Colombia: AIDS in the Time of War

Colombia’s armed conflict is taking the AIDS epidemic among the country’s women and displaced population in radically new directions. Both guerrillas and paramilitaries often run prostitution rackets in areas under their control, forcing sex workers to have unprotected sex and extract bits of information from enemy clients. Combatants themselves are five times more likely than civilians to contract HIV.

July 16, 2008

A few months before Myrian Cossio’s 20th birthday, in San José del Guaviare, a bustling frontier town deep in Colombia’s eastern tropical lowlands, armed men forced her into a car. She immediately knew they were from one of the three armed groups fighting in Colombia’s decades-long civil war—army, paramilitary, and guerrillas. They took her to the town’s outer limits and put a gun to her head. “We know you have AIDS, and we know you work with those whores and faggots,” they told her. She had 48 hours to leave town, or they’d kill her.

Cossio’s problems began the year before, in February 1996. At the health clinic where she worked as an administrator, her boss enlisted the staff for a blood drive, and Cossio had dutifully rolled up her sleeve. “I wanted to be a good example, so the community would do the same,” she remembers. Two weeks later, the results of her blood screening came back HIV positive. Her boss told the entire staff before telling her; she was the last to know. Co-workers stopped using the bathroom she used. At the cafeteria, she no longer received her lunch on normal plates like everyone else; her meals now came on disposable plates with plastic utensils. Eventually, she was fired.

As news of her diagnosis spread around town, parents at her two-year-old son’s kindergarten forced her to withdraw her child, even though he tested negative. “It’s like we say: small town, big hell,” Cossio says. After being forced out of town by the armed group—whose identity she asked not be disclosed—Cossio moved to Bogotá and found what she calls her “second life.” Her arrival in 1997 coincided with a groundswell of organizing by Colombian activists on HIV issues. Immersed in this new life, Cossio went on to become a founding member of the Girasol Project, a network of Colombian women living with the virus that now has several offices around the country.

Cossio’s story encapsulates the battle in Colombia over HIV. On one side, the country’s armed conflict not only makes it dangerous to be involved with anything HIV related, but may also be aggravating the spread of the virus. On the other side, powerful activist groups are fighting for their rights, together with the usual obstacles facing HIV activists around the world, in a country at war.

International health organizations and the Colombian government consider HIV/AIDS in Colombia a “concentrated epidemic,” meaning that while specific groups of people exhibit high rates of infection, there is a relatively low prevalence in the general population (between 0.3% and 2.5%, according to United Nations estimates). The higher rates are mostly concentrated among men who have sex with men and intravenous-drug users. In 2001, UNAIDS found that almost a fifth of men who have sex with men tested in Bogotá were HIV positive.

Roberto Sicard, an HIV/AIDS specialist at the Bogotá office of the UN Refugee Agency (UNHCR), laments that the statistics on the general population have led international agencies and specialists to focus attention on more “needy” areas of the world. The first big blow came late last year, when the Global Fund to Fight AIDS, Tuberculosis, and Malaria declined to renew Colombia’s grants. “Sure, it’s hard to compare Colombia with what’s happening in parts of Africa,” Sicard says, “but parts of Colombia have almost African characteristics for the virus in terms of violence, displacement, poverty, and state weakness.”

Sicard adds that Colombia is seeing a steady increase in heterosexual transmission, which means that HIV is being transmitted from groups with high concentrations to previously less affected populations, particularly women. A government study published in 1994 reveals the feminization of the epidemic: In 1985, there were 55 men infected for every one woman; in 1993, the ratio had fallen to seven to one; today, it stands at two to one, according to UNAIDS.

Cossio says she received her surprising diagnosis nine months after her husband, who she later realized had infected her, died victim of a botched robbery. But she quickly adds, “We can’t generalize by laying all the blame on men, because women have to take responsibility for our bodies. Loving someone shouldn’t include ceding control and care of our own bodies.” She didn’t always think this way. Before her run-in with the armed men, a health worker in San José del Guaviare told her about a meeting in Bogotá of women living with the virus. The meeting was life changing.

“I realized I wasn’t a walking virus, that I was a person,” she says. The conference participants gave her practical information about treatments and her rights, and she became part of a support and information network of HIV-positive women. Armed with information and the backing of a growing network, Cossio returned to San José del Guaviare, where she immediately began holding meetings with gay men and sex workers. It was these meetings that sent the armed men after her.

“I started organizing around HIV out of necessity, but also out of solidarity,” Cossio says. The Girasol Project now works with at least 600 women across the country, providing counseling, entrepreneurial projects, workshops, and legal aid. The organization also tries to publicize the epidemic’s feminization through research, having recently conducted 70 interviews with HIV-positive Colombian women. The study found that husbands are the main source of infection for most of them; some discover their HIV status only when their partners become sick or die.

Consensual sex is not the only factor driving the epidemic’s feminization. The UNHCR’s Sicard worries that the armed conflict is taking the epidemic among women in radically new directions. “Unfortunately, in a war, a woman’s body is considered territory,” he explains. Both guerrillas and paramilitaries often run prostitution rackets in areas under their control, forcing sex workers to have unprotected sex, which garners a higher price, since clients prefer sex without condoms. Paramilitaries and guerrillas have also discovered that brothels are effective intelligence-gathering sources, often forcing prostitutes to extract bits of information from enemy clients. “These women are basically in a situation of sexual slavery,” Sicard notes. “Their bosses are the ones with the guns, so they have no way of opposing these impositions.” This puts them at exceptional risk of both contracting sexually transmitted diseases and suffering reprisals from opposing groups that consider them enemy spies.

The armed groups themselves are a vulnerable sector, according to UNAIDS, which concludes that Colombian combatants are five times more likely than civilians to contract the virus. This is largely the result of a lifestyle that generates behaviors and circumstances conducive to sexually transmitted diseases: little access to education or health care, and extended periods away from families, often in areas home to thriving sex industries connected to local economic bonanzas in oil, mining, or coca. HIV is mentioned in the diary of Tanja Nijmeijer, a guerrilla whose account of life in the Revolutionary Armed Forces of Colombia (FARC) was discovered and made public by the Colombian military. In an entry from June 2006, Nijmeijer writes, “I almost forgot the big news: Two comrades have AIDS, and there may be more. No one here uses contraceptives. The girlfriend of one of them has no idea what it means.”

Sexual abuse, mainly of women and children, has become a common part of the armed groups’ violent repertoire. A government study found that 9% of forcibly displaced women reported being raped. Another government report estimates that 30,000 children are involved in sex industries. “If girls, boys, and women are sexual commodities within the perverse logic of the war,” Sicard reasons, “then they’re going to be the ones most affected by the epidemic.”

Colombia’s most vulnerable population group is the 4 million internal refugees—the second-largest internally displaced population in the world after Sudan’s. Almost half are under the age of 18, and three quarters are female. The UNHCR calls HIV among Colombia’s displaced population a “hidden epidemic.” The first difficulty in tackling this problem, according to Sicard, is a lack of research. He admits, “Scientifically, we don’t know exactly what’s happening, but we do know there is a serious causal relationship between the epidemic and displacement.”

An array of factors makes displaced people particularly vulnerable to the virus. Most importantly, they are subjected to conditions of absolute poverty and insecurity, along with a host of other precarious social and psychological conditions. Government health and education programs are practically nonexistent in high-conflict zones and scarce in areas where displaced people end up, like urban slums. The loss of livelihoods and the disintegration of family ties or other support networks are inherent parts of displacement. Surveys by humanitarian groups show this can lead youths to become sexually active at a younger age or to see prostitution as a viable source of income.

A brothel in a village near Colombia’s northern coast. Both guerrillas and paramilitaries often run prostitution rackets in areas under their control, forcing sex workers to have unprotected sex, which garners a higher price, and to serve as informants on enemy clients. (By Stuart Butler)

Furthermore, along with normal impediments, like social stigma, the presence of armed groups discourages people from getting tested, making it difficult to know the true extent of the virus’s spread in Colombia. “It will be years before we know the true gravity of the epidemic,” Sicard says. “And then we’ll realize that the phenomenon is terrible, that it’s huge, and that generations are living with the virus. And we’ll realize this when it’s too late.” A UNHCR report estimates that Colombia’s HIV-positive population could nearly triple by 2010 to 600,000, of which 15,000 would be below the age of 15.

Jorge Gómez (not his real name, which he asked be withheld) has dedicated his life to making sure such grim predictions never come true. He began working in HIV prevention 15 years ago in the region surrounding his hometown of Barranquilla, a port city on Colombia’s Caribbean coast. His work mostly involved promoting government-sponsored HIV testing and assistance programs for people living with the virus. For his efforts, he was threatened just as Cossio was.

In November 2006, two men, who he later learned were paramilitaries, approached him after he dropped his children off at school. They demanded a list of all known HIV-positive people in the region. As they peeled off on a motorcycle, one of the men turned back and warned him, “Next time I see you, you better have that list.”

The list would have ostensibly guided paramilitaries in one of their notorious “social cleansing” operations of so-called undesirables: in this case, people living with HIV. Sicard explains, “They see the virus as something dirty, something they can eliminate. They call it ‘the faggots’ disease,’ and anything that smells gay to them has to be killed.”

At night, cars would slowly move toward Gómez’s house and then quickly pull away. Neighbors told him that “strange men” were asking about him in the neighborhood, and two days later the Gómez family left Barranquilla for Bogotá, realizing that the paramilitaries had made him a marked man. “I never could have turned over that list,” Gómez says. “I never could have lived with the weight of all those murders on my shoulders.”

Thinking he had left his problems behind in Barranquilla, Gómez began working in an HIV-prevention program in Bogotá with demobilized paramilitaries who had laid down their guns through a government amnesty program. Explaining this masterstroke of irony, Gómez says matter-of-factly, “It’s my life’s work, and I don’t know how to do anything else. I just wanted to help.”

But seven months later, he noticed strange men once again lurking around his Bogotá home like vultures. Soon, the paramilitaries were calling in threats to his home, and this time the threats were specific. The men on the phone talked about his kids and said they knew where he lived and that they were watching his extended family back in Barranquilla. “They also told me: ‘We have a nice little piece of land picked out for your hole of a grave.’ ” When the government’s only offer of protection was a bulletproof vest and a radio for his wife in case of an emergency, Gómez left the country with his family, seeking asylum in Canada.


Javier Leonardo Varón of the Colombian Network of People Living With HIV or AIDS (Recolvih) sounds a hopeful note, saying the movement has made great progress. “Before, we were just a bunch of crazies in the street with sticks and stones,” he says, “and now we’re in centers of power where decisions are made.” A major victory for Colombian activists came in 2005, when the legislature passed a national HIV/AIDS law that compels the government to provide people living with the virus integral care. “We were there sitting at the table in the discussions,” Varón says proudly.

Varón, who describes himself as “openly gay and openly HIV positive,” cut his political teeth organizing campesinos near his native city of Ibagué, on the eastern slopes of the Colombian Andes. As a young activist, he began tracking how the local government was either misspending or stealing public health funds. By the time he received his HIV diagnosis, he already knew the ins and outs of government health programs. This knowledge has served him well over the last decade, in which he has become one of Colombia’s most outspoken HIV activists and the leader of Recolvih. “Like all activists in the movement,” he says, “I learned about things like law, international trade, intellectual property, along the way—in the march.”

He attributes these gains to grassroots muscle, which he says is what differentiates Colombia’s HIV experience from those of many other countries. He points to examples in Brazil and Thailand, where governments or international agencies were the driving force behind efforts to reduce the price of HIV medicines. “In these countries, civil society got on the government bandwagon, and that’s the way it should be,” Varón says. “Civil society shouldn’t have to exhaust itself defending what should be a human right.”

With the Colombian government, drug prices are “an unmentionable issue,” according to Varón. Along with Mexico, Colombia has the highest HIV drug prices in Latin America. According to Latin Trade, a regional business magazine, a month’s supply of the drug cocktail used to treat the virus in Colombia can cost as much as $900, while the country’s monthly per capita GDP is estimated at $600. “This is atrocious,” Varón says. “It’s an affront to health and shows that health is a business. We’re fighting this with everything we’ve got.”

Recolvih and other organizations have led the charge against the pharmaceutical giants without any government help. On April 7, in an alliance with a coalition of NGOs, Recolvih sent a packet of documents to Abbott Labs, a U.S.-based producer of antiretroviral drugs. The packet is a request that Recolvih receive a “voluntary license” on Abbott’s drugs. If granted, the organization would pay Abbott a relatively negligible 4% royalty. By reducing royalties and buying in bulk, Recolvih would be placing Abbott’s drugs in competition with generic-drug makers, thus driving down prices.

Varón talks rapidly as his excitement swells in explaining the process. If Abbott refuses or does not reply, he says, the next step would be pressuring the Colombian government to gain an “obligatory license” from Abbott. “Is there a clear instance of civil society forcing a government to do that?” he asks. “No, it’s never been done before.” Not missing a beat, he adds, “Even better! Colombia would be the first.”

Government-provided health care covers about half of Colombia’s population. But even when a patient is insured, forcing health care providers to cover HIV-related expenses is an uphill battle. People like Varón and Cossio have become experts in filing legal suits against reluctant providers. Both activists describe the process of ensuring patient rights as being on a war footing, with alarm bells constantly sounding.

While fighting these battles, Colombian HIV activists face the challenge of cultivating future generations of activists. Varón says grassroots groups have lost some of their brightest and most committed activists to better-funded agencies like the UN, while others have succumbed to the disease. “We all used to feel invincible,” Varón recalls. “But some of us have started dying or falling really sick. It reminds us: There’s something destructive going on inside our bodies.”

He thinks back to his early days in the movement. A reporter had invited him to be part of a panel on HIV for a TV news talk show. He called his mother to tell her he was going to be on television and said he was worried that his appearance could trigger a backlash against his family back in Ibagué (small town, big hell). She shot back: “Don’t worry, I know your appearance will help a lot of people. And just in case, I’ll get my bags packed.”

The TV panel was a public relations coup. He was presented as the sole HIV-positive person on a panel made up of prominent experts and government health officials. As soon as he was given a chance to speak, Varón unloaded. He talked for several minutes rattling off laws and statistics. Finishing, he looked into the camera: “We need free treatments, we need to be included in decisions. We can’t let these people sitting beside me make the decisions on our behalf.” The panelists were stunned.

The next day, the health ministry called him for an appointment.

Teo Ballvé is a freelance reporter and editor based in Colombia.


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