Abstract

Introduction

The African continent, and especially the Sub-Saharan region, a group of African countries south of the Sahara desert, has been prominent as the most impacted area by the Human Immunodeficiency Virus (HIV) since its emergence, showing higher morbidity and mortality rates from causes related to Acquired Immunodeficiency Syndrome (AIDS) and concentrating more than two thirds of all people living with HIV in the world¹1 Kaiser Family Fundation. The Global HIV/AIDS Epidemic [Internet]. KFF; 2021 [citado 3 mar 2021]. Disponível em: https://web.archive.org/web/20210314172148/https://www.kff.org/global-health-policy/fact-sheet/the-global-hivaids-epidemic/
https://web.archive.org/web/202103141721... .

It is estimated that two African regions (East Africa and Southern Africa) accounted for more than half (54%) of all people living with HIV in the world in 2021; two thirds (67%) of children living with HIV/AIDS are in the Sub-Saharan region. The epidemic is widespread in almost every country in the region and South Africa, a country in the far south of the continent, has the largest number of people living with HIV in the world, with 7.5 million people. Eswatini (formerly known as Swaziland), also located on the African continent, has the highest prevalence in the world (27%)¹1 Kaiser Family Fundation. The Global HIV/AIDS Epidemic [Internet]. KFF; 2021 [citado 3 mar 2021]. Disponível em: https://web.archive.org/web/20210314172148/https://www.kff.org/global-health-policy/fact-sheet/the-global-hivaids-epidemic/
https://web.archive.org/web/202103141721... .

Not unlike the other countries on the continent, Guinea-Bissau, a Portuguese-speaking African country, has the HIV epidemic among its three main public health problems. Its prevalence in adults (15 - 49 years) was 3.1% in 2021. Thus, with the exception of Equatorial Guinea (6.9%) and Mozambique (no indicator available), Guinea-Bissau has the highest prevalence rate among the Portuguese-speaking African countries (PALOP): Angola (1.6%), São Tomé and Príncipe (0.5%) and Cape Verde (0.6%), as well as the countries with which it shares borders: Guinea (1.7%) and Senegal (0.3%), all located in sub-Saharan Africa. It also has a higher prevalence compared to other Portuguese-speaking countries that don’t belong to Africa: Brazil 0.6%, Portugal 0.5% and East Timor 0.2%²2 UNAIDS. Programa Conjunto das Nações Unidas sobre HIV/AIDS. UNAIDS Data 2022 [Internet]. Geneva: Unaids; 2022 [citado 20 Abr 2023]. Disponível em: https:/www.unaids.org/sites/default/files/media_asset/data-book-2022_en.pdf
https:/www.unaids.org/sites/default/file... .

Guinea-Bissau is considered to be a fragile, politically insecure low-income country, reflected in its low level of human development, with a Human Development Index (HDI) of 0.483, ranking 177th out of 191 countries³3 Programa das Nações Unidas para o Desenvolvimento. Relatório do Desenvolvimento Humano de 2021/2022 [Internet]. Nova York: UNDP; 2022 [citado 18 Abr 2023]. Disponível em: https://hdr.undp.org/system/files/documents/global-report-document/hdr2021-22overviewpt1pdf
https://hdr.undp.org/system/files/docume... . Faced with the challenge of HIV/AIDS and living in a situation of extreme economic hardship, the country has received support from the Global Health Initiatives (GHI) to control this epidemic, and its actions depend mainly on external funding⁴4 Lima HMM. Diagnóstico Situacional sobre a implementação da recomendação opção B+, da transmissão vertical do VIH e da Sífilis congênita, no âmbito da comunidade de países de língua portuguesa - CPLP [Internet]. Guiné-Bissau: OPAS; 2018 [citado 30 Jun 2022]. Disponível em: https://saude.cplp.org/media/vz3abzdo/cplp_guine-bissau_2018.pdf
https://saude.cplp.org/media/vz3abzdo/cp... .

The unprecedented suffering caused by HIV and other epidemics gave rise to the creation and expansion of GHI. Launched in the early 2000s, IGS are global partnerships formed to reverse the course of HIV/AIDS and other diseases. They are characterized by acting on issues of international concern and carrying out far-reaching and well-funded programs in several countries. The US President’s Emergency Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis and Malaria and the World Bank’s Multi-Country AIDS Program are the three IGS that account for two-thirds of external funding for HIV⁵5 Kidane A, Mwanri L. Systems Thinking for Global Health Initiatives (GHIS) in Sub-Saharan Africa. In: Larkan F, Vallières F, Mannan H, Kodate N, editors. Systems Thinking for Global Health. Oxford: Oxford University Press; 2023. p. 234-45. doi: 10.1093/oso/9780198799498.003.0018.
https://doi.org/10.1093/oso/978019879949... .

Despite the various efforts undertaken over the last few decades in relation to HIV in African regions - and in Guinea-Bissau in particular - the question arises: why does the epidemic persists and is even worsening in sub-Saharan Africa, compared to other regions of the world? How and why has Guinea-Bissau historically been one of the countries most affected by HIV? Why is the country unable to control the HIV epidemic, even with the help of the GHI? Will the country be able to meet the targets set by the Joint United Nations Program on HIV/AIDS (UNAIDS) for 2025? Given the questions raised, the aim is to reflect on the persistence and worsening of the HIV/AIDS epidemic in Guinea-Bissau and the (im)possibility of the country meeting the targets set by the Joint United Nations Programme on HIV/AIDS for the year 2025.

Methods

This is a descriptive study, of the reflective analysis type, which allows the authors to carry out a critical-reflective analysis of the subject. The study was based on central themes for reading and analysis, such as: the HIV epidemic in Africa and Guinea-Bissau; world geopolitics; power relations; stigma/prejudice; capitalism; coloniality; and the targets set by UNAIDS for the year 2025. To complement and exemplify these concepts, databases such as EMBASE, PubMed and Google Scholar were used. As this is a reflection article and not a literature review, the descriptors, type and year of publication, exclusion and inclusion criteria for the selection of bibliographic material were not systematized. It should be noted that scientific research and academic production on the subject (HIV/Aids) in Guinea Bissau is still scarce, especially qualitative studies, which makes it impossible to analyze beyond the country’s official documents⁶6 Galjour J, Havik P, Aaby P, Rodrigues A, Mpinga EK. Chronic Political Instability and the HIV/AIDS Response in Guinea-Bissau from 2000 to 2015: a systematic review. Trop Med Infect Dis. 2021; 6(1):36. doi: 10.3390/tropicalmed6010036.
https://doi.org/10.3390/tropicalmed60100...

7 Jensen MM, Byberg S, Jespersen S, Olesen JS, Silva ZJ, Medina C, et al. The HIV care continuum of Guinea-Bissau; Progress towards the UNAIDS 90-90-90 targets for HIV-1 and HIV-2. Acta Trop. 2023; 241:106887. doi: 10.1016/j.actatropica.2023.106887.
https://doi.org/10.1016/j.actatropica.20... ^-88 Sanca AM, Motta MGC, Giugliani C, Rocha CMF, Riquinho DL. Cotidiano de pessoas que vivem com VIH em Bissau, Guiné-Bissau: perspectivas, desafios e vulnerabilidades. Esc Anna Nery Rev Enferm. 2023; 27:e20210507. doi: 10.1590/2177-9465-EAN-2021-0507pt.
https://doi.org/10.1590/2177-9465-EAN-20... . This was also the reason for choosing to carry out a reflection on the subject.

Reflection

The Sub-Saharan African countries are generally characterized as “underdeveloped” and culturally diverse. These characteristics are commonly highlighted as the main factors for the persistence of the HIV epidemic. However, understanding this epidemic in the countries of the region, particularly in Guinea-Bissau, requires a minimal understanding of the role that the African continent plays in world geopolitics.

Africa remains on the margins in the geopolitical context, serving the dominant economic system for the extraction of materials that are essential for economic development, in view of its possession of prestigious resource reserves, and for the purpose of depositing nuclear waste and other harmful materials, despised by the so-called “developed” countries, whose effect is drastic on public health, causing countless illnesses9. In this perspective, for the perpetuation of such a system, it is crucial that Africa remains lethargic, so a sufficient dose of remedies is applied to the continent, as an intervention not to kill it, but insufficient to cure it, thus avoiding continental anarchy and a simultaneous return to consciousness. These remedies are: exploitation and plundering of its resources, unfair and illegal trade, interference in internal affairs and the promotion of wars, among others. It is therefore astute for the dominant economic system to keep Africa in poverty and promote its devaluation on the world stage.

This situation begs the question: how and why did Africa fall and remain in the “claws” of this system? The clues may lie in the relationship between historical events such as enslavement, colonialism and coloniality, based on capitalism and racism.

In order to distinguish between the concept of colonialism and coloniality, it is stated that:

The logic of colonialism has been perpetuated through the reproduction of the three dimensions of coloniality: being, knowledge and power. The other two dimensions of coloniality, that of being and that of knowledge, are particularly situated in this last dimension. Still on the subject of the coloniality of power, it has a complex structure of intertwined levels that manifests itself through controls: of the economy; of authority; of nature and natural resources; of gender and sexuality; and of subjectivity and knowledge¹²12 Mignolo W. Desobediencia epistémica: retórica de la modernidad, lógica de la colonialidad y gramática de la descolonialidad. Buenos Aires: Ediciones Del Signo; 2010..

Colonialism should be seen as a product of imperialism and imperialism as a product of capitalism. The terms “colonialism” and “imperialism” were coined at the turn of the 19th to the 20th century and are indispensable elements for understanding the different dynamics of modern capitalism’s expansion within the interstate system¹³13 Ballestrin LMA. Modernidade/Colonialidade sem “Imperialidade”? O Elo Perdido do Giro Decolonial. Dados Rev Cienc Soc. 2017; 60(2):505-40. doi: 10.1590/001152582017127.
https://doi.org/10.1590/001152582017127... . Capitalism is understood as a social and economic system that began and developed in Europe at the end of the Middle Ages, with the aim of replacing the feudal order. This system expanded its area of influence and became globally dominant in the 18th and 19th centuries as industrial capitalism, with a high level of technology and linked to a massive accumulation of capital¹⁴14 Jaeggi R. O que há (se de fato há algo) de errado com o capitalismo? Três vias de crítica do capitalismo. Cad Filos Alem. 2015; 20(2):13-36. doi: 10.11606/issn.2318-9800.v20i2p13-36.
https://doi.org/10.11606/issn.2318-9800.... .

The birth of neoliberalism in the first half of the 20th century profoundly transformed capitalism by changing societies too much. Neoliberalism can be understood as the “set of discourses, practices and devices that determine a new way of governing men according to the universal principle of competition”. This model transcends the limits of a simple ideology or type of economic policy; it is a normative system whose influence extends throughout the world, extending and implementing the logic of capital to all social relations and in all areas of life¹⁵15 Dardot P, Laval C. A nova razão do mundo: ensaio sobre a sociedade neoliberal. São Paulo: Editora Boitempo; 2016..

The implementation of the neoliberal agenda relied on the elimination of agents/systems of resistance and opposition through violence. However, this is not the power that sustains the system of disciplinary and industrial society, which was repressive, workers exploited by factory owners, usually foreigners, which led to protests and resistance. In this repressive system, not only oppression, but also the oppressor was visible, and a revolution was possible to overthrow the dominant relationship of production, with a concrete opponent, a visible enemy against whom to oppose¹⁶16 Han BC. Capitalismo e impulso de morte: ensaios e entrevistas. Philipson GS, tradutor. Petrópolis: Vozes; 2021..

The visibility of oppression and the oppressor made possible protests such as the one that took place on August 3, 1959, in the city of Bissau, resulting in the “Pindjiguiti” massacre - one of the key episodes in triggering the struggle against colonialism in the country. Like the transformation of a virus, neoliberalism has reinvented itself (mutation of the social virus), to the point where it is no longer judged by workers as repressive, but seductive, in other words, fascinating.

In this scenario, a possible protest would be in opposition to what or whom? Against oneself? The class struggle has become a paradox - an inner struggle with oneself. Those who fail today blame themselves, ashamed of their personal inability to beat other competitors in an extremely competitive world.

The analysis initially refers to examples such as platform-mediated business deliverers, where each worker considers themselves a free entrepreneur and responsible for all the risks and costs arising from their work, while the platform company shirks its labor responsibilities - contemporary forms of eliminating labor rights¹⁷17 Abílio LC, Amorim H, Grohmann R. Uberização e plataformização do trabalho no Brasil: conceitos, processos e formas. Sociologias. 2021; 23(57):26-56. doi: 10.1590/15174522-116484.
https://doi.org/10.1590/15174522-116484... . From this perspective, when considering countries as a unit of analysis in a geopolitical context, one can see that countries like Guinea-Bissau are captured within this logic. The discourse of an independent state, free from colonialism, encompasses the status of freedom, individualization, responsibility and blame for failures, insofar as it ignores the reinvention of colonialism, coloniality. Thus, taking into account the purpose of neoliberalism and the tricks of coloniality, we understand that the factors for the persistence of HIV in Guinea-Bissau transcend the country’s borders.

Unbridled and blind accumulation, violence and death produced by the current economic system, whether through diseases such as AIDS or in other ways, are justified as a way of denying death¹⁶16 Han BC. Capitalismo e impulso de morte: ensaios e entrevistas. Philipson GS, tradutor. Petrópolis: Vozes; 2021.. Violence that kills produces a sense of growth, power, strength, invulnerability and perpetuity. By killing, it protects itself from death and, at the same time, takes possession of it. In other words, this accumulation gives the owner predator status and immunity from death. Thus, the death drive generated by neoliberal capitalism is paradoxical, since it leads life to death so that the lives of only a few may live¹⁶16 Han BC. Capitalismo e impulso de morte: ensaios e entrevistas. Philipson GS, tradutor. Petrópolis: Vozes; 2021..

In order to understand this power and/or the game of life and death, the concept of biopolitics¹⁹19 Foucault M. História da sexualidade I: a vontade de saber. Albuquerque MTC, Albuquerque JAG, tradutores. 19a ed. Rio de Janeiro: Edições Graal; 1988.is presented as politics in favor of life - which is exercised by biopower (power in favor of life, of making people live). By relating Foucault’s notion of biopower to the concepts of state of exception and state of siege, the neologism “necropolitics” was created to explain how the state of exception and the relationship of enmity underpin the normative basis of the right to kill¹⁸18 Mbembe A. Necropolítica. São Paulo: n-1 edições; 2018.. For the author, power, not necessarily state power, continually (works to produce and) refers to and appeals to the exception, the emergency and a fictional notion of the enemy. Thus, biopower operates by biologically separating the human species into groups and subgroups, explained²⁰20 Foucault M. Em defesa da sociedade: curso no Collège de France (1975-1976). Galvão ME, tradutor. 2a ed. São Paulo: Editora WMF Martins Fontes; 2010. as state racism, and deciding which people should live and which should die.

The sovereign right to kill and the mechanisms of biopower are enshrined and can be seen as constitutive components of the power of all modern states. The Nazi state is presented as a faithful example of a state exercising the right to kill. For its implementation, the archetype of power generation was used, which brought together the characteristics of a racist state, a murderous state and a suicidal state²⁰20 Foucault M. Em defesa da sociedade: curso no Collège de France (1975-1976). Galvão ME, tradutor. 2a ed. São Paulo: Editora WMF Martins Fontes; 2010.. “Race is, from a political point of view, not the beginning of humanity, but its end (...) not man’s natural birth, but his unnatural death.”²¹21 Arendt H. Origens do totalitarismo. São Paulo: Companhia das Letras; 2012. (p. 232).

Although the Nazi regime is known worldwide as an example of a racist and murderous state, a model of exercising power that should never be reproduced, it was applied more rigorously to Africans during the period of enslavement and colonialism and which, even in a sophisticated way, has still been applied in the mold of coloniality to Africans and Afro-descendants. This model became repulsive to European “humanity” (the only one recognized as such) only when the Nazi regime applied it to their fellow white Europeans. It can be seen that, unlike other regions of the world, the power strategies used in Africa are not just about maintaining the most diverse forms of exploitation of the continent, motivated by neoliberal capital, but also as a form of exercising necropower¹⁸18 Mbembe A. Necropolítica. São Paulo: n-1 edições; 2018., where racism acts as the basic element and driving force for the destruction of the fictional enemy, and the continent as the geographical and symbolic space of this enemy. Racist, suicidal and murderous status are constitutive elements of the power of all modern states, not just Nazism. What differentiates the Nazi state from today’s states is the degree of intensity of the application of each of these statuses and the (in)ability of the oppressed to identify oppression and the oppressor¹⁶16 Han BC. Capitalismo e impulso de morte: ensaios e entrevistas. Philipson GS, tradutor. Petrópolis: Vozes; 2021., in relation to neoliberalism.

Necropolitics is understood as the ability to determine paradigms in which the submission of life through death is legitimized, in other words, the legitimization of the exercise of necropower. The “killable” body is the non-sovereign body - constantly at risk of death due to the basic defining parameter of race¹⁸18 Mbembe A. Necropolítica. São Paulo: n-1 edições; 2018.. Thus, it is understood that, in the geopolitical context, African countries, especially sub-Saharan countries like Guinea-Bissau, operate as non-sovereign “body-spaces”, which consequently translate the “biological bodies” that inhabit them (population) into non-sovereign bodies, whose living condition is equivalent to the class of “living dead”.

“Sovereignty means occupation, and occupation means relegating the colonized to a third zone, between the status of subject and object”¹⁸18 Mbembe A. Necropolítica. São Paulo: n-1 edições; 2018. (p. 39). Necropolitics acts as a model for the exercise of sovereignty that is based on the expansion of slavery and colonial logic. Individual punishments - based on the chains and lashings used in colonialism - have been replaced by condemnations to material poverty and diseases such as AIDS, which not only punishes physically through physical illness and death, but also morally, through the stigma and prejudice arising from HIV seropositivity and the feeling of failure and guilt. And collective punishment, as the population is not offered basic survival conditions to cope with this epidemic. Thus, it is understood that the persistence of the HIV epidemic in sub-Saharan Africa, particularly in Guinea-Bissau, stems from a necropolitical project, which uses the lack of control of HIV/AIDS as a weapon to punish the imaginary enemy.

It is believed that, although a country like Guinea-Bissau has no way of choosing what type or form of oppression will befall it, it does have the capacity to determine the way in which necropolitical power affects and spreads throughout the population. In the case of HIV, considering it as one of the weapons in the exercise of global necropower, the incidence on Guinean territory makes it clear how the state is unable to cancel this regime of death. However, it is responsible for determining, through the creation and implementation of public policies, who among its population can live and who should be exposed to death or die from HIV, thus forming sub-zones of death within the country, of a zone of death that is the country in relation to the rest of the world.

From this, we can see the relativity of sovereignty, the stratification of power that exists in space between sovereign and non-sovereign bodies, in other words, the “pseudo-sovereignty” of bodies. The Guinean state, as a body, is inscribed in this space of sovereignty by having the status of a non-sovereign body in the geopolitical context and the status of a sovereign body in relation to its population.

The limited understanding (induced or not) of the dimensions of power to which the body is subjected facilitates its submission to other sovereignties and, consequently, its inscription in the zones of death. The example of a “biological body” summarizes the concept of sovereignty in basic acts such as being able to eat, come and go or live - associated with the freedom to shorten one’s life through suicide. So this “body-biological” is unaware of or ignores the possibility of other powers (sovereignty of others over oneself), whose capacity can (in)directly define the type, quantity and quality of food, access spaces and shortening the time or quality of life through exposure to certain pathogens. It applies to “body-space” if a state understands that its sovereignty is limited to the ability to protect its population against the physical invasion of foreign forces, or rather to traditional concepts of sovereignty. In this case, it is unaware of or ignores the possibility of other powers (sovereignty of others over itself), whose capacity can interfere in the quality of life of its population, through the implementation of the mechanisms of necropolitics - the veiled promotion of internal wars, poverty, the proliferation of diseases, the restriction of access to essential technologies and medicines.

Martin Heidegger points out “that ‘being for death’ is the decisive condition of all true human freedom, (...) one is free to live one’s life only when one is free to die one’s death”¹⁸18 Mbembe A. Necropolítica. São Paulo: n-1 edições; 2018. (p. 66, emphasis in original). From this perspective, it can be said that the opposite is true, that is, one is free to die one’s own death only when one is free to live one’s own life. It should be emphasized that a broad understanding of which body is subject to power relations does not automatically imply the cancellation or non-inscription of these bodies in these zones, since sovereign bodies are coercive bodies. This understanding allows the non-sovereign body to glimpse the possibilities and/or wage struggles to escape from sub-zones and death zones.

In the context of the HIV epidemic, states use their criteria to define death subzones as a way of managing the necropolitics involved - defining who among their population can live and who should be exposed to death. The materialization of these sub-zones of death, in some analyses, is referred to as key populations which, according to each society, take on a different configuration, but are generally: transsexuals, transvestites, gays and other men who have sex with men (MSM), sex workers, injecting drug users, people deprived of their liberty, the poor and, in many countries, black people.

In Guinean society, the key populations: homosexuals, transgender people, sex workers, MSM and the prison population are inscribed in this subzone of death⁴4 Lima HMM. Diagnóstico Situacional sobre a implementação da recomendação opção B+, da transmissão vertical do VIH e da Sífilis congênita, no âmbito da comunidade de países de língua portuguesa - CPLP [Internet]. Guiné-Bissau: OPAS; 2018 [citado 30 Jun 2022]. Disponível em: https://saude.cplp.org/media/vz3abzdo/cplp_guine-bissau_2018.pdf
https://saude.cplp.org/media/vz3abzdo/cp... . Because the HIV epidemic has historically been linked to these populations, their inclusion in the death zone seeks both to eliminate the risk, by eliminating or exposing people with the potential to transmit a deadly agent - HIV - and to punish their transgressions, which is to belong to the social minority. From this perspective, “the new technologies of destruction are less concerned with inscribing bodies in disciplinary apparatuses than with inscribing them, at the right moment, in the order of maximum economy, now represented by ‘massacre’”¹⁸18 Mbembe A. Necropolítica. São Paulo: n-1 edições; 2018. (p. 59, emphasis in original).

The mechanisms for maintaining necropolitics over these “space-bodies” - poverty, internal wars, the lack of preventive strategies in relation to certain diseases or infections, when associated with discrimination based on the identity categories of the subjects (class, gender, sexual orientation, etc.), produce an exacerbation of the sub-zone of death in question. Analyzing and understanding the intersection between these two points - necropolitics and discrimination - is a crucial element in understanding the creation and maintenance of death zones, as well as the position of certain subjects in this subzone.

Reflecting on the use of resources (technological and economic) used by “developed” countries to build weapons of mass destruction and space exploration, while countries - such as Guinea-Bissau - with high rates of HIV prevalence and morbidity and mortality, face the absence or insufficiency of basic resources to combat HIV, such as diagnostic tests, antiretroviral drugs, pre-exposure prophylaxis, post-exposure prophylaxis and others, the veiled isolation of this region from the fight against this epidemic becomes clear, constituting a veritable “aparthaids”. The implementation of this “aparthaids”, in this case, obeys both the capitalist logic of capital accumulation, rejecting its sharing, and the racist colonialist punitive logic, instigating the persistence of the epidemic and maximizing the destructive capacity of this virus in its death zones.

Factors such as the non-recognition of the HIV epidemic as a social and public health problem, the purposeful precarization of health care for people living with HIV, prejudice, discrimination and social isolation act as constitutive elements of the “aparthaids” of “biological bodies”, which in turn foster death within this sub-zone of death.

The bodies’ awareness of their inscription in these zones and sub-zones of death instigates movements of opposition to the oppressive forces that, for the time being, seem insurmountable. The unveiling of the forces in favor of the HIV epidemic and the implementation of strategies such as “aparthaids‘ proves that, in practice, the fight against the HIV epidemic is not a fight ’for all of us”, since some fight against the epidemic and others not only remain neutral, but also fight, in a veiled way, for its persistence.

The HIV epidemic, like others, is attracting efforts and investments to control it. This includes the creation of UNAIDS and the creation of the GHIs, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria; the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the World Bank’s International AIDS Program²²22 World Health Organization Maximizing Positive Synergies Collaborative Group, Samb B, Evans T, Dybul M, Atun R, Moatti J-P, et al. An assessment of interactions between global health initiatives and country health systems. Lancet. 2009; 373(9681):2137-69. doi: 10.1016/S0140-6736(09)60919-3.
https://doi.org/10.1016/S0140-6736(09)60... . However, in general, the GHI are a step backwards because they allocate most of the global health resources to vertical interventions, giving little importance to social determinants or redressing health inequalities²³23 Ravindran STK. Pobreza, segurança alimentar e acesso universal a serviços de saúde sexual e reprodutiva. Questoes Saude Reprod [Internet]. 2016 [citado 5 Nov 2024]; 9:37-50. Disponível em: https://srhm-cdn-1.s3.eu-west-2.amazonaws.com/wp-content/uploads/2018/03/19145841/Questao-Saude-2016.pdf#page=37
https://srhm-cdn-1.s3.eu-west-2.amazonaw... . Generally, GHIs are developed in offices in wealthy countries, considering Western culture, to be implemented in a low-income region, with cultures and worldviews totally different from those who created them, ignoring or disregarding the knowledge of the people who live in the realities in which they wish to intervene²⁴24 Martins AA. Bioética e saúde global a partir de baixo: o global a partir da realidade local. Atual Teol. 2021; 25(67):100-18. doi: 10.17771/PUCRio.ATeo.53664.
https://doi.org/10.17771/PUCRio.ATeo.536... .

For this and other reasons, progress in the fight against HIV in African countries has been slow and, at times, has gone against the rest of the world, even showing an increase in rates. General global data showed a 31% reduction in new HIV infections between 2010 and 2020; a 64% reduction in mortality from AIDS-related causes since 2004 and a 47% reduction since 2010; and Antiretroviral Therapy (ART) coverage among people living with HIV reached 73% in 2020. Unlike North Africa, which saw a 25% increase in new HIV infections, with no reduction in the AIDS mortality rate, and 38% access to ART, the lowest of all the world’s regions. It should also be noted that in the West and Central regions of Africa, ART coverage among pregnant women fell from 62% in 2016 to 58% in 2019, showing the decrease in ART coverage among this population in recent years¹1 Kaiser Family Fundation. The Global HIV/AIDS Epidemic [Internet]. KFF; 2021 [citado 3 mar 2021]. Disponível em: https://web.archive.org/web/20210314172148/https://www.kff.org/global-health-policy/fact-sheet/the-global-hivaids-epidemic/
https://web.archive.org/web/202103141721... .

The aforementioned data shows the “accordion effect” in the fight against the HIV epidemic in these regions, which corroborates the thesis that Africa is given enough drugs not to kill it and not enough to cure it⁹9 Matos PA, Teixeira RC. África imaginada na geopolítica global: perigos e armadilhas. Cad Geograf. 2022; 32(71):1247-68. doi: 10.5752/P.2318-2962.2022v32n71p1247.
https://doi.org/10.5752/P.2318-2962.2022... . Furthermore, the countries of sub-Saharan Africa have the greatest difficulties in meeting the main targets set by international organizations for combating the HIV epidemic. An example of this is Guinea-Bissau’s 90-90-90 target for 2020. This target aimed for 90% of people living with HIV to know that they have the virus; 90% of people diagnosed with HIV to receive antiretroviral treatment; and 90% of people on antiretroviral treatment to show viral suppression. However, in 2020 in Guinea-Bissau, 67% of people living with HIV knew they had the virus, 59% of people diagnosed with HIV were receiving antiretroviral treatment and there was no data available on how many people were on antiretroviral treatment and had viral suppression²⁶26 UNAIDS. Programa Conjunto das Nações Unidas sobre HIV/AIDS. On the Fast Track to end Aids [Internet]. Geneva: UNAIDS; 2015 [citado 15 Abr 2023]. Disponível em: https://www.unaids.org/sites/default/files/media_asset/UNAIDS-strategy-2016- 2021_es.pdf
https://www.unaids.org/sites/default/fil... .

These targets were revised and redefined in June 2021: by 2025, 95% of people living with HIV will know they have the virus; 95% of people diagnosed with HIV will receive antiretroviral treatment; and 95% of people on antiretroviral treatment will be virally suppressed. If these targets are met, with diagnosis and treatment accessible to the entire population, the aim is to end the HIV epidemic in the world by 2030, within the scope of the Sustainable Development Goals (SDGs), closing a long chapter in the history of AIDS as a threat to public health²⁷27 UNAIDS. Programa Conjunto das Nações Unidas sobre HIV/AIDS. Estados-membros das Nações Unidas adotam nova Declaração Política para enfrentar desigualdades e acabar com a AIDS [Internet]. Brasília: Unaids Brasil; 2021 [citado 11 Jul 2022]. Disponível em: https://unaids.org.br/2021/06/estados-membros-das-nacoes-unidas-adotam-nova-declaracao-politica-para-enfrentar-desigualdades-e-acabar-com-a-aids/
https://unaids.org.br/2021/06/estados-me... . However, the arguments and evidence hereby presented point to the impossibility of meeting this target, at least in some African countries, such as Guinea-Bissau.

Final considerations

Reflection on the persistence and worsening of the HIV epidemic in Guinea-Bissau and the (im)possibility of the country meeting the targets set by UNAIDS for the year 2025 calls for the use of new paradigms that allow us to understand the forces that govern world geopolitics and the role of each body within these power relations. The Eurocentric vision used to explain these events so far deliberately ignores some of the conditions of possibility extrinsic to some countries - such as slavery, colonialism, coloniality and neoliberal capitalism’s obsession with death - and focuses on the political, economic and cultural factors intrinsic to these countries, aiming to blame them, while updating new forms of domination and exploitation.

The use of the HIV epidemic as one of the main weapons of necropolitics is a way of managing the death of certain people, based on parameters related to race, social class, gender, sexual orientation, etc. From this perspective, its effect depends on the violation of people’s social rights, which transform them into non-sovereign bodies so that they can be inscribed and maintained in the death zone and sub-zone. The application of “aparthaids” to sub-Saharan countries, particularly Guinea-Bissau, is subject to the prevailing economic logic of capital accumulation, rejecting its sharing. It is also anchored in racist, colonialist and punitive logic, which favours the spread of this virus and maximizes its destructive capacity.

At the local level, “aparthaids” materializes through neglect of the HIV epidemic, the purposeful precarization of health care, prejudice, discrimination and social isolation of people living with HIV, promoting death within this subzone of death.

The use of HIV as a weapon, when combined with other forms of necropolitics, poverty, hunger, political and economic instability, the discontinuity of HIV policies, prejudice, discrimination, social isolation and other elements of “aparthaids”, has turned Guinea-Bissau into a breeding ground for HIV, thus weakening the country in the face of the epidemic and making it impossible to meet the main UNAIDS targets, such as the 90-90-90 targets and possibly the 2025 targets, even with the help of the GHIs.

There is an urgent need for a critical stance on the part of the media, advocacy bodies and human rights activists and a theoretical-practical engagement that seeks not only to dismantle the view that places socio-economic, cultural and behavioral factors - intrinsic to certain countries - at the heart of the HIV epidemic, but that takes into account the use of the disease as an instrument of necropolitics, especially in the current geopolitical context.

It should be noted that this reflection has not ruled out the influences of socio-economic, cultural and behavioral factors on the HIV epidemic; on the contrary, it recognizes these influences. It has not sought to find the “culprits” for the persistence of the HIV epidemic in Guinea-Bissau, but rather to provoke reflections on how the HIV epidemic in this region and country is generally analyzed, thus expanding other possibilities of analysis beyond geographical borders.

HIV/Aids is not a disease of “all of us” because we are not equally vulnerable, in the same zone and sub-zone of death, but as long as it is conceived as a disease of the “other”, “aparthaids” will remain and the zones and sub-zones of death will become ever more violent. The fight against HIV/AIDS must be based on the fight against all forms of barbarism against humanity, such as hunger, poverty, stigma and discrimination against minorities, in other words, all the other gears of necropolitics. Encouraging people to (re)seduce themselves with their humanity and to build a society based on the principles of freedom, fairness and equality between people who are different is perhaps the only way to transform the world and eradicate the construction of death zones and subzones.

References

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