Divine targets: youth at the centre of Catholic and Pentecostal responses to HIV and AIDS in Brazil

This study explored the focus on youth in Catholic and Evangelical Pentecostal discussions about and responses to HIV and AIDS in Brazil. Key informant, oral history and in-depth interviews revealed a disconnect between young people's views of themselves as leaders in their religious institutions' responses to HIV and other social problems, and adult religious leaders' views of young people as vulnerable and in need of being ‘saved’. Religious leaders presented young people as institutional commodities, emphasizing their symbolic value as signs of the health and future of their churches. We explore the unofficial exchange between religious institutions and young people, who benefited from the leadership opportunities and communities provided by their churches and youth groups. We discuss the political economy of youth in religious institutions' responses to HIV and AIDS within the context of Brazil's high levels of religious mobility as well as the broader, global commodification of spirituality and religion.     

Strange bedfellows: the Catholic Church and Brazilian National AIDS Program in the response to HIV/AIDS in Brazil

The HIV epidemic has raised important tensions in the relationship between Church and State in many parts of Latin America where government policies frequently negotiate secularity with religious belief and doctrine. Brazil represents a unique country in the region due to the presence of a national religious response to HIV/AIDS articulated through the formal structures of the Catholic Church. As part of an institutional ethnography on religion and HIV/AIDS in Brazil, we conducted an extended, multi-site ethnography from October 2005 through March of 2009 to explore the relationship between the Catholic Church and the Brazilian National AIDS Program. This case study links a national, macro-level response of governmental and religious institutions with the enactment of these politics and dogmas on a local level. Shared values in solidarity and citizenship, similar organizational structures, and complex interests in forming mutually beneficial alliances were the factors that emerged as the bases for the strong partnership between the two institutions. Dichotomies of Church and State and micro and macro forces were often blurred as social actors responded to the epidemic while also upholding the ideologies of the institutions they represented. We argue that the relationship between the Catholic Church and the National AIDS Program was formalized in networks mediated through personal relationships and political opportunity structures that provided incentives for both institutions to collaborate.     

The impacts of AIDS movements on the policy responses to HIV/AIDS in Brazil and South Africa: A comparative analysis

Abstract

Brazil and South Africa were among the first countries profoundly impacted by the HIV/AIDS epidemic and had similar rates of HIV infection in the early 1990s. Today, Brazil has less than 1% adult HIV prevalence, implemented treatment and prevention programmes early in the epidemic, and now has exemplary HIV/AIDS programmes. South Africa, by contrast, has HIV prevalence of 18% and was, until recently, infamous for its delayed and inappropriate response to the HIV/AIDS epidemic. This article explores how differing relationships between AIDS movements and governments have impacted the evolving policy responses to the AIDS epidemic in both countries, including through AIDS programme finance, leadership and industrial policy related to production of generic medicines.     

Beyond faith-based organizations: using comparative institutional ethnography to understand religious responses to HIV and AIDS in Brazil

Religious institutions, which contribute to understanding of and mobilization in response to illness, play a major role in structuring social, political, and cultural responses to HIV and AIDS. We used institutional ethnography to explore how religious traditions--Catholic, Evangelical, and Afro-Brazilian--in Brazil have influenced HIV prevention, treatment, and care at the local and national levels over time. We present a typology of Brazil's division of labor and uncover overlapping foci grounded in religious ideology and tradition: care of people living with HIV among Catholics and Afro-Brazilians, abstinence education among Catholics and Evangelicals, prevention within marginalized communities among Evangelicals and Afro-Brazilians, and access to treatment among all traditions. We conclude that institutional ethnography, which allows for multilevel and interlevel analysis, is a useful methodology.     

Outcomes and processes at a camp for youth with HIV/AIDS

The impact of HIV/AIDS on the lives of youth with this chronic illness suggests the need for additional support as youth develop. Summer camp can serve as a therapeutic intervention for youth with HIV/AIDS. Using a case study employing observations, focus groups, and interviews, we examined outcomes associated with participation in a camp for youth with HIV/AIDS, and program processes that influenced outcomes. Findings showed that camp played a major developmental role for youth. Three outcomes of camp emerged: (a) forming caring connections (awareness of commonalities, lack of isolation); (b) feeling reprieve and recreation (fun activities, anticipation of and reflection on camp, sense of freedom); and (c) increasing knowledge, attitudes, and skills (conflict management, disclosure, skill learning and education, medication adherence). Processes included formal and informal education, staff-camper interactions, long-term relationships, outside-of-camp support, activities, planning for camper needs, accessibility, and freedom from worry. We discuss implications for youth programs.     

Assessing business responses to HIV / AIDS in Kenya

A consulting firm conducted interviews with managers of 16 businesses in 3 Kenyan cities, representatives of 2 trade unions, focus groups with workers at 13 companies, and an analysis of financial/labor data from 4 companies. It then did a needs assessment. The business types were light industry, manufacturing companies, tourism organizations, transport firms, agro-industrial and plantation businesses, and the service industry. Only one company followed all the workplace policy principles recommended by the World Health Organization and the International Labor Organization. Six businesses required all applicants and/or employees to undergo HIV testing. All their managers claimed that they would not discriminate against HIV-infected workers. Many workers thought that they would be fired if they were--or were suspected to be--HIV positive. Lack of a non-discrimination policy brings about worker mistrust of management. 11 companies had some type of HIV/AIDS education program. All the programs generated positive feedback. The main reasons for not providing HIV/AIDS education for the remaining 5 companies were: no employee requests, fears that it would be taboo, and assumptions that workers could receive adequate information elsewhere. More than 90% of all companies distributed condoms. 60% offered sexually transmitted disease diagnosis and treatment. About 33% offered counseling. Four companies provided volunteer HIV testing. Almost 50% of companies received financial or other external support for their programs. Most managers thought AIDS to be a problem mainly with manual staff and not with professional staff. Almost all businesses offered some medical benefits. The future impact of HIV/AIDS would be $90/employee/year (by 2005, $260) due to health care costs, absenteeism, retraining, and burial benefits. The annual costs of a comprehensive workplace HIV/AIDS prevention program varied from $18 to $54/worker at one company.     

Policy responses to HIV/AIDS in Central Asia

The countries of Central Asia (Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan) are confronted with one of the fastest growing HIV/AIDS epidemics worldwide, largely driven through injecting drug use. This article, based on a review of academic and grey literature, explores how they have responded. We find major similarities and differences across the region. At one extreme is Turkmenistan, which denies that there is any problem, does not offer harm reduction services or HIV/AIDS treatment and does not report any meaningful data to the international community. Uzbekistan is also pretty closed to outside influences, has discontinued its opioid substitution project and shares with Turkmenistan the legal prohibition of male-to-male sex. Kyrgyzstan originally led many progressive approaches in the region and, like neighbouring Tajikistan, has received substantial assistance by international agencies, in particular the Global Fund. Kazakhstan, with a much higher gross domestic product per capita, has taken on the financing of harm reduction activities through its national budget and has liberalised its drug policies. Yet, across the region punitive approaches to injecting drug use and people living with HIV/AIDS persist as do stigma and discrimination, while coverage with harm reduction programmes and treatment services is still low although with substantial variation across countries.     

HIV/AIDS and sexual behaviour among youth in Zambia

This study was carried out in selected urban areas in Zambia; its objective was to examine the sexual networking and activities of urban youth in Zambia: specifically to determine how sexual behaviour among young people might influence the course of the AIDS epidemic and also to suggest policy interventions. Sexual behaviour among young people both in-school and out-of-school, aged between 12 and 25, may be vital in influencing the spread of AIDS in Zambia. The results indicate that sexual matters are discussed with close friends of the same sex and peer group, or with cousins who are of the same age. Sometimes grandmothers are consulted for advice by co-resident grand-daughters. Girls and boys engaged in sex or thought about engaging in sex at quite an early age. Girls discussed their intentions about sex with their close friends, many of whom appeared poorly informed about sex themselves. The general views of both sexes about STDs should be a source of concern. The youth do not seem to take STDs seriously basically because most of them, aside from AIDS, are curable. Many young people do not regard AIDS as a threat to their lives and do not even consider it as a hindrance to sexual relationships. A number of recommendations are made for information and education of young people, parents and teachers.     

Multisectoral responses to HIV/AIDS: applying research to policy and practice

The KwaZulu-Natal Enhancing Care Initiative is a program developed by a consortium of members who represent 4 sectors: academia, government, nongovernmental and community-based organizations, and the business sector. The Initiative was formed to develop a plan for improved care and support for people with HIV/AIDS and who live in resource-constrained settings in the province of KwaZulu-Natal, South Africa. A needs analysis helped to determine the following priorities in prevention, treatment, care, and support: training, grant-seeking, prevention, and care and treatment, including provision of antiretroviral therapy. A partnership approach resulted in better access to a wider community of people, information, and resources, and facilitated rapid program implementation. Creative approaches promptly translated research into policy and practice.     

Household and community responses to HIV and AIDS in developing countries

Household and community responses to HIV and AIDS are shaped by the contexts in which women, men and children live and socialize. In this study carried out in the Dominican Republic, Mexico, India, Tanzania and Thailand, factors relating to economic resources and gender influenced the forms of care and support made available to people living with HIV and AIDS. Adults and children in poorer households and communities suffered most. Beliefs about sexual transmission were influenced by what was, and was not, thought to be appropriate conduct for men and women. Prevailing gender relations affected what care was provided, by whom, to people living with HIV and AIDS. Future programmes of HIV-related prevention and care should place more stress on the vulnerability of poorer households and women. More attention needs to be paid to investing in, and supporting, those in the informal sector (mostly women) who provide care. Furthermore, the responsibilities of men to appraise their own HIV-related risk and to protect and support their partners should be addressed.     

Brazil and access to HIV/AIDS drugs: a question of human rights and public health

I explore the relationship between public health and human rights by examining the Brazilian government's policy of free and universal access to anti-retroviral medicines for people with HIV/AIDS. The Brazilian government's management of the HIV/AIDS epidemic arose from initiatives in both civil society and the governmental sector following the democratization of the country. The dismantling of authoritarian rule in Brazil was accompanied by a strong orientation toward human rights, which formed the sociopolitical framework of Brazil's response to the HIV/AIDS epidemic. Even if the Brazilian experience cannot be easily transferred to other countries, the model of the Brazilian government's response may nonetheless serve as inspiration for finding appropriate and lifesaving solutions in other national contexts.     

A Public Policy Approach to Local Models of HIV/AIDS Control in Brazil

Objectives. We investigated involvement and cooperation patterns of local Brazilian AIDS program actors and the consequences of these patterns for program implementation and sustainability.Methods. We performed a public policy analysis (documentary analysis, direct observation, semistructured interviews of health service and nongovernmental organization [NGO] actors) in 5 towns in 2 states, São Paulo and Pará.Results. Patterns suggested 3 models. In model 1, local government, NGOs, and primary health care services were involved in AIDS programs with satisfactory response to new epidemiological trends but a risk that HIV/AIDS would become low priority. In model 2, mainly because of NGO activism, HIV/AIDS remained an exceptional issue, with limited responses to new epidemiological trends and program sustainability undermined by political instability. In model 3, involvement of public agencies and NGOs was limited, with inadequate response to epidemiological trends and poor mobilization threatening program sustainability.Conclusions. Within a common national AIDS policy framework, the degree of involvement and cooperation between public and NGO actors deeply impacts population coverage and program sustainability. Specific processes are required to maintain actor mobilization without isolating AIDS programs.In low- and middle-income countries, the HIV/AIDS epidemic continues to spread among the most vulnerable groups, ¹ notably the poor and women (with vulnerability defined as “the extent to which individuals are capable of making and effecting free and informed decisions about their life”^2(p441)).^3,4 The global cumulative prevalence of HIV-infected people is 33.2 million persons. Countries of sub-Saharan Africa are particularly affected, with an HIV seroprevalence of 18% among young adults in some countries.¹ Where there are weak health care systems, control of the epidemic remains an unsolved issue.⁵In Brazil, the HIV seroprevalence among young adults is estimated at 0.65%, and AIDS mortality has decreased significantly since 1997, when highly active antiretroviral therapy became available for free.⁶ The Brazilian federal and local (state and municipal) AIDS programs are considered to be a model for low- and middle-income countries because they have developed a close cooperation between government, health services, and nongovernmental organization (NGO) actors (persons or groups involved in the formulation and implementation of policies and programs). The Ministry of Health defined ambitious prevention policies and provided free access to antiretroviral treatment.^7–13Implemented at 3 levels—federal, state, and municipal—the AIDS programs have been developed within the Brazilian universal health system (Systema Unico de Saude), impelled by the sanitarist movement.^14–16 This movement involved physicians, public health workers, and politicians who in the 1980s advocated and then implemented this new health system, which is based on prevention and free access to care. Programs have been established in 27 states and more than 400 municipalities. In these states and municipalities, several HIV/AIDS facilities have been implemented, including voluntary counseling and testing centers, specialized assistance services for ambulatory care, and hospital services.¹⁷ Many NGOs, whether AIDS-specific (AIDS NGOs) or generalist, are involved in service provision and policy-making.¹⁸During the past decade, the Brazilian epidemic has changed.¹³ Initially, the epidemic affected mainly urban men of middle and upper classes in the southeastern part of the country. Thereafter, it affected more and more the poor^19–21 and women^22,23 and diffused throughout the country. The national AIDS program has also been confronted with the rising cost of antiretroviral drugs, making the sustainability of the existing programs questionable.^24,25 These changes require strategic evolution of the current AIDS policies.To address these new trends, Brazil has, among recent initiatives, decentralized the handling of AIDS policies through incentivos (incentives), financial incentives allocated to states and municipalities that develop AIDS programs appropriate for the local epidemiological situation and integrated into the local health system. Within the incentives policy framework, states and municipalities define their action plan yearly. Such plans are adopted by state or municipal health councils, composed equally of health care professionals, end-users, and local government representatives. After approval by the national program, the states and municipalities receive federal resources earmarked for AIDS programs.The responses to these new trends in the HIV/AIDS epidemic have been studied by focusing on national AIDS policies, ignoring what happens at subnational levels.^7–13 Moreover, very few published articles have adopted a political science stance and public policy analysis to identify what happens at the front line, to assess how different actors cooperate, and to assess what consequences their cooperation induces for prevention of HIV infection, care of the patient, and sustainability of AIDS programs.We studied how decentralized approaches to the HIV/AIDS epidemic in Brazil addressed the new trends of the epidemic, highlighting positive effects and difficulties, and make recommendations for Brazilian policymakers and to other low- and middle-income countries.