By Monte Reel
Washington Post Foreign Service
Thursday, March 2, 2006
RIO DE JANEIRO -- Paula Duran is an outreach worker with a style of her own. That style -- heavy on fishnet, tattoos and suggestive poses -- is at the heart of an ideological disagreement between Brazil and the United States over the best way to fight AIDS.
Duran, 35, is a prostitute in Villa Mimosa, a red-light district in this seaside city where an estimated 3,500 sex workers lounge in the doorways and lean out the windows of scarred, decaying buildings.
Each time she snags a customer, she fishes in her purse for a government-supplied condom. Often she repeats information on disease transmission that she learned at a state-funded workshop for prostitutes around the corner.
"I'm always telling people that they should never do anything without a condom," Duran said. "A lot of the young people who come around here don't know anything about it, so I try to teach them whatever I can."
But the U.S. government strongly disapproves of such unorthodox methods. Two weeks ago, Brazil received a letter from USAID declaring the country ineligible for a renewal of a $48 million AIDS prevention grant. The United States requires all countries receiving AIDS funding help to formally state that prostitution is dehumanizing and degrading, and Brazil last year -- alone among AIDS aid recipients -- was unwilling to do that.
A working partnership with prostitutes, health officials here say, is a key reason that the country's AIDS prevention and treatment programs are considered by the United Nations to be the most successful in the developing world. There are at least 600,000 people infected with HIV in Brazil -- but that is only half the number predicted by the World Bank a decade ago.
"When we started in the 1980s, our projected AIDS rates were exactly the same as Africa's, but now it's a completely different story," said Mariangela Simao, deputy director of Brazil's national HIV-AIDS program in Brasilia. "I'm convinced it's a result of the way the government has responded. We provide information and resources, and don't enter into moral or religious issues."
Brazil's annual Carnival, the rowdy pre-Lenten festival where clothes and inhibitions are mostly considered optional, began last weekend. At parades and block parties attended by millions throughout the country, the government's approach to AIDS and reproductive health appeared as unrestrained as the revelers themselves.
In Rio, free condoms were passed out like candy as part of a national goal to distribute 25 million of them before Carnival ended Tuesday. At a suburban bus stop, pamphlets distributed by the Health Ministry advertised a character called "Maria Without Shame," a cleavage-flaunting cartoon prostitute who reminds sex workers to take pride in their jobs and tells people that condoms should be used without guilt.
At celebrations in the northeastern city of Salvador, health officials also planned to pass out morning-after pills, according to local newspaper reports.
Brazil has more Roman Catholics than any other country, and the church at times voices mild complaints about the government's programs. But church leaders haven't pressed the issue. The idea of emphasizing abstinence as the basis of prevention efforts -- a stand the United States has officially adopted -- hasn't taken hold here.
"Brazil's sexual culture is very different from the puritanical tradition in the United States," said Sonia Correa, an AIDS activist in Rio who is also the co-chair of the International Working Group on Sexuality and Social Policy. "Our AIDS programs have also been radically different. The denial and the stigma that you find attached to sexual health issues in so many places isn't found in Brazil."
A number of other countries, especially in Africa and the Caribbean, have experienced high levels of HIV transmission through prostitution, but no other government has taken Brazil's unorthodox approach to the problem.
Brazil has also found itself at odds with the United States on AIDS treatment, but for different reasons. Brazil has led an international fight against pharmaceutical companies to allow countries to break the patents on AIDS medications, which would let governments produce the drugs at a much lower cost. The United States, where several of the large drug companies are based, says the patent protections encourage the companies to innovate. Without the financial benefit, they argue, there is no incentive for companies to develop new medicines that could improve patients' lives.
"Brazil has been using threats of breaking patents as a bargaining tool to negotiate lower prices with drug companies," said Michael Bailey, a senior policy analyst with Oxfam, an international nonprofit development aid group, speaking from its headquarters in Britain. "A lot of other countries are watching Brazil very closely to see what it does. This is very, very big business."
About two-thirds of Brazil's AIDS program budget -- or more than $400 million annually -- goes to buy antiretroviral medications, which the government offers free to anyone infected.
The loss of U.S. funding adds more financial pressure to Brazil's AIDS programs, though health officials here say the loss isn't crippling. Some nongovernmental organizations report recent lags and shortfalls in the government's distribution of condoms, but they don't attribute it to the loss of U.S. funds.
To help manage costs and keep up with the demand for condoms, Brazil later this year expects to become the first country directly involved in the condom business. It plans to open a state-run condom factory in the western city of Acre, producing condoms made from latex tapped from the region's wealth of rubber trees.
Gabriela Leite, 54, said she hopes the project will help condom supply meet demand. A former prostitute, she now runs an advocacy group for prostitutes that serves as a link between the government and sex workers. Her last government shipment included only 11,000 condoms -- about one-fourth the usual batch. Because the prostitutes aligned with her organization handed out large numbers of condoms at street parties during Carnival, she's afraid the supply will be quickly exhausted.
When asked if she believes such an approach is a better way to battle AIDS than promoting abstinence, she said she was certain of it. She also said she has made a point of trying to persuade activists and officials in other countries to join Brazil in refusing to go along with U.S. ground rules, even if the United States is easily the biggest provider of funding help in the world.
"It's strange, this attitude of the United States that says its way is the best, even in another culture that is completely different," said Leite, who said she retired from prostitution in 1979. "If that's the way it's done in your culture, that's fine. But it's different here, and we'll do it our way."