HIV/AIDS and the Reform of the Health Care Systems of Latin America and the Caribbean

J. Alejandro S. López

Introduction

During the 1990s, governments in several countries around the world started reform processe of their health care systems, as a consequence of the growing importance of the health care sector not just as a physical and biological issue but also as an economic one.

Health is a good that people consider as a right; in fact several federal constitutions in different countries establish "Health as a Right". However, some economist have considered that health is not a "social good" that should be paid with public money; on the contrary, they say it is a "luxury good". This last reasoning, in turn, is based on another fact: the empirical evidence that nations as well as individuals tend to spend more on health goods as they get richer, not just in absolute terms but also as a share of their income. This also has another implication in the sense that poorer individuals prefer to spend their limited resources on a number of other more basic goods such as food, clothing, housing, transportation, education, and so forth; in a marginal way, they will also spend resources on products that directly produce health. The same thing is true of nations: developed countries tend to spend a lot more on health, in per capita terms and also as a percentage of their public budget, than developing countries.

Why should health be considered a social good that has to be funded with public resources? Health, as opposed to other kind of goods, is something that most people are born with. Goods¾ such as food, housing, dress, education, transportation¾ can be obtained later, and to purchase those goods every individual has enough information on how to acquire them and also on how to lose them. In the case of health, to loose it is a risk and there is not enough information on how to avoid that, and keep healthy for a lifetime. When health has been lost, people get sick and goods that produce health or bring it back, such as drugs or surgery, are not the kind of goods that an individual will freely choose to purchase; there is no satisfaction involved in spending on them and people think that it is possible to avoid that waste.

These are the reasons why people think that government should set aside enough resources to protect the health of its population.

We might say that there are three different roles that governments in the world assume, in different degrees, regarding the health care sector: regulation, financing, and the provision of health services.

Not all governments provide health services in a direct way; all, however, finance them in different levels and without a doubt all assume regulation of health as a state matter.

With the notable exception of the United States, all developed countries (Western European countries, Canada, Japan, Australia) have universal coverage health care systems, which provide a comprehensive amount and variety of health services as well as good quality¾ the cost, on average, is US $1,000 per capita in these countries. However, middle-income developing countries, such as some countries in Latin America and in the Caribbean (LAC) spend close to US $100 per capita on their health care systems, a figure which includes both public and private expenditures. Except for the United Sates, all developed countries have universal coverage health-care systems, whcih include prepayment schemes or social security that pays for health expenses when necessary. This king of health-care coverage is almost nonexistent in LAC.

Health reform processes in developed countries include, among their objectives, ways to improve the quality of care while at the same time looking for cost containment. In the case of the United States, health-care legislation is currently being considered which also attempts to achieve universal coverage.

In a simple comparison, we can conclude that amounts spent in LAC are very limited, even with the latter countries’ health care reform and with their willingness to hypothetically spend 100% of their whole public budget on the health care sector, leaving out sectors such as education, justice, and the military. Public resources will still be insufficient to provide the same kind of quality, quantity and variety of services that rich nations offer.

The AIDS issue

Nevertheless, the very recent emergence of AIDS as a health problem comes as an additional burden for the health care systems of developing countries. Indeed, this problem is not one of transition to development, but an emergent one that is having its worst impact on poor countries, mainly Africa, where most of the world cases are located. Therefore, no LAC government should consider AIDS as a problem peculiar to the United States or Europe, or one that originates mainly from cities like New York and San Francisco.

The United Nations Programme on AIDS (UNAIDS) estimated that, as of July 1996, the number of HIV infected living population was 21.8 million, of which developing countries accounted for 20.4 million (94%)(1)^.

The fact that the LAC area currently has a fewer number of reported AIDS cases than Europe, Africa or North America does not mean that it is a secondary matter; and the reason is simple: the number of reported cases refers to persons who have already developed the full AIDS syndrome. However, the United Nations Programme on AIDS (UNAIDS) has estimated that for 1996 most of the HIV-positive cases in the Americas are in LAC(2).

Distribution of HIV/AIDS cases in the Americas, according to UNAIDS estimates for July, 1996.

On the other hand, new cases of HIV infections are still growing, getting into younger population, and also cases of heterosexual transmission are showing higher rates than man-to-man transmission. All these new cases will take several years to be detected as AIDS cases.

A higher number of cases does not only mean a growing epidemiological problem, but also a social and economic problem, due to the fact that appropriate care has a high cost that will impact the limited resources of heath-care services.

Health as a priority for governments

The fact that no country in the world has enough resources to provide all health-care services to the entire population as a free good(3) implies a need for priority setting; at the same time, it is a recognition that there are limited resources.

Perhaps some Health and Finance Ministries in LAC are asking themselves, How can I spend my limited resources on AIDS if I still have a high incidence of other health problems that are causing my country most of the mortality? What usually happens is that health ministries tend to incorporate almost every illness into their set of priorities; cumulating them one by one, by the end they have a huge amount and it is almost impossible to distinguish which ones come first when spending resources are limited.

It is also common that health ministries do not have a clear perception of how limited public resources are in developing countries, and that all other sectors¾ such as education, justice, and so forth¾ also exert pressure to obtain a higher share from the public budget. In LAC the public budget for health usually goes to different public institutions which compete among themselves to obtain a higher share of resources, ignoring the fact that even with a different distribution, resources will still be limited and that the answer for developing countries’ health-care sectors is to start a process to set priorities clearly, to identify the role of government in the health system, to carry out the needed reforms, and to ensure the funding of those priorities.

On the other hand, finance ministries of LAC usually do not have a clear perception of the importance of the health care sector. They tend to allocate public resources taking into account certain ceilings or percentages to be shared by each social sector. Once they have assigned the public budget to health they forget about that problem, assuming that the health system will do its best to be efficient in spending the resources and obtaining the best possible outcomes for each dollar spent, ignoring the issue that health systems need to be reformed in order to deal with limited resources and confront rising costs. Without the reforms it will be very difficult for health ministries to deal with emerging problems like AIDS and also to ensure care for other kinds of patients. Reallocating the public budget will only result in uncovering other problems when trying to cover the new one.

With such limited resources, how can a LAC government deal with AIDS?

As was stated previously, there are several roles the government can assume in terms of health: the first one, which is also the distinctive one for a government, is regulation. It is precisely concerning the role of regulation that LAC countries have a great opportunity to do something about AIDS and to try to ameliorate some of the problems associated with this health problem.

Regulation and government labor legislation

Unlike other sectors where less government regulation may lead to the flourishing of industry, commerce and finance, the health-care sector needs specific and strong provisions in order to regulate everything that can be hazardous to health or a risk to losing it. In other words, government intervention is necessary because, on the one hand, there are too many externalities that affect health; and, on the other, people do not have enough information to choose the best alternative to keep their health throughout their lifetime.

Since there is not enough empirical evidence in the international context to guarantee that leaving the health market free will produce benefits for the people, governments that are strong free-market advocates, like the United States, are also among the toughest when setting regulations to protect the health of their people.

Regulation in order to prevent discrimination and to ameliorate the suffering of people living with HIV/AIDS . During the XI International Conference on AIDS in Vancouver, Canada (July, 1996), one of the most recurrent issues in several conferences and presentations was the fact that in many developing countries people living with AIDS (PLWA) not only confront their health problem but also the stigma and the suffering that it represents. There are many societal groups in these countries were AIDS is seen more as a moral problem and less as a health problem. On top of that is the additional issue that in the Western hemisphere people who are the most common victims are also members of traditionally marginalized sectors of society (gays and prostitutes), who are rejected from social programs because of prejudices that have already been overcome by more developed societies such as Canada, Denmark, Sweden or Holland and, to a certain extent, in the rest of the developed world.

There are also times when people infected have less opportunities to obtain or to remain in a job, just because they test positive to HIV.

Legislation to protect employment. Fortunately, the ways to get infected by the AIDS virus are already known: a) through semen in direct contact with a mucose or a skin injury; b) through blood by transfusions or infected needles; and c) through the transplacenta from mother to baby. As can be seen, there are no ways that an employee can be a hazard to the rest of his or her co-workers. The government should pass a specific regulation in order to protect the employment of infected people and avoid discrimination based on their HIV status.

Besides the moral, ethical, or economical implications of losing a job for a HIV positive person and his or her family, the point is that the way that HIV is transmitted is already known and it can be assured that the virus does not go through a hand shake, a hug, a sneeze, air, mosquitoes, or by using the same desk, chair or other working instruments. If all these ways are not valid ones for HIV transmission, What could be a strong argument to fire someone?

The experience accumulated through all these years since the start of the AIDS epidemic, mainly in LAC countries, shows that in some circumstances it is not enough that the law does not mention HIV as a reason to fire someone; there is a need to state clearly that to test HIV-positive should not be considered a reason for not employing someone. On the other hand, an HIV-positive person can be a fully potential worker with all his or her intellectual and physical abilities to perform any kind of job. Nonetheless, even after being diagnosed as an AIDS patient, he or she can regain his or her capabilities with the proper antiretroviral and prophylactic drugs.

Legislation to prevent social discrimination. People Living With AIDS (PLWA) do not only have problems with job issues; sometimes they also confront problems in order to be members of clubs, enter certain schools, colleges, gyms, churches or to join some other social activities. The same rationale that applies for a job, applies here. What could be a reason not to accept an HIV-positive as a participant in these activities? The law should be there in order to protect them from being discriminated.

Mandatory HIV testing. Outside of the mandatory testing of blood packages to be used for transfusion, the government should ensure that all other mandatory testing performed by private or public entities also be joined by a commitment to provide the needed medical care, including drugs to all employees found to be HIV-positive. There should be a reason for wanting to know the HIV status of one’s employees; in those cases, the reason should be to provide them with care. If that is not the reason, what reason could there be to mandate a test?

Such kind of legislation to protect people from social and job discrimination can be a good starting point for LAC countries in order to be consistent with the Paris Summit Declaration on AIDS (see box), which states the commitment of governments to "Promote and protect the rights of individuals, mainly of people living with HIV/AIDS"(4). This summit declaration was signed by the governments of 42 countries, including the LAC countries of Argentina, Bahamas, Brazil and Mexico. Despite that this declaration was promoted by the World Health Organization, most of the LAC governments have not signed it yet. That is why health ministries from other LAC countries should submit this declaration to their respective congresses or proper authorities in order to obtain authorization to sign it and formally join this international effort. Unfortunately, in many of the countries that have already signed the declaration, outside of their respective health ministries and the non-governmental organizations working with AIDS, hardly anyone else knows about this declaration.

DECLARATION OF THE PARIS AIDS SUMMIT (Resume) We the Heads of Government or Representatives of 42 States assembled in Paris on December 1, 1994l MINDFUL. That the AIDS pandemic, by virtue of its magnitude constitutes a threat to humanity, that its spread is affecting all societies, that it is hindering the social and economic development, that poverty and discrimination are contributing factors in the spread of the pandemic, that it not only causes physical and emotional suffering, but it is often used as justification for grave violations of human rights, II SOLEMNLY DECLARE. Our obligation as political leaders to make the fight against HIV/AIDS a priority, our determination to ensure that all persons living with HIV/AIDS are able to realize the full and equal enjoyment of their fundamental rights and freedoms without distinction and under all circumstances III UNDERTAKE IN OUR NATIONAL POLICIES TO: Protect and promote the rights of individuals in particular those living with or most vulnerable to HIV/AIDS, Make available necessary resources to better combat the pandemic , including adequate support for people infected with HIV/AIDS, non governmental organizations and community based organizations working with vulnerable populations.

A good moment to start promoting the Paris Declaration on AIDS to some other ministries¾ such as education, labor, defense, and so forth¾ or to other kinds of social organizations, unions, industry associations and the mass media, is each 1st of December, World Day on AIDS. It is a day that has the advantage of attracting general popular interest on AIDS. Therefore, at least on that day, it is possible that people will read or pay attention to the Paris Declaration. The health ministry has the possibility of sending official notifications to other ministries and offices inside governments in order to inform them of the official international health commitment that the national government has undertaken.

In many cases, but mainly concerning HIV/AIDS, official international commitments cannot be fulfilled only by the health sector. There is a need for the participation of other sectors. However, these other sectors can do little if, to begin with, they do not even know about the existence of such commitments. Ministries that should receive a copy of the Paris Declaration on AIDS and, moreover, that should be informed that they are expected to comply with the Declaration and to enforce it, if necessary, include the following:: education, labor, defense, communications, human rights commissions, as well as regional and local authorities, and of course private and public institutions related to health.

Often, for public entities, it is not enough for an official declaration or international commitment to have been published in the newspapers; they will take action only until they receive an official memorandum instructing them to do so. That is why mass-media promotion is not sufficient, and there is a need for additional sources of notification.

Life and Health Insurance Regulations. It is well known that the profitability of private insurance companies largely depends on the possibility of also insuring low-risk people with a lower likelihood of illness or death, i.e., insurance-paying beneficiaries who are unlikely to use the policy in a short period of time. There are cases when private insurance companies explicitly discriminate against HIV-positive people, even if the virus was acquired months or years after the insurance policy was purchased. Cases have been reported of some bank institutions that have offered free life insurance policies to their clients’ savings accounts; however, the policy will cover any cause of death except AIDS(5). Government regulation should try to avoid this kind of discrimination. LAC governments are reforming their health sectors with a view to opening their domestic markets to private insurance companies from abroad. Then actions are needed to prevent discrimination, especially when it is also known that some of these same companies based in developed countries do not have such exclusion clauses when acting in their own countries. This last point is another reason to believe that there is a lack of government regulation in health in LAC.

The role of government in the financing of public health

Public Financing of HIV/AIDS prevention campaigns. Measures to prevent HIV/AIDS are well recommended due to their high cost/benefit index. LAC governments can be sure that money to promote those strategies will be a well spent public resource that will produce a decrease in the incidence of new cases, as has been demonstrated in several other countries.

Within the health reform processes in several LAC countries, one of the first things governments have realized is that there are limited resources and that, therefore, there is a need to identify those high-impact interventions in order to obtain a better use of public resources and to save money in the future by providing care to preventable diseases. There are several studies that have estimated these costs, among others, a study in Chile(6), conducted in 4 public hospitals in Santiago, that concluded that direct costs of care for an AIDS patient, including antiretroviral drugs, add up to US $4,000 per year on average.

Mass media campaigns are some alternatives that a government has in order to let people know about AIDS. Such campaigns should be directed, primarily, at promoting awareness of the magnitude of the epidemic worldwide and locally; they should, moreover, provide information on existing preventable measures, on the transmission mechanisms of the virus, on places and telephones available for those who seek more detailed information and should also include the broadcasting or publishing of messages on the need to avoid discrimination and harrasement of people who already are living with HIV/AIDS.

Gay meeting places and the role of government.There is no place in the world were it has been demonstrated that closing gay places diminishes homosexual population. In the case of HIV/AIDS this can even be a dangerous policy action because then the possibilities of accessing this vulnerable and high risk group with preventive measures turns to be extremely difficult. It is also in these places were is easier to access bisexuals, which can be one of the main sources of transmission of the disease to women and to heterosexual population in general. NGO´s that work with HIV/AIDS get an easier job by contacting high risk population in socializing clubs or meeting points were gay people usually go. Therefore, it is not a recommended policy for a government to allow extortion or to difficult the operation nor to promote closing or to put barriers to the opening of gay places, on the contrary they should be treated in the same way these kinds of places are permitted for the general population. One of the worst public policies in the AIDS era is to diminish the possibilities that the highest risk group get lack of access to places were they can freely socialize and without stigma or social pressure they can obtain detailed information on alternative ways to avoid high risk practices and how to prevent other people from getting infected.

Mass Media and Alternative Strategies. Usually health ministries or National Councils on AIDS are the entities in charge of producing the educational messages to be broadcast to the general population. Some countries have made great efforts to produce good quality messages that involve attractive social marketing strategies; however, private mass-media companies (usually the ones with higher audience ratings) have refused to trasmit such messages because they consider that some images, words(7,8) or timetables are not appropriate and compatible with their information policies, and that some of the contents may be objected by their audience. Such barriers to providing the population with sufficient information about AIDS might be overcome by the health ministries through different channels such as: 1) in an extreme case to declare it a national priority that the message has to be broadcast due to State reasons and to obligate the broadcasting of the message by the company; 2) to produce the messages as a joint venture with the broadcasting company(9), 3) to use some other media (different TV channels, radio stations or other newspapers and magazines); 4) to use alternative diffusion means in public places such as posters and brochures; 5) production and diffusion with the help of non-governmental organizations or interest groups who are willing to do that kind of work, as has been done many times in Mexico(10). The NGOs may not be capable of reaching massive populations; however, they can be more effective than governments on targeting high-risk groups. A reform of the health care systems in LAC should consider ways on how health ministries may have the legal power to choose from any of these alternatives in order to reach the public health interest of a country.

NGOs that work with AIDS. In many countries, NGOs and other interest groups have demonstrated to be more efficient than governments in delivering educational messages and preventive measures reaching high-risk groups(11). Some of these NGOs achievements can be illustrated with case studies of groups and projects through all LAC countries. As an example, we should mention that in Guatemala City(12), two associations¾ "Talleres Holísticos" (Holistic Workshops) and "La Casa de la Cultura para Gays/ Bisexuales y Lesbianas" (Gay/Bisexual and Lesbians Culture House)¾ by organizing cultural events, discussion groups, entertainment activities and workshops, have influenced the change of risky behavior in high-risk groups that otherwise would be hard to reach through government channels.

In the context of the reform of health care systems in LAC, NGOs should be welcomed alternatives in order to promote preventive measures, to deliver education and care, mainly in the case of AIDS. In other words, health ministries should not consider NGOs as competition. On the contrary, the experience shows that, ever since the first case of AIDS appeared, the best way to reach these difficult-to-access groups (see Table), is through NGOs or interest groups. The government should encourage the formation and participation of these groups in order to reach higher goals that in the end will benefit the general population. NGOs are also likely to advise individuals about their rights and legal means to protect themselves from discrimination. This additional kind of participation by NGOs can be seen in countries like Venezuela(13), where a Caracas-based organization provides legal advise to individuals who tested HIV positive and who are dealing with problems to remain in their jobs. This Venezuelan organization has also helped to promote the Paris Declaration on AIDS, obtaining presidential recognition of that declaration.

The Policy of Condom Distribution to High-Risk Groups. This policy has demonstrated to be quite effective in the prevention of HIV/AIDS. During the initial stages, when the goal is to promote the use of condom by high-risk population, there is a need for a marketing strategy were the use of the condom because of health reasons is not the only message that should be sent. There is also the need to send the message that using the condom does not interfere with the pleasure of sex; this last point is usually the main reason why people do not use condoms even knowing the risk they are into. Promotion of the use of condom among young people has additional advantages and positive externalities by preventing undesired pregnancies.

Some countries have included condom distribution inside their national family planning or reproductive health programs. Although these strategies are encouraged to be continued, they are not enough in the case of AIDS prevention. And the reason is simple: the highest risk group still is the one that usually does not seek family planning programs or reproductive health advice (homosexual men). This means that the targeted distribution of condoms to high-risk groups through NGOs must be an additional public policy that cannot be substituted by family planning or reproductive health programs.

In condom promotion campaigns, it is suggested that governments take advantage of condom production or distribution companies as co-partners in devising marketing strategies, because, once the condom use starts to rise, they will be in charge of satisfying the new demand, leaving the government the responsibility to distribute free condoms only to low-income high-risk groups who are less likely to buy condoms by their own means. On the other hand high-income groups, once they are convinced that they should use condoms, have demonstrated that they are willing to pay for them.

Once again, the alternative to reach low-income high-risk groups is through NGOs, mainly those located in poor neighborhoods or that offer services to the poor.

Additional Gains because of Condom Use. Earlier this document mentioned the advantages for family planning. However, that it is not the only additional positive effect. Experiences studied and reported by some other developing countries, like Thailand and Zaire, as well as by a sex-worker targeted project developed in La Paz, Bolivia(14), have demonstrated that campaigns structured to the prevention of AIDS also provide additional benefits by diminishing the incidence rates of some other sexually transmitted diseases, such as gonorrhea, syphilis and genital warts.

On this point, the central government should take a look at other kinds of regional or local laws, which sometimes interfere with AIDS campaigns, in order to advise local authorities about the consequences of keeping people ignorant about the problem and how this ignorance will make them more vulnerable to be infected by the AIDS virus.

Decentralization in the health systems of LAC must take into account all these facts related to local beliefs; but the central authority should also be kept to supervise and enforce compliance with the the national priorities which are mandatory in all parts of the country regardless of their decentralized status. Local authorities should know that AIDS is an infectious disease that will not respect geographic boundaries, city limits or political considerations, and that, therefore, it is likely to follow temporary migratory flows and population movements(15).

Are AIDS prevention campaigns needed in rural areas? Some governments hold the belief that AIDS is mainly an urban problem. They support their assumptions on statistics that show that most of the cases are located in large metropolitan areas. However, there is also a need to know about some additional facts: the numbers registered by official statistics are of cases that have already manifested the full syndrome and have been diagnosed as AIDS cases. On the other hand, there is the point that, according to reports from several countries, the highest growing rate of new cases are being detected in population with fewer educational levels and low income. This has to be taken into account because, in LAC, rural areas concentrate higher indexes of illiterate population and extreme poverty. These rural areas are sometimes more likely to look like Sub-Saharan Africa communities than like modern urban cities of LAC. Their socioeconomic characteristics make them as equally vulnerable as the communities in the most affected area of the world. Finally the so-called temporary migration flowing to cities are peasants and indigenous population who, because of economic reasons, migrate for short periods of time to high prevalence areas. This seems to be the case for Mexican temporary workers, where some studies have reported that 25% of the initial diagnosed cases of AIDS in Mexico had the antecedent of a temporary stay in the United States(16).

The ignorance about the alternatives to prevent an HIV infection make such migratory workers more vulnerable to spreading the infection once they have returned to their rural communities. Therefore, it is an indispensable policy to stop AIDS for prevention campaigns to reach rural areas. What is probably needed is that messages to be delivered to these areas should be adapted to their cultural beliefs, native languages or traditions in order to make them more effective to make the message understood.

In these cases, health ministries can be helped by NGOs or even by some other public institutions who already have experience in working with rural and indigenous communities. This way, messages will not just be translated to native languages but also get enriched with local exemplifications that are closer to their needs and beliefs.

Direct provision of care, role of government?

Direct provision of care is something not always performed by governments. In fact, many of the reform processes now in place in LAC are considering to diminish or abolish the role of government as a direct provider of health services. The question is whether the government has been efficient as a direct provider of health services. Almost no one is questioning that the government should regulate. In the case of financing, the issue is what to finance and if the public financing should go to everyone.

So, the issue of who should provide the services, if not the government, in the case of AIDS but also in health care in general, is in the sense that, for developing countries, among the best alternatives are NGOs or non-profit organizations, that can receive public subsidies but also have other means to obtain funds to provide less expensive care. NGOs can operate these kinds of services not only in urban areas but also in rural areas.

However, in the case of AIDS, the main point is not who provides the care, but who pays for it. Currently medical care is something that health systems in LAC provide in some degree by public, private and non-profit organizations.

With current prices of antirretroviral drugs, to pay for them out of pocket is something accessible only to rich people in LAC; we might say that only between 10-15% of patients will have that possibility.

In the case of private insurance, if they have not stated exclusion clauses for AIDS patients, they might be covering almost the same amount than out of pocket, but usually be covering exactly the same population that were capable of paying out of pocket. Therefore, no great additional coverage is expected through these insurance schemes.

The most important component of the cost of care of an AIDS patient are antirretroviral drugs. Combined therapies of two or three drugs are obtaining better results; these are usually based on AZT plus other drugs. The price of each pharmaceutical is high. This happens because according to pharmaceutical laboratories they need to recover their investment made during the research and testing processes before the product was available on the market. Since such processes are being continued, there is no hope that prices may fall in the short run, unless the entrance of new drugs and competition forces them to cut prices.

Currently, there are several LAC countries that provide all pharmaceuticals needed to AIDS patients at no charge. These pharmaceuticals include combinations of two or three antirretroviral drugs, plus ambulatory or hospital care (the Chilean case). There are several other countries that also provide this same kind of care but only to patients that are registered as social- or private-security covered.

It is estimated that as the number of cases increases, both kinds of countries will be in difficulty to keep providing those services at no charge, mainly services financed by public budgets. Among the alternatives to try to contain costs are to convince physicians and public and private hospitals of the need to start changing to ambulatory care. This can be obtained through the cooperation of the patient’s family or the patient’s partner.

To obtain the cooperation of the patient’s partner there is a need for health-care professionals not to have moral or social prejudices, because in many cases they will need to talk and advise the partner or close friends of a gay man, whom should be regarded as if they were the family in order to obtain the best help from them during the ambulatory care in order to obtain the best help possible.

Therefore, a fundamental step in ambulatory treatment schemes for the AIDS patient is the proper information for and training of not only to the patient but also his or her family and partner or close friends, so that they can provide the AIDS patient with the necessary care and be able to identify symptoms and alarm signs that can be associated with the need to see a doctor right away or ones that can be managed through home care. The AIDS patient’s "family" will also need to know how to prevent the disease and the minimum hygiene to be observed to avoid risks and to be aware of the contact with used needles or blood samples.

The hospital and the physician, when dealing with the patient’s family or partner/friends, should know that they are not just helping the family and helping the hospital and the health system as a whole in cost containment, but also they will be helping the patient to achieve a better quality of life.

The painful issue is for those very low-income patients who are not covered by a private insurance or social security scheme and do not live in a LAC country where AIDS care expenses are fully covered by public funds. These cases are the ones who will need charity care or will be in the need of entering a pharmaceutical research protocol in order to get at least some free drugs.

Unfortunately, there are few alternatives for these patients. That is why countries who are not providing enough public funds to treat all patients need to promote and facilitate international aid to provide care to these patients through charity organizations and to facilitate the development of research protocols who provide drugs. There are also some NGOs that are capable of obtaining donations of drugs from families of a dead AIDS person who are willing to give all their drugs left in order to be utilized by poor PLWA. And of course NGOs are also able to obtain voluntary work from health professionals who like to donate their time to charity care. In many LAC countries it is also more likely that some people will leave legacies to charity NGOs rather than to government hospitals. There are some international agencies that prefer to channel their international aid to NGOs rather than to government agencies; therefore, governments should be prepared to promote and facilitate all these alternative ways to provide care to low-income AIDS patients.

To answer the question, should all kind of AIDS treatment be financed with public resources? It is sometimes forgotten that even knowing that AIDS treatment is expensive, it is not by any means the most expensive disease. There are some other diseases that are more expensive. Therefore, governments, before they start cutting or slowing the growth of resources for AIDS, should ask themselves if they are fair to do so, if they have done cost/benefit studies concluding that AIDS has a lower index than care for patients with stomach cancer, liver transplants or some other high-technology procedures for cardiac patients, among others. Unfortunately, LAC countries do not have enough resources to finance all their health needs and provide a care with equal access and quality as that provided in the developed world. That is the reason why reform processes are dealing with the issue of priority setting of some health interventions or to finance with public budgets only services to low-income and marginal groups.

Deregulation for the entrance of new HIV/AIDS drugs to LAC markets. Another measure that LAC governments should be encouraged to take is the deregulation for the entrance of new antirretroviral drugs, mainly the ones that have been already approved by developed countries such as Canada or the United States. The rationale for doing it is that they already passed through a series of thorough regulations and controls in those countries in order to be approved for human use. The other rationale will be that patients who have the means to pay for those drugs will obtain them anyway by going to the black market or by making highly expensive trips to those countries in order to obtain the drugs, putting an unnecessary extra burden on the economy of the people living with HIV/AIDS and on that of his or her family.

Conclusions

The main point of this chapter is to realize that even if a LAC country does not have enough economic resources to provide free drugs and care to all its population living with HIV/AIDS, that does not mean that they can do little. In fact, governments can do a lot of things in order to ameliorate the suffering of its people and to diminish the growth of incidence rates.

The role of government as a regulator / legislator is critical during this epidemic that is causing a huge socioeconomic impact in many developing countries. Government action should contribute to lowering the degree in which it is affecting families and individuals, mainly those who are in higher risk and in marginal positions and who are traditionally outside of social benefits from public programs.

The prevention of HIV/AIDS has demonstrated to be very cost/efficient measure; therefore, it is desirable that LAC countries increase public resources for these measures in order to impact the growth of incidence rates before they can be fully overcome by the epidemic in their capacity to provide care services in the medium run.

Taking into account the number of infected population in LAC countries by UNAIDS, there are some countries that will start suffering the consequences of this high number of cases in a short period of time; therefore, they will need to start taking legal provisions in their health care systems in order to facilitate international aid for AIDS to meet with less bureaucratic barriers.

Governments should also become involved in promoting social solidarity for PLWA. However, this effort should go through the action of NGOs and interests groups who have the capabilities and honesty to make the best use of resources for this kind of work..

Countries in LAC during their reform processes should have a clear idea that even knowing that pubic resources for health will always be limited, there are always alternatives in the policy arena to benefit the population. These alternatives can go beyond medical care. However, health ministries will still be responsible for surveillance and for ensuring that such policies are complied by the proper authorities and legal entities.

Finally, in terms of medical care, LAC health ministries must be aware of new advances and discoveries in AIDS care, so that they can incorporate to the health systems the treatment schemes that start demonstrating to be cost/efficient for developing country settings, such as the case of AZT short treatment for HIV positive pregnant women reported in a recent study in Thailand. This intervention alone can prevent the birth of a new infected person in a significant degree(17) and should be a policy action to be taken in all developing countries’ health care systems.

References

1.UNAIDS, The HIV/AIDS situation in mid 1996, Global and Regional Highlights. Fact Sheet, 1 July, 1996.

2. UNAIDS, The HIV/AIDS situation in mid 1996, Global and Regional Highlights. Fact Sheet, 1 July, 1996.

3. Bobadilla JL. Prioridades en Salud en América Latina y el Caribe y el VIH/SIDA. Gac Med Mex 1996;132 Suppl 1. En Prensa.

4. El Legado de la Cumbre sobre SIDA, en París. Preparado por el Consejo Internacional de Organizaciones con Servicio en SIDA, julio, 1996. LACASSO- América Latina y el Caribe.

5. Saavedra J. Comentarios sobre Establecimiento de Prioridades en Salud en América Latina el VIH/SIDA. Gac Med Mex 1996;132 Suppl 1. En Prensa.

6. Trujillo F, et al. Comisión Nacional del SIDA, Ministerio de Salud Chile. Direct Costs of Medical Care Rendered to HIV/AIDS Seropisitive Adult Patients in Four Public Hospitals in Santiago, Chile. XI International Conference on AIDS, Vancouver, Canada, July 7-12. (Abstract Tu.D.255.)

7. Graham J. Overcoming Media Obstacles To Stop the Spread of HIV. XI International Confference on AIDS, Vancouver, Canada, July 7-12. (Abstract Pub.D.1436.)

8. Sepúlveda J, Bronfman M. Las Campañas de Prvención del SIDA en México. Gac Med Mex 1996;132 Suppl 1. En Prensa.

9. Chinai R. Media Approaches To Quality Writing On Aids. XI International Confference on AIDS, Vancouver, Canada, July 7-12. (Abstract Pub.D.1391.).

10. Maulen-Destefani G, Silva BJ, Del Rio C, Uribe P. Three Years of Mass Media Communication Campaigns in Mexico. XI International Confference on AIDS, Vancouver, Canada, July 7-12. (Abstract Pub.D.1394).

11. Hoff C, et. al. Gay Men at Highest Risk are Best Reched Through Outreach in Bars and Community Events. Center for AIDS Prvention, University of California, San Francisco. XI International Confference on AIDS, Vancouver, Canada, July 7-12. (Abstract Tu D.360.)

12. Martínez LF. et al. Asociación de Talleres Holísticos. The Guatemalan Gay/Bisexual and Lesbian Culture House (GGLCC): Alternative Activities Fostering Self Steem, Behavioral Changes and AIDS Prevention. XI International Confference on AIDS, Vancouver, Canada, July 7-12. (Abstract Tu D.363.)

13. July arrasco E. Programme of Action and Promotion of AIDS Related Human Rights in Venezuela. XI International Confference on AIDS, Vancouver, Canada, 7-12. (Abstract Tu.D.350).

14. Levine W, Higueras G. et al. Rapid Decline in Sexually transmited Disease Prevalence Among Brothel-Based Sex Workersn in La Paz, Bolivia: The Experience of Proyecto Contra SIDA, 1992-1995. XI International Confference on AIDS, Vancouver, Canada, July 7-12. (Abstract Mo.C.441).

15. Bronfman M, Amuchástegui A, Martina RM, Minello N, Rivas Martha, Rodríguez G. SIDA en México migración, adolescencia y género. México: Información Profesional Especializada, 1995.

16. Muñiz Martelón Melba, Baez-Villaseñor J, Del Río C. et al. Mexican Migrant HIV issues: Problems and Strategies. XI International Confference on AIDS, Vancouver, Canada, July 7-12. (Abstract Tu.D.246).

17. Gordon, Mansergh ¨" Cost Effectiveness of Short-Course Zidovudine To Prevent Perinatal HIV in Developing Country Settings. Mailstop E-45, DHAP, NHCHSTP.