the agenda of national and international public policies. By making HIV/AIDS invisible, the current Brazilian government restores the policy of silence and death, because this semantic change allows the State to gradually “take away responsibility” for effective responses to the effects of an epidemic that affects almost 1 million Brazilians and causes about 12,000 deaths per year.

The uncertainties resulting from the restructuring proposed in Decree 9795 – and especially for the lack of transparency in the conduction of this process – generate anxieties and concerns for the thousands of Brazilians impacted directly and indirectly by the HIV/AIDS epidemic. We then question the Ministry of Health about what will be done to respond to these people. In addition, we present below a set of points that deserve clarification:

In a context in which several states do not invest enough in the response to AIDS and in which it is signalized for the end of the blocks of financing of the SUS, what is the impact that the reduction of the importance of the HIV/AIDS on the federal level will have at the local level?

  • What is the message that this dismantling of the Department of Surveillance, Prevention, and Control of STIs, HIV/AIDS and Viral Hepatitis, which has become an international reference, sends to the world – that is, to the global agenda of response to HIV/AIDS?
  • In relation to the DDCCI, what will be the level of autonomy of each one of the coordination and programs that cover different areas and strategies of public health?
  • What will be the distribution of financial resources within the DDCCI?
  • What stage has been reached in the preparation of the budget proposal for 2020 and what changes, resulting from the restructuring, in the amounts being requested for each department, coordination, and program? And, in particular, in relation to the area of HIV/AIDS?
  • What will be the mechanisms for monitoring and evaluating the implementation of the resources allocated to each pathology?
  • What impact will this restructuring have on the fulfillment of goals already assumed by the country such as the elimination of Hepatitis C by 2030 (according to the national plan approved in 2017) and the elimination of AIDS by 2030 (according to the UN declaration signed by Brazil in 2016)?

[i] R$1,7 billion BRL.

[ii] R$2,2 billion BRL.

[iii] US$25 million of this increase refer to the purchase of ARV, that has gone from US$301,8 million in 2018 (as informed by Access to Public Governmental Information Law under request N. 25820002168201945) to US$327 million in 2019 (as informed on Brazil’s Parliament page).

*Exchange rate USD-BRL from Bloomberg on May 29th, 2019.

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