**Featured interview in this article by Anne Deslandes, published by Foreign Policy on November 13, 2019. Available here.**
HIV in Mexico is once again a time bomb that will explode.” That’s how Aram Barra described the current trajectory of the immunodeficiency virus in the country at the International AIDS Society Conference on HIV Science in Mexico City in July. The public health activist and program officer at Open Society Foundations was specifically referring to February’s deep funding cuts to civil society organizations. These funding changes, intended to address corruption, have put Mexico’s model of funding and distribution for organizations that work with HIV patients at risk, just as a groundbreaking rollout of a new treatment regimen could set a global example.
In February, Mexican President Andrés Manuel López Obrador announced that government funding for social programs would cease. This funding has traditionally supported a range of civil society organizations providing community-based services, including those that work with HIV-affected and other vulnerable populations, providing services such as distribution of medicines for people living with viruses including AIDS, HIV, and hepatitis C. Instead, the president said, government money earmarked for social programs would go directly “from the federal treasury to the beneficiary.”
López Obrador defended the change by alleging that the previous system of government funding for civil society organizations in Mexico led to spending on office renovations and employee salaries, and fudged numbers to line the pockets of organizational executives. It wasn’t just community services, including women’s shelters and child care services for working mothers, that faced cuts around this time—hospitals, sporting, and scientific organizations also lost funding. These cuts have been made on the general basis that López Obrador’s new federal administration is committed to ending Mexico’s so-called golden bureaucracy: a system whereby public servants used government funds to live a life of luxury.
There’s a real danger that the president is throwing the baby out with the bathwater here. López Obrador’s commitment to pulling certain financial levers to stamp out corruption is laudable and needed for Mexico, as is the prospect of fine-tuning social policy to ensure greater benefit flows to those who need it. But the consistent provision of important health and social services for the Mexican people, along with the many migrants who continue to pass through Mexico on their way to the United States, could be the cost. Many organizations that relied on government funding must now scramble harder than usual to stay alive, by seeking donations from elsewhere in the community or reducing the services they offer to those that can be funded by overseas sources such as Open Society Foundations. Some may close altogether.
In cities on the U.S.-Mexico border, several civil society organizations that work with HIV-affected and other vulnerable populations have already been severely hurt by the funding cuts. According to Marc Krupanski, the senior program officer who oversees this harm reduction work at Open Society Foundations, use of injected drugs is concentrated in cities on the border. He noted that border cities such as Ciudad Juárez, Mexicali, and Tijuana have also historically had a higher prevalence of sex workers. People who use injected drugs and sex workers are among key populations targeted for support and treatment as part of the global HIV response. Krupanski said there are many local organizations in border cities now facing some critical obstacles due to the funding cuts.
For example, Prevencasa, a community-based service for people living with HIV in Tijuana, has been directly affected by López Obrador’s funding cuts. “We know from them that people have been unable to keep up with their treatment due to lack of availability [of medications],” Krupanski said. The risks of these interruptions are not just about treatment—they also affect vital interventions such as sterile syringes and needles, outreach programs, and condom distribution, which are critical for HIV prevention and mitigating HIV outbreaks.
Prevencasa’s Alfonso Rivera confirmed that the cuts have placed pressure on the services the organization provides, particularly on the provision of medicines that could previously be bought with government funding. He also noted that the crackdown on migrants at the U.S. border has created reluctance among its clients to seek treatment. While treatment for HIV is legally provided for free and without discrimination in Mexico, a heavy cultural stigma already prevents many from getting tested and treated.
Funding cuts and migrant crackdowns have only compounded this problem. “We had a couple of migrant patients with HIV who did not want to seek treatment because they did not have their immigration status resolved, for example, while they were waiting to cross into the United States,” Rivera told Foreign Policy. The patients were in Mexico while they waited for the outcome of their political asylum claims under the so-called Remain in Mexico policy that requires asylum-seekers to wait on the Mexico side of the border until their case is due to be heard in the United States.
As a result, treatment needs for any migrants living with HIV within Mexico have increased. Clínica Condesa, which has been serving people living with HIV in Mexico City for the past 20 years, includes a program known as Clínica Santuario (Sanctuary Clinic) through which migrants from any country and with any migration status can access testing and treatment. From January 2017 through June 2018, 941 patients, or roughly 49.7 percent of the clinic’s overall migrant clientele were from Venezuela, Colombia, and Central America, especially Honduras and El Salvador, many passing into Mexico in the hope of reaching the United States. The year before, the total number was 241, the clinic’s medical director, Florentino Badial Hernández, told the national news agency Notimex in November 2018.
Concerns about access to HIV treatment across Mexico were also raised in May when the federal government—which, in practice, provides free universal access to these life-saving medications for people living with HIV—made a change in how it purchased medications from pharmaceutical companies. The change was welcomed by HIV advocates, but the changeover period resulted in delays in buying and distributing the drugs, which then delayed access to treatment for some patients for a brief period of time.
Despite the funding change, Brenda Crabtree-Ramírez, a staff physician in the Infectious Diseases Department at the National Institute of Health Sciences and Nutrition Salvador Zubirán in Mexico City, said she feels optimistic about the future of HIV treatment in Mexico—specifically because Mexico is about to become the first country in Latin America to launch a large rollout of Biktarvy, a new generation of HIV treatment drugs that entails a one-pill-a-day treatment regime. The rollout was proposed as part of negotiations between the national HIV/AIDS agency, Censida, and pharmaceutical companies to change purchasing arrangements for HIV medicines in Mexico. Biktarvy manufacturer Gilead agreed to a massive purchase at a lower price, and Mexican stocks of Biktarvy will be the largest in the world.
The Biktarvy rollout is a bright spot in the recent tumult around access to medications and funding—promising that shortages of medicines will not recur (because it replaces other pills, and there will be a continuous supply) and that first-time patients in particular will have a new and simple way to receive the antiretroviral drugs they need.
Krupanski, the Open Society Foundations officer, also noted that Mexico is working from a very solid foundation in supporting people living with HIV within its borders. The creation of Censida and its working relationships with Mexico’s National Institute of Social Development were particularly positive, he said. “Those agencies set up funding through local civil society organizations who are well placed to support people with HIV, who have trust with key populations—I think many others were hoping that other countries would be able to follow this model,” Krupanski said. Lately, the global sector had been “looking to Mexico as having among the best practices for the assumption of national funding for HIV prevention and treatment.”
While Krupanski said the recent funding changes have put Mexico’s model at risk, he added that going forward he hopes Censida will continue its support of local organizations providing direct services to vulnerable populations—especially given that civil society organizations, such as Prevencasa, are bringing the number of infections down in addition to providing community support for people living with HIV.
For instance, Programa Compañeros, in Ciudad Juárez, reports that it significantly reduced the rate of HIV among clients from key populations who are the focus of the global HIV response—migrants, sex workers, and those who use injected drugs. An analysis of 66,973 people included in harm reduction programs across Mexico, published in August, showed that an estimated 869 HIV infections were averted between 2015 and 2018 due to participation in those programs.
Civil society organizations such as Programa Compañeros and Prevencasa are some of the strongest links in Mexico’s globally respected HIV response. They are safe spaces free of shame and stigma where testing and treatment can begin and continue for a range of vulnerable populations. The border state of Nuevo León passed a law on Oct. 21 allowing doctors to object to treating patients with HIV—a troubling development that underscores the urgency of support for groups that provide treatment.
Responding to criticisms of the announced funding cuts, López Obrador said that the overall program of government funding for civil society organizations is being analyzed with a view to ensuring that there are no intermediaries between the treasury and the funds’ intended beneficiaries. Exactly how this will be ensured has not yet been revealed.
If the president does not want a ticking “time bomb” to explode under his administration, he must make sure that these community organizations are not disadvantaged by the recent changes in policy and find a way to return the government resources these groups had been relying on. Other parts of Mexico’s HIV response, such as the Biktarvy rollout, are still leading the world—it is not too late to reverse course to keep key populations supported and keep the rate of HIV infections down.