AIDS in Nicaragua
Ten years ago, on June 5, 1981, the Center for Disease Control in Atlanta published a short report on an unusual outbreak of a strain of pneumonia among five gay men in Los Angeles. Though nobody at the time could have imagined it, that was the official beginning of what has become a worldwide AIDS epidemic. By 2000, the World Health Organization says, some 40 million people worldwide will be infected with AIDS.
Historical epochs have often been marked by epidemics that ravage entire communities and send the population into hysteria as the disease runs its course. While a dramatic cholera epidemic almost surely awaits Nicaragua, AIDS—a far more hidden disease—has already entered to much less fanfare. Though there is no known cure for AIDS, measures can be taken to prevent it, but they go to the very heart of what have long been considered intimate and largely taboo issues. If AIDS is to be successfully confronted in Nicaragua, general taboos and stereotypes about sexuality will have to be dealt with in an honest and open way.
At first glance, the regional statistics available on AIDS and the HIV virus would suggest that the threat in Nicaragua, compared to other Central American countries, is very small. Honduras reports over 1,000 cases, with 319 deaths registered by the end of 1990. The first AIDS cases reported in Central America were in 1985 and involved prostitutes working near US military bases in Honduras. There are 232 cases in Costa Rica, with 122 deaths, while El Salvador lists 323 cases and 63 deaths. By January 1991, Nicaragua had reported 14 deaths. Nicaragua's first official AIDS deaths were reported in 1988 when the Ministry of Health revealed that two young men had died from AIDS that year. Thirty-one people in Nicaragua are currently listed as HIV-positive: that is, they carry the virus, but have not yet developed symptoms. The majority of those testing positive are young men between 25 and 34 years of age. Some HIV-positive people will never develop the disease, but are obviously still at risk of passing it on to others.
There are several reasons, however, to look beyond the immediate statistics at what is potentially a very serious situation for Nicaragua. First, diseases that carry a heavy social stigma such as AIDS are traditionally underreported in Nicaragua. The Ministry of Health estimates that only about 30% of all sexually transmitted diseases, none of them as stigmatized as AIDS, are reported to its offices. The Pan-American Health Organization says that Nicaragua's system of reporting and tracking diseases is not sufficient to give an accurate picture, even if only in the very broadest terms, of the shape of the AIDS profile in Nicaragua today.
In many countries, about half the total number of all reported AIDS cases are deaths. Looking at the Nicaraguan case would further suggest serious underreporting of AIDS. Nicaraguan Health Minister Dr. Ernesto Salmerón calculates that for each reported case of AIDS (that is, someone who has developed symptoms and is ill), 10 people carry the HIV virus in their blood. But Pascual Ortelles of the Managua-based AIDS research and education foundation Nimehuatzín calls that estimate "conservative," citing research indicating that between 30 and 50 people will be identified as HIV positive for each single case of AIDS. Of that number, about 30% are likely to develop the disease themselves within a 3-year period.
Ana Quirós of the Center for Health Information and Consulting Services (CISAS) says that a further problem in Nicaragua is that relatively few tests for AIDS are done. She attributes that to limited access to the tests on the one hand, and the fact that there is relatively little public consciousness about AIDS on the other, so people—both patients and health workers—often mistakenly identify AIDS symptoms as other diseases still common in Nicaragua, including pneumonia, tuberculosis and complications related to diarrhea.
A third reason she gives for the low number of tests is that many people have little motivation to find out whether or not they are HIV-positive—a fatalistic resignation that if they're sick, there's little that can be done in any case. "People are not too interested in getting tested, although during the workshops, they'll tell you, yes, they'll get tested." In addition, Quirós says, the poor treatment that some AIDS patients have received in hospitals here contributes to a climate in which it is simply easier not to get tested. Earlier this year, a young man in León died of AIDS and, according to Quirós, "there was such a lack of ethical behavior by the health care workers there that everyone knew everything, even the names of the people he slept with. If you know that's going to happen, why go get tested?"
Along with underreporting, another element affecting what, to date, has been a relatively low incidence of reported AIDS cases in Nicaragua is that the country was fairly isolated from neighboring countries during much of the 1980s. While border restrictions earlier regulated the flow of people between countries, particularly in terms of commerce, increased interaction now between Nicaragua and its neighbors—especially Honduras, with its alarming rate of AIDS—could soon change that situation. Also, the US embargo against Nicaragua meant that few blood products from abroad entered the country; in other countries, blood and plasma imports have been one way for the AIDS virus to enter.
Given the number of reported cases in Nicaragua, one could estimate that between 400 and 700 people may well be carrying the HIV virus now and as many as 200 will develop the disease within several years. In any case, it has entered Nicaragua and whatever its rate of development, its incidence is sure to increase dramatically in the coming years.
The disease profileAIDS has been stereotyped as a disease affecting primarily gay men, which was long the case in the United States. Particularly in the early years of the AIDS epidemic there and in other developed countries, several key risk groups could be identified: gay men, prostitutes and IV-drug users. Today, however, AIDS in the US is rapidly expanding, and exponentially in poor urban communities. As this happens, the relatively narrow risk group categories are becoming less and less relevant. In Nicaragua, the HIV virus has had this broader impact from the start. Ortelles says, "We think there really aren't risk groups per se. That way of looking at the disease isn't useful here. We're talking instead about practices that put people at risk."
In Nicaragua, AIDS to date has been concentrated in the heterosexual community and is potentially a more serious problem in the country's rural, rather than urban areas. AIDS is fast becoming the new disease of the poor and marginalized throughout the world, and that is the community likely to be most affected in Nicaragua as well.
Gay Community. While AIDS has not been primarily a "gay" disease in Nicaragua, work around AIDS has given the gay community here a somewhat higher profile. Some of the earliest efforts to confront AIDS were done by a popular education collective that worked principally in Nicaragua's gay community during the late 1980s. Workshops on AIDS by the Ministry of Health, CISAS and Nimehuatzín all reach out to the gay community, but not as a single or even primary focus.
Repatriating Contras and Refugees. As the contra war wound down, health professionals were quite concerned that the demobilized contras and refugees returning from Honduras could well pose a significant threat to Nicaragua, given the high level of AIDS concentrated in and around US bases there. As part of the repatriation process, AIDS tests were done on thousands of refugees and demobilized contras last year.
The Pan-American Health Organization tested 6,000 of the 20,000 demobilized contras who went through the CIAV processing stations. Of that number, only one person tested positive. In the refugee processing centers under the auspices of the UN High Commission on Refugees, some 6,000 people were tested—about half of the total who passed through. Four people tested positive. While these numbers are very small, they do not necessarily represent the non-tested populations. It is possible that people who had reason to think they carry the HIV virus simply refused to be tested.
The question of testing raises important issues of medical ethics. Ana Quirós of CISAS notes that the Health Ministry originally intended to do AIDS tests on all repatriates and demobilized contra forces, without informing them. But, she says, "There was protest on the part of the international health workers who were working with the repatriates and contras." They demanded that people be informed about the test and also urged that some basic educational work be done, both before and after—particularly, of course, for those testing positive.
Prostitutes. One group at high risk because of their sexual practices is prostitutes. Since prostitutes in Nicaragua are not an organized group able to advocate for and protect themselves against the possibility of AIDS within their ranks, they are more difficult to reach. In other countries, including Brazil, prostitutes have organized around health issues, including AIDS, but that day is far off in Nicaragua. Some basic educational work has been done, but fear and mistrust have to be dealt with as well as their understandable unwillingness to have much to do with anyone seen as representing any kind of official position.
In April, some media in Managua reported in a fairly sensationalistic manner that a young prostitute had contracted AIDS, and had possibly infected more than 100 people. Sensationalizing the problem will do little to confront the issue, particularly since prostitution is on the upswing with the deteriorating economic situation.
Education and preventionThe key to confronting a potential AIDS crisis in Nicaragua can be summed up in one word: prevention. Prevention, in turn, is dependent on a thoroughgoing, broad and open education program about what AIDS is and what measures must be taken to confront it. Both CISAS and Nimehuatzín, along with the Ministry of Health, are involved in the key work of education and prevention. Pascual Ortelles underscores the need for people to change, or at least modify, their habits if prevention is to be at all effective. He emphasizes that it is a question of explaining to people which of their practices may be putting them at risk. In the US, AIDS prevention campaigns have provided intravenous drug users with clean needles to diminish the possibility of spreading the disease. This in turn touched off protest among some sectors that claimed that drug use was thus being encouraged. The point, says Ortelles, is not to moralize or preach, but rather to reach and educate people.
In Nicaragua, where the traditional risk group categories do not apply, one group at high risk—and desperately in need of information and education—is young people. A 1990 Nimehuatzín survey noted that young men are often sexually active as young as 13, with young women following at only a slightly older age. Young Nicaraguans also tend to change partners often, a practice that puts them at greater risk of contracting and spreading AIDS. Recently, the recorded number of both pregnancies and sexually transmitted diseases among young women has increased significantly, further indicating that AIDS could well become a serious problem among Nicaragua's youth. Lack of education among young people is well illustrated by a mid-April report in a Managua newspaper quoting several university students as attributing the spread of AIDS to "lack of hygiene."
AIDS educators emphasize that Nicaragua needs a broad-based sex education program, so AIDS can be discussed in a wider context. Without that wider focus, some warn, discussions about AIDS tend to turn around issues of fear and longstanding social prejudice—attitudes that can only damage potentially effective responses to the problem. CISAS is currently working with the Sandinista Youth to train a number of base-level promoters in sex education who would take up AIDS as one of a number of general issues relating to sexuality.
The case of El Viejo. CISAS has been working for several years in El Viejo, Leon. The work there began in the gay community, and dealt with general health and social issues. The result, according to Quirós, is that people are beginning to understand the importance of being tested for AIDS, and CISAS provides counseling both before and after the tests. In addition to the gay community, CISAS is working with returning refugees in conjunction with the Nicaraguan Repatriation Institute, as well as doing general work with the youth of El Viejo.
Ideological obstacles in the "new" NicaraguaIf AIDS is to be effectively addressed, topics long considered off limits in Nicaragua will finally have to be put on the table. The UNO government is bent on reinforcing traditional patterns of sexuality, family planning and the like. So, while reality indicates an increasing number of youth becoming sexually active at an early age, with all the risks that implies, the new school textbooks insist on upholding a traditional morality that simply does not correspond to Nicaraguan life.
AIDS is in Nicaragua, like it or not, says one AIDS educator, and it is everyone's responsibility to set moral prejudices aside and see it for what it is—a public health problem that has the potential to be devastating if we are not able, at these crucial early stages, to respond to it.
One example of official refusal to deal with AIDS as a scientific public health issue rather than a moral crusade is Nimehuatzín's recent experience with Channel 6, Nicaragua's state-owned television station. The foundation filmed a public service announcement about AIDS and how it is spread—as the clip showed a couple kissing, the voiceover emphasized that kissing does not spread the disease. Channel 6 has refused to run the PSA. The official line, far from promoting safe sex, would seem to be insisting on "just saying no" to sex in general.
Last December 1, to celebrate international anti-AIDS day, some 18 organizations came together in a national anti-AIDS campaign. The campaign, which has been carried out every December for several years, is aimed at educating people about AIDS in a humorous way—getting rid of the image of death and doom that tends to surround discussions of the topic.
This year, Health Minister Salmerón, who had initially commented that AIDS simply was not a problem in Nicaragua, was forced to make several, generally useful, public statements. As part of the campaign, free condoms were handed out in different places throughout the country. The Catholic hierarchy, whose response to AIDS thus far had been to simply ignore the problem, called the campaign "irresponsible and sinful"—proof, one educator said, that it was finally beginning to have an effect.
Other ideological obstacles to effectively dealing with AIDS are embedded in Nicaraguan culture. It is common for men to have several sexual relationships outside their marriage or consensual unions—many men consider it virtual proof of virility or sexual attractiveness. Coupled with men's general reluctance, if not outright refusal, to use condoms—essential to safe sex—this creates a potentially grave problem. Spouses of partners with multiple relationships often may not even know they are at risk because of their partner's sexual practices. A significant, and largely hidden, proportion of heterosexual men are also involved intermittently in homosexual relationships. These men may not even admit to themselves that they are at risk.
A 1989 survey about attitudes towards AIDS reported that, of nearly 300 people interviewed, 27% had no idea how AIDS was contracted or spread: 93% thought it came from giving blood; 54% thought it was by kissing; 49% through mosquitoes. Only 6% said they regularly used condoms. After several years of educational workshops in many different social sectors, those first statistics have almost certainly changed. But the number of people who regularly use condoms has likely changed little. What is missing is that crucial step between consciousness and action.
In addition, some Nicaraguans feel that because AIDS has not been a huge problem to date, their country has somehow been spared—AIDS has more than once been characterized as "a gringo disease." But though the disease did in fact seem to get a late start here, geometric rates of expansion similar to those seen in other countries can be expected here as well.
People with AIDSPeople who wish to be tested for AIDS can go to the Red Cross offices in Managua or the central offices of the Ministry of Health. AIDS tests have been done in Nicaragua since 1988; the maximum number of tests done annually is about 30,000. The first test done, the "Elisa" test, costs US$0.75 and has an intermediate level of specificity, thus further testing must be done if it comes out positive. The next test, known as the "Western blot," costs $9.
AZT, an experimental drug that has seen fairly wide use in some areas of the developed world, costs approximately $12,000 annually for one patient, putting it virtually out of reach for Nicaraguan AIDS patients.
Once someone develops AIDS in Nicaragua, deterioration in their health tends to be dramatic and rapid. This is due in no small part to the general poor health level throughout the country. In the United States and other developed countries, people with AIDS often survive several years. Here, the lag between diagnosis and death is usually less than three months.
The family unit, as in other key issues of health, life and death, is really an AIDS patient's key support system in Nicaragua. Given that the already overstressed and under-budgeted health and social welfare systems will be ill-equipped to deal with a possible epidemic, on whatever scale, the family will bear the brunt of the care for AIDS patients. To lighten its load, the critical combination of education and prevention is urgent.