Does the Brazilian Response to HIV/AIDS Deserve a World Wide Applause?

Violence, Police Corruption and the World Cup 2014

The Brazilian government has spent billions of dollars preparing stadiums, infrastructure and security for the World Cup 2014, hoping to raise high expectations through to the opening on the 2016 Olympics.  The double draw of the hat to host two mega sporting events has raised expectations and generated hope of building future benefits for the Brazilian people and country. The hope seems to be that these events will leave a lasting “legacy” to target the socioeconomic determinants of living, for example an improved economy, higher employment levels and liveable social environments. These legacy gains are undoubtedly needed and the unequal distribution of wealth and opportunity in Brazil is a multi-faceted mess that a brief article simply could not do justice to.  In respect of this, the article will focus on just one area of unjust inequality: HIV and sex workers.

A harrowing story is already taking shape on the streets. Sex workers across the country are worried about the World Cup bringing violence, with reference to the police. Brazil has a good reputation for its response to the HIV/AIDS epidemic (Gómez 2010; Global Health Governance 2013) and has been noted in HIV polices around the world for its work in this area (UNGASS 2012; UNAIDS 2010). However, the government has given very little consideration to the circumstances that create high risk groups, such as sex workers, vulnerable to physical and sexual risks. For over thirty years, the attention on sex workers health and wellbeing has been narrowed towards HIV/AIDS (The World Bank 2013), in particular contraception and treatment. However, transgender, bisexual, homosexual, female and male sex workers are frequently affected by a range of issues that directly and indirectly affect their wellbeing and impact on public health, including discrimination and violence, both of which can act as barriers in accessing any HIV/AIDS interventions. Studies have come to the conclusion that the most vulnerable sex workers are at high risk from suffering sexually transmitted infections, but are treated as social outcasts or criminals, making services out of reach due to the attachment of stigma (Sumartojo 2000).

The Brazilian government’s engagement with sex work can be seen in the light of its approach to the AIDS epidemic.  In 1988, a new constitution was established, with a focus on human rights and people living with HIV, giving legal protection against discrimination and the right to free healthcare (UNAIDS 2003).  This constitution does not prohibit any groups of people from accessing treatment.  The National Health System (NHS) in Brazil provides access to health as a fundamental right of the entire population and a duty of the state, through social and economic policy implementation to reduce disease and other health problems, irrespective of background or social status. Globally, there is a continued assertion that sex workers are the most vulnerable to HIV infection in the world today (UNAIDS; WHO 2004). However, the Brazilian state does not regulate sex work, with no mandatory health checks or legal rights and this brings into question the rights sex workers have to access health entitlements.

Non-governmental organisations in Brazil are working to address these wider issues of sex worker rights, including the bigger picture of health and wellbeing, and the social aspects of living. For example, the Brazilian Network of Prostitutes is a national network of more than 30 organizations (Prostitute Network 2013) with a history of partnership working with the Ministry of Health to design and implement HIV prevention projects centred upon human rights, stigma and discrimination, decriminalization of prostitution, access to health services and strengthening the capacity of sex worker organizations in Brazil. Berkman and Garcia et al. (2005) suggest that successful interventions towards sex workers have been noted for the focus on human rights and decreasing stigma. However, as Hinchberger (2005) highlights there exists political controversy over the government’s intentions to work in partnership with Civil Society Organisations working with sex workers.

The 2013 World Bank report suggests that stigma and discrimination continues against sex workers in Brazil and is the primary barrier to service access, prevention and advocacy actions (The World Bank 2013). The risk of sexual transmission of HIV infection of sex workers who are not able to access services are heightened, with strong reference to the frequent experience of violence, prolonging the inability to protect themselves and maintain good sexual health (Human Rights Watch 2003). Sex workers also find it challenging to negotiate safe sex with clients,[1] including the use of condoms, physical and sexual violence (Carrington and Betts 2001).  Sex work in Brazil is not against the law, but it is considered as an immoral profession in a strongly Catholic state. However, regardless of questions of morality, the criminalization of sex work encourages the toleration of violence and harassment, leaving many less likely to enjoy protection from these offences (Rekart 2005).

Police Brutality as the Primary Issue Facing Brazilian Sex Workers

Violence is an ongoing threat to those involved in the sex industry, with perpetrators not just clients, but also those who serve under a duty of protection to the public, the police. Globally, there has been enough research to suggest that harsh police tactics are faced in all parts of the world by sex workers, including violence, harassment and extortion (The World Bank 2013).  For example SWAN (Sex Workers’ Rights Advocacy Network) of Central Europe and Asia conducted a participatory study to research and record the existing human rights violations against sex workers.  From the twelve countries that participated, ten found that there were worryingly high levels of physical and sexual violence from police officers (SWAN 2009).  If violence was not experienced directly, it was of knowledge that such acts were taking place in Brazil by the police. One Brazilian sex worker, for example, stated that: “The police are very corrupt here, that’s why we need sex work not to be a criminal offence, otherwise it will continue in this way.”

Violence is a recurring reality in parts of Brazil, with particular reference to two of Brazil’s biggest cities, Rio de Janeiro and Sao Paulo. From the experience of organisations working directly with sex workers (in particular from Pelavidda and Trans Revolução[2]) it is likely that violence is set to continue, especially through to the World Cup. Violence is also brought from dealing with neighbourhood upset, when people call the police if they witness sex workers. These situations often involve assault or forced movement without consent, and even threats to clients. Sex workers want to be able to provide a peaceful service. There is also reason to believe that police corruption takes place on the basis that pimps will give police officers money that they unfairly obtain from sex workers. These street pimps are also known to be a source of violence against sex workers, with one of the sex workers interviewed indicating that sex workers are being murdered, especially transgender. Sex workers report being happy to pay money to the police, if they are given a service of protection to allow safe working, however this does not happen often, with one support worker noting that: “The police are extremely harsh towards sex workers, because they assault them.” A sex worker similarly stated that “[their] colleagues have encouraged me to go to the city, Sao Paulo, but I am too scared because of the violence from the police I have heard of.A world leading professional, Dr Gilly McKenzie who works for the International Police Organisation, Interpol and the United Nations agreed that sex workers had reason to worry and expect continued violence to escalate:

There is no question that violence will be experienced by sex workers over the World Cup 2014. It is the number one challenge faced by sex workers. Police are extremely corrupt in Brazil. I have been to Rio de Janeiro and other parts of South America on numerous occasions. A huge part of my job with Interpol is to get the police working together to support safer environments; however for Brazil it may be too late, given the extent of events which are taking place next year. There is not enough manpower to deal with the corruption.

The World Cup 2014: “More Negative Than Positive”?

“It could be more negative than positive”; police and authorities enforce, “social hygiene” around big events in an attempt to clear the streets of activity; they want to show Brazil as a “clean” country, with no sex work going on.” (Sex worker)

Those interviewed for this primary research study are in agreement that the World Cup could bring worrying consequences for sex workers, at a time in Brazil when there is huge social unrest and doubt over the Brazilian government’s priorities. There is especially concern over the lack of intervention on improving constitutional rights such as education and health, with priority instead being given to tourist cable cars and football stadiums. Current services available to support the needs of sex workers fear for their future at such a crucial time with the nearing World Cup. These services are faced with disapproval, especially from church-led organisations, as well as no funding support. There is virtually no support from the Government in terms of finance; as a support worker told me, “We have submitted recommendations addressing the needs of sex workers to the Ministry of Health, and we do receive formal responses, but there is never any guarantee from the government.”

Organisations have expressed concern about the welfare of sex workers and clients (with reports of robbery both from and by clients). Sex workers have battled with clients who will try to get services free of charge, and sex workers have robbed clients who live on the streets. Transgender, transvestites and male sex workers tend to be the poorest and considered the “lowest of the low”. Transvestites are particularly poor in Brazil, with many sleeping on the streets, with allegations of opportunism and theft rife, especially during periods of increased tourist attraction. Food was also explained to be a frequent method of payment for sex services. The increase of street conflicts between clients, street pimps and the police will make sex workers more susceptible to violence, and will even increase the risk of contracting HIV/AIDS.

The Divide Between the Brazilian Government and Civil Society Organisations

There is a divide in Brazil between civil society organisations and the Brazilian government on the subject of sex workers. This was particularly noticeable in 2013 when a campaign, with the slogan: “I am happy being a Prostitute”, was released on International Day of the Prostitute to raise awareness about safe prostitution and to work against the stigma that surrounds the profession. However, this was seen as “distasteful” by the government, and resulted in the resignation of a Government Health Minister after public pressure, despite the campaign’s promotion of safe sex and use of contraception.

An organisation interviewed told of a very positive working relationship with the government, but admitted that they did not get the funding support they needed entirely. One civil society organisation, the subject of a case study in my research, had a strong focus on HIV/AIDS, and was therefore likely to be seen in a more favourable light by the government compared to the other organisations working on activism and aspects of human rights. This organisation works by the referral of healthcare professionals encouraged to go to this organisation for HIV/AIDS support. In contrast, the other organisations employ volunteer human rights lawyers, who work significantly on a daily basis for sex workers. Legal services assisting sex workers in court have achieved decisions that deem sex workers eligible for services and legal protections. However, my case study of an HIV positive sex worker showed that it is not always simple for them to get support needed from government led services, especially from health professionals. One sex worker stated:

I went to my doctor for a transportation card so I could get to the hospital for regular HIV treatment, but she refused to sign me permission for a card…with no explanation as to why she wouldn’t allow this. If it wasn’t for the work of City Hall and a volunteer lawyer, I probably wouldn’t have the card to help me get the treatment I need.

Another explained that  “The government are not interested in working with us”. A support worker indicated that while positive work was being done with the government, financial issues remained: “We do work positively with the government, but we still have problems of funding”. However, another support worker disagreed with this assessment, stating: “We do not receive any support from the Government”.  The differences in scattered support relates to how the Government judges an organisations efforts to 1) Abide by HIV/AIDS in the context of treatment and contraception and 2) Capping the wider implications of health and wellbeing, despite increased understanding and inference of the social determinants that can impede a person from achieving a positive health status. The promotion of human rights, social gatherings and helping sex workers to receive social benefits such as pensions, doesn’t seem to be on the Brazilian Government’s agenda, contradicting years of public health messages, evidenced based practice and most notably, the sheer effort made by those who have extended the understanding of HIV/AIDS to what we now know today.

Conclusion

My research has sought to gather unheard voices from sex workers and organisations, helping to give a valuable insight into a reality that exists throughout Brazil. The research hopes to raise matters of concern, months before the World Cup 2014 and two years before the 2016 Olympics. High levels of discrimination were revealed in the study, increasing the vulnerability to violence, which made the sex workers more prone to the risk of HIV/AIDS and social disadvantage. These challenges, with the expected spike in international tourism is now causing sex workers and organisations to be aware and more alert for potentially harmful consequences for those in the sex industry over the 21st century sporting events. The Government of Brazil should be encouraged to protect the rights of, and minimise discrimination against groups particularly vulnerable to HIV, as well as violence and mistreatment. As my research shows, one of the groups requiring specific, and urgent, attention are sex workers.

Janine Ewen in Brazil.

Janine Ewen in Brazil.

Janine Ewen is a Public Health and Human Rights Researcher. In 2013 she was nominated and shortlisted for a British Red Cross Humanitarian Award for efforts on home soil in Scotland, but for efforts conducted in East Africa and Rio de Janeiro in primary research, health promotion and sustainable medical treatment of minor and major injuries. Janine has written news reports for both Politics First in the UK and Scottish Policy Now. Work experience has been in the following fields; public health, policy development and the charity sector.  Janine will now be focussing on Scotland’s Commonwealth Games 2014 and is due to attend the 2nd International Mega Events conference in Rio de Janeiro this year. Twitter: @JanineEwen. Email contact: Janine.ewen@gmail.com.

Further information on the sex worker movement in Brazil can be found on the websites of the following organisations: ABIADavidaGrupoAssistencial SOS VidaPelavidda and Trans RevoluçãoINTERPOL recently signed agreement with the Rio 2016 Organizing Committee to provide law enforcement support to the sporting event, and ensuring that the millions of fans, competitors and officials at the Games can enjoy them as safely and securely as possible. INTERPOL are committed to ensuring that all citizens receive an inclusive service of social protection, including sex workers.

References

Berkman, A. J and Garcia, et al. (2005). “A Critical Analysis of the Brazilian Response to HIV/AIDS: Lessons Learned for Controlling and Mitigating the Epidemic in Developing Countries.” American Journal of Public Health 95 (7): 1162–1172.

Carrington C and Betts C (2001). Risk and violence in different scenarios of commercial sex work in Panama City. Research for Sex Work. 4:29-31.

Hinchberger, B. 2005. “Support for sex workers leaves Brazil without US cash.” The Lancet 366: 883–884.

Human Rights Watch (2003).Fanning the flames. How human rights abuses are fuelling the AIDS epidemic in Karzakhstan. Vol. 15, No. 4 (D).New York, USA, Human Rights Watch.

Prostitutes Network 2013 www.akissforgabriela.com [accessed 07/07/2013]

Rekart M. L (2005) Sex-work harm reduction. The  Lancet. 366 (December):2123-2134.

Sumartojo E (2000) Structural factors in HIV prevention: concepts, examples, and implications for research. AIDS 14: S3–S10.doi

Swan 2009. Arrest the Violence. Human rights abuses against sex workers in Central and Eastern Europe and Central Asia.Sex Workers’ Rights Advocacy Network.

The Huffington Post 2013 www.www.huffingtonpost.co.uk (accessed 06/09/2013)

UNAIDS and WHO 2004. AIDS epidemic update.Geneva, Switzerland, Joint United Nations Programme on HIV/AIDS and World Health Organization.

UNAIDS, 2003.HIV-Related Stigma, Discrimination and Human Rights Violations.Case studies of successful programmes. (UNAIDS best practice collection).

World Bank 2013.The Global HIV Epidemics among Sex Workers, Washington, D.C. http://www.worldbank.org/content/dam/Worldbank/document/GlobalHIVEpidemicsAmongSexWorkers.pdf [accessed 12/07/2013]

Eduardo J Gómez 2010. What the United States can learn from Brazil in response to HIV/AIDS: international reputation and strategic centralization in a context of health policy devolution Health Policy Plan. (2010) 25 (6): 529-54.

Berkman A, Garica J et al. 2005. A Critical Analysis of the Brazilian Response to HIV/AIDS: Lessons Learned for Controlling and Mitigating the Epidemic in Developing Countries”, American Journal of Public Health 95, (7).

WHO/UNAIDS/UNICEF 2011. Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access.

UNGASS 2012 Progress Report on the Brazilian Response to HIV/AIDS (2010-2011). Brazilian Ministry of Health, Department of STD, AIDS and Viral Hepatitis.

UNAIDS 2010. The United Nations and the response to AIDS in Brazil.  Joint United Nations Programme on HIV/AIDS (UNAIDS).


[1]This term is used to describe those purchasing sexual services.

[2] The author conducted field research in Brazil, including interviews with Brazilian NGOs in August 2013 and this forms the basis for the empirical findings within this article.

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