Roadblocks on the Road to Treatment: Lessons from Barbados and Brazil

Abstract

On a beautiful tropical day, two women living thousands of miles apart enter public clinics. One walks past the neatly parked cars in the parking lot, to the front door of the newly built, well-equipped Ladymeade Reference Unit, which stands across from the largest public medical facility on the island of Barbados. Everything about this experience is neat and well-ordered, from the facilities the woman is entering, to the pill boxes bearing brand-name labels that she receives at the in-house pharmacy, to the referral system that sent her here after she delivered a baby across the street. The second woman’s experience appears a bit less ordered. The clinic she enters, which sits on the outskirts of one of Brazil’s slum-ridden cities, is shabby, with peeling paint and a utilitarian concrete structure. Inside, there are no shiny, manufacturersponsored posters to match the pills being dispensed, because these pills do not bear familiar brand-name labels. Though the pictures may appear quite different, they bear a crucial similarity—both women are living with HIV, and both are fortunate to live in countries that have committed themselves to providing universal treatment access for their HIV-positive citizens. The scourge of HIV/AIDS has affected every country across the globe, though nations have been overwhelmingly slow and incomplete in their responses. At the same time, great strides have been made in the development of treatments. It is now possible to use a combination of antiretroviral medications (ARVs) to render what was once an inevitably fatal disease into a manageable, chronic condition. However, only a few countries have made the commitment to provide these medications to all their people who need them. Within that very short list are two countries that represent extremes in size, power, history and heterogeneity. Brazil: diverse, large in geography and population, with a legacy of turbulent transitions and up-andcoming as a regional power, and Barbados: a tiny island nation, with a small acreage and citizenry, fairly homogenous population, and long-standing history of peaceful and democratic governance. The governments of both countries have made a commitment to their people to provide them with the therapies that, in most low- to middle-income countries, are only available to the few who can afford to pay for them. It is no accident that these countries have two additional commonalities that have had major consequences for people living with HIV. Facilitating both countries’ commitments has been sufficient political will as well as recognition of health care as a human right. What most clearly differentiates the effectiveness of their approaches has been the relative engagement of civil society, and especially of people living with HIV/AIDS (PLWHAs) themselves, in enforcing this commitment.