Inequities in Prevention and Treatment of HIV and TB, and the Influence of Social Determinants on Health in Rosario, Argentina

A man walks down the street past a building with graffiti on it.
Street graffiti on a HIV NGO in Rosario after the Pride parade (“Prevention is not a cure”), 2022

In the city of Rosario, the communities speak as well as the walls. Rosario is a region with 1.3 million inhabitants, 300 km from the city of Buenos Aires. It is a place where feminism, sexual diversity and even HIV activism cross.

It is impossible to think about the health of individuals or communities from the mere presence or absence of a disease. The historical view, an approach that recognizes the tensions caused by a multiplicity of problems, shows that demanding policies and interventions by and for health is not a simple task.

Infections like tuberculosis and HIV are indicative of these difficulties. These are public health problems that are unequal among jurisdictions, and handled in unequal ways, with a tendency toward increased incidence in recent years. These infections mostly affect groups of young people, with a concentration in large urban areas. The inequalities are not distributed randomly, but are deeply determined by the social, political, sexual, ethnic and economic structures in which we live.

From the epidemiological point of view, there has been an increase in the incidence of diagnosed and reported cases of tuberculosis in the city of Rosario, as well as the appearance of late or very late diagnoses of HIV, which leads to the person presenting symptoms of AIDS marker diseases accompanied by a very low CD4+ count.

The Other Face of the State: Inequities in the Face of Right

As community representatives or people involved in primary health care, we believe it is absolutely necessary that the State (national government), with its public policies, analyze and evaluate how the diversity of social determinants have an impact on late diagnosis, on inequities in access to prevention policies, and on difficulties in access to treatment, which often only reach the middle-to-upper sectors of society.

From a rights-based perspective, it is possible to observe an increase in exclusion, inequality, and social fragmentation that have generated a direct impact on the increase of TB cases and late diagnosis of HIV during the last decade and following the COVID pandemic. There is an increase in the number of people accessing primary health care later than in previous years, and it is possible to observe how situations of poverty were aggravated, and how these situations affected key and stigmatized populations. This made class differences more clearly evident, demonstrating the vulnerability of migrant populations (people from bordering countries who come into the public health system with clear symptoms of tuberculosis), and highlighting how inequalities in access to prevention, diagnosis and treatment policies are carried out across racial and gender differences in parts of the LGTBQIA+ community.

Given this context, we see the need to build more comprehensive prevention and support tools that allow key populations to access diagnosis and treatment, while at the same time improving the quality of life of these stigmatized and vulnerable groups.

A combination prevention policy is being implemented currently in Rosario which unfortunately does not reach the most excluded population groups. Community work has much to contribute regarding access to prevention and diagnostic policies, such as dissemination through social networks, significantly increasing testing sites, developing strategies that favor accessing the health system earlier by those who arrive too late to be attended, and participating in the education and training of health personnel in order to make the public health system more culturally responsive.

We believe that policies aimed at a more equitable distribution of income, providing educational opportunities, reducing precarious employment conditions, and drastically reducing the housing deficit, among other policies, would surely attenuate the above-mentioned inequalities.

Although these are broader social objectives that should not be forgotten, there are actions that community advocates can take along the way, and this is our challenge.

A woman walks down a street, the building next to her is covered in graffiti.
LGTB activism graffiti in Rosario after the Pride Parade, 2022 (in pink, center, “My blood is on the battlefield”, “pride”, “HIV rich”)

Relationship between HIV and Tuberculosis

There is a high prevalence of HIV among people who have tuberculosis, and there is an increasing number of cases of people who seek care in public health systems with symptoms of tuberculosis and who are also found to have HIV as a co-infection. Despite the inconsistencies that exist in the reports provided by different levels of the government and health sub-sectors (reports from the public, private and mixed medical spheres, which report new cases in a partial manner), it is clear that both diseases show no signs of decreasing.

While the ways in which both illnesses exist and are transmitted are clear and have been known for more than 40 years, we still need to work for the eradication of HIV and tuberculosis in our region. With policies that intervene in different ways and with very different intensity in different segments of the community, the incidence has remained stable but is increasingly occurring in young people. What else is necessary to implement to take a greater step forward?

Although it is necessary to think beyond biomedical prevention, broadening the dimensions of the health-disease-care process is a task that must not be abandoned. Understanding the social determinants of health should be a key training requirement for healthcare workers. They must also understand that the configuration of health problems is not the individual's fault, but the result of a historical process to which societies have been exposed.

Our bodies and our illnesses have stories that still deserve to be told. And with scientific advances, our quality of life is improving every day. But that is only the first step: having laws to protect us and loving bonds to accompany us in living with illness is one of the greatest signs of love.

Living with HIV is a political situation, and so is living with tuberculosis. Understanding the perspectives of groups that demand a cure, including stigma, is a requirement not only for community, health or political groups, but also for the entire population. People living with HIV and TB should not be exposed to late diagnosis, isolation, difficulties in accessing treatment, or the fear of discontinuity due to shortcomings in health services.

Gustavo Osimani and Lautaro Martín Maino work to ensure community members are engaged and meaningfully involved in HIV research conducted at the Centro CAICI Clinical Research Site.