CARACAS, Venezuela — The wheezing bus pulled in late from the slums, so Carmen Hernández was practically jogging toward the clinic now. It had opened 20 minutes ago, and she needed to be early. Late meant lines, and the 49-year-old mother of five couldn't wait.
She was wasting away.
Her high cheekbones were protruding more, and the headaches were getting worse. A fearless tough talker, she didn't flinch at the crackle of gunfire on her street. But this was different. She'd dropped eight pounds in four weeks. She was scared.
"I should be at the clinic already," she said, her voice on edge.
That would be the state infectious disease clinic, where a doctor in July had said the words that meant Venezuela's chronic shortages had finally ensnared her. With the economy collapsing, many things were hard to find. But this was her Viraday, the HIV drug keeping her alive.
"We have none left," the doctor had told her. "Try again in August."
So an hour after first light one August morning, she was doing just that. Her eyebrows furrowed as she approached the clinic's black gates.
Doctors inside were struggling to cope with a surging HIV/AIDS crisis that experts fear could become the worst in Latin America in years. In a country where a six-pack of condoms — which can prevent transmission — costs almost a full day's minimum wage, the number of newly infected patients was jumping. Surging prices and shortages of medicines and food, meanwhile, were hitting those already infected, with increasingly devastating consequences.
"Hola, mi amor," a grinning guard at the gate said, sizing up Hernández. She couldn't afford breakfast, but she had managed blue eye shadow and a dash of fuchsia on her lips that matched her skintight leggings. His smirk said he knew she was not from around here — a middle-class district. This woman was pure Catia, one of the capital's toughest slums.
"What are you looking for today, my love?" he said.
She took a second, hugging herself in a knockoff Adidas jacket that hid the loose skin from her rapid weight loss.
"Viraday," she said.
"I need Viraday."
Sickness and shortage
Already living with the world's highest inflation rate and an increasingly repressive government, Venezuelans are facing an imploding health system.
During the 14-year rule of President Hugo Chávez, a charismatic socialist who died in 2013, oil-rich Venezuela was praised by health experts for its HIV prevention programs and free treatment. But the national health system is now buckling as years
of government mismanagement and corruption, coupled with lower oil prices, have plunged the economy into chaos. Authorities import many drugs, including antiretrovirals, at discounted rates via the Pan American Health Organization. But the local currency is in free fall, putting those cut-rate drugs, as well as basic imported medical supplies such as needles and saline, increasingly out of reach.
Amid the cascading medical crises is the spike in complications from HIV/AIDS. Free HIV tests have been mostly unavailable since November. Pinched by costs, prevention programs offering free condoms ceased last year. Amid pill shortages, otherwise healthy carriers like Hernández are going weeks, sometimes months, without antiretroviral drugs.
As a result, Caracas's largest hospitals are now scrambling to cope with an influx of both newly infected and deteriorating HIV patients, their emaciated bodies evoking the distressing images that defined the virus in the 1980s.
"We used to have about one or two HIV patients a day; now we have four and five, up to 25 a week," said María Eugenia Landaeta, head of infectious diseases at Caracas University Hospital, one of the capital's largest medical centers. "We've had too many patients die because we can't offer treatment."
"It is," she said, "a nightmare."
According to statistics from the United Nations' AIDS agency, based on information from Venezuela's Health Ministry, the number of AIDS-related deaths in the country surged 25 percent to 2,500 between 2010 and 2016, even as they fell 12 percent on average across Latin America. Many Venezuelan medical experts believe the numbers could be even higher.
The number of newly diagnosed infections in Venezuela fell slightly during the same period, easing to 6,500 from 7,000 annually, according to the figures. But shortages of medication, the lack of tests and the disintegrating economy, experts say, appear to be sharply worsening the HIV crisis now, making the country an outlier in a region that is generally making gains against the virus.
Severe shortages of HIV drugs go back to at least April, doctors say. But before July, the state clinic Hernández counts on had regularly supplied her with the combination drug Viraday, known as Atripla in the United States. Its powerful compounds act against the enzymes that cause the HIV infection to spread.
"When they told me they ran out, I left, sat down on the street and cried," Hernández said. "I couldn't stop. People passed by and stared."
Venezuela's Health Ministry did not respond to repeated calls and written requests for comment.
The government of Nicolás Maduro, Chávez's anointed successor, has routinely rejected offers of international humanitarian aid. Nonprofit groups say Venezuelan authorities have refused even small-scale help.
Jesús Aguais, founder of AID for AIDS International, said his nonprofit used to have a permit to bring up to $2 million worth of HIV drugs into Venezuela annually. Without citing a reason, the government abruptly refused to renew its license in 2014, he said.
"We send drugs to 42 countries," said Aguais. "What is happening in Venezuela hasn't happened anywhere else."
Out of options
The AIDS patients at Caracas University Hospital are a vision that haunts Hernández. Last year, she went to the facility for lab work.
"I remember an extremely skinny one in a wheelchair," she said. "It affected me."
Today, some of the hospital's hallways are darkened by burned-out bulbs; one hallway has a caved-in floor. On a recent day, the 14 beds reserved for HIV patients in the infectious-disease ward were filled. So the spillover went to internal medicine, a 150-bed unit that was 40 percent occupied with patients suffering from HIV/AIDS complications.
In one large ward, AIDS patients, some wasting and shriveled, languished in their beds. The stench of diarrhea floated in the halls; there was little medication to treat it. If patients need IV dips or many antibiotics, they have to buy them.
Many can't afford it. A destitute 31-year-old AIDS patient, a hairdresser who had been splitting his antiretroviral pills in half to make them last, lay in a fetal position in his bed. Skipping doses or taking insufficient amounts of the medication for weeks, doctors say, can increase the virus's tolerance of HIV drugs, allowing it to spread.
The young man's feet were scaly and white, a sign of dehydration. His mouth hung open, his eyes wide in their jutting sockets.
Lacking the right antibiotic to treat him or IVs to rehydrate his rail-thin body, his doctor prescribed an antacid and a plastic bottle for drinking tap water. The complication: The hospital's water supply, doctors said, had been contaminated by bacteria.
"We can discharge them, which is often safer for them," said David Flora, a medical resident in the ward.
"Or we can watch them die. Those are really our choices."
'Scared of decaying'
Parrots squawked in distant palms as Carmen Hernández strode through Catia, the western Caracas slum where she was raised. This was her market day, four days before she would go back to the clinic in search of meds, and she felt weak.
Her irregular jobs as a hairdresser and errand runner earned her about 60,000 bolívares, or $4, a week — a sum that didn't go very far, even in Catia. Skyrocketing food prices have hit all Venezuelans. For HIV carriers, who require a good calorie intake for their weakened immune systems, they are a crippling blow.
But Hernández didn't let the street vendors smell blood.
"How much?" she demanded of a butcher, asking the price of carapacho, or chicken carcasses with the meat removed. It's a popular dish for a growing number of Venezuelans. They make soups, suck out marrow.
"Five thousand," he replied, meaning 5,000 bolívares — about 30 cents.
"What? For bones!" she exclaimed. She puffed air out of her cheeks, moving on.
"They used to give it away for free," she said.
Thirty minutes later, she'd spent 70 percent of her weekly salary on three days of food.
Hernández is down to just tea for breakfast, and usually eats one or two meals later in the day. But prices for some foods — tomatoes, corn flour — have doubled in recent weeks. So she's cut back even more. She couldn't tell if it was that, or four weeks without Viraday, causing the pounds to fall off.
Last year, her cousin died of HIV complications. She gave in, Hernández said, by not taking her meds. Hernández can understand. Life is hard in Venezuela, but it's a lot harder with HIV.
"I'm scared of decaying," she said.
Her walk home takes her past a trash heap and up a hill. On the way, there's graffiti from the pro-government thugs that now run Catia, controlling distribution of subsidized food and instilling fear through violence. Painted on another wall, the eyes of Chávez loom large.
She liked Chávez, even loved him. He fought, she said, for the poor. But under Maduro, she said, people in Catia were casting votes for the government out of fear.
"Everything is a disaster, and they rob so much," she said.
In her aluminum-walled two-room hut, she occupied herself making tea. These days, her adult children come by sometimes, but none of them are helping her with food. They have families, their own mouths to feed.
She was diagnosed with HIV in 2013. Her husband had recently left her, she said, plunging her into a depression eased by men and liquor. She had no idea who gave her the virus. "It doesn't matter," she said. "I have it."
Lottery of life
After being waved in by the clinic guard on the morning in early August, Hernández rushed toward a pharmacy window in a small courtyard. She took a clipboard and signed in.
She sat down on a bench, chewing her lip and watching as patients were called to the window.
One man asked for a different HIV drug. "No, we don't have it, sorry," a doctor said. The patient closed his eyes and sighed.
The next man — an older patient — was looking for the same drug.
"Nothing, sir. Hasn't arrived," the doctor said.
"Hernández, Carmen," a doctor finally called out from the window.
She rushed forward.
"Viraday," Hernández said.
No, they didn't have it.
But they did have the generic.
The doctor told Hernández she was lucky. Only 500 monthly doses had arrived for 2,900 patients.
"What happens to the patients who come next week?" Hernández asked.
The doctor looked down, shaking her head.