The genesis of the AIDS policy and AIDS Space in Brazil (1981-1989)

ABSTRACT OBJECTIVE To analyze the genesis of the policy for controlling AIDS in Brazil. METHODS Socio-historical study (1981-1989), based on Bordieu’s genetic sociology, by document analysis, bibliographical review, and in-depth interviews. It consisted of a connection between the analysis of the paths of 33 agents involved in the creation of a social space focusing on AIDS-related issues and the historical possibility conditions of the drafting of a specific policy. RESULTS AIDS Space is a gathering point for the paths of agents from several social fields (medical, scientific, political, and bureaucratic fields). A specific space for relationships, which enabled the drafting of a policy for controlling the AIDS epidemic, but also a place where the authority to talk about the meaning of the disease, the methods to prevent and treat it was under dispute. The analysis showed how the various structures (democratic administrations in Sao Paulo and at the national level, with public health officers taking important positions) and the lack of a specific therapy contributed to social agents of different ranks and backgrounds to initially set prevention as a priority. CONCLUSIONS The rise of the sanitary movement, the organization of SUS, and the dominance of the medical field at the AIDS Space contributed to foster treatment as a part of the measures to control the epidemic. These conditions allowed drafting a policy based on the integrality of care, by linking prevention and treatment in the following decade, with important participation from state bureaucracy and researchers.


INTRODUCTION
To analyze the genesis of a public health care policy is to seek to understand the historical and social circumstances that enabled the State to intervene to implement specific measures for controlling a certain health problem 22 .
The studies on the origins of Brazil's AIDS policy, which were reviewed, focused on analyses of state cases, especially Sao Paulo a,b,c,d or on the relationships between non-government organizations (NGO) and the State 11,e,f,g , whether by highlighting the political focus of these organizations or by emphasizing the drafting and implementation of the policy for specific groups 10 at the different levels of the health care system h,i . Those who analyzed the government response to the epidemic at the national level have not investigated the participation of medical and scientific fields, nor have they considered the social and professional paths of agents 13,15,18 .
By putting the concept of social space developed by Bourdieu 5 into practice, Pinell et al. 22 studied the universe of possibilities for the rise of a movement to fight AIDS in France, its structure, and its dynamics of relationships of AIDS Space agents between 1981 and 1996. This space was created in that country through a popular mobilization that aimed to replace state institutions in the performance of this public role. The policy against AIDS was drafted by the initiatives of militant associations, the advancements in the medical field, and the illness social representation as a threat to French society.
The study by Mendonça et al. 17 , based on Bordieu's field concept, connected the position at the "HIV/AIDS field" with entrepreneurial action methods. Their analysis focused on the medical field and on specific associations, but did not explore the interaction between the paths of agents and conditions of possibility. The development of a space for fighting AIDS is understood to depend on the medical knowledge on the disease, but not to fulfill all the requirements of a field, as proposed by Bordieu. The concept of AIDS Space as suggested by Pinell et al. 22 is more appropriate because it is a space of relationships among the agents in different social fields.
The studies reviewed do not shed light on how the AIDS Space was organized in Brazil (composition, agents, disputes, interests) nor do they explain why a policy was drafted at a time when there was no evidence on its extent and vulnerability. Neither have they systematically analyzed the liaisons between agents, the points of view or strategies they chose regarding the policy on AIDS, concerning their fields of origin.

METHODS
A socio-historical study was conducted between 1981 and 1989, the time when the AIDS policy had its genesis. This period was defined according to a broader research periodization comprising the interval between 1981 and 2001 j , considering the main groups affected, times, and priority actions of the government response and its relationship with medical knowledge ( Table 1).
The concept of social space is based on the idea of difference: agents are distributed in it according to the various kinds of capital 5 (Table 2). In turn, the concept of field corresponds to a network of relationships, a relatively autonomous microcosm comprising agents and institutions that have habitus, common perception and action schemes, and illusio, a shared interest 4,7 . The AIDS Space was operationalized as a space of relationships between agents in several fields, with common interest in a problem: AIDS 22 . To rebuild the dynamics of this space and its connections with the medical field, the Collective Health Space 25,k and the political field, we analyzed the social and professional trajectories of 33 agents (in-depth interviews) (Table 3) and the historical conditions for the rise of the policy (document and bibliographical sources).
The sample was delimited through the saturation of oral information, which were confirmed and complemented by document analysis. The classification of the agents according to their social fields was conducted according to volume indicators of scientific, bureaucratic, militant, and political capital, as proposed by Vieira-da-Silva and Pinell 25 (Table 4).
The project was approved by the Universidade Federal da Bahia' s Collective Health Institute' s Research Ethics Committee. The interviewed subjects signed informed consent forms and agreed to have their names disclosed.

RESULTS AND DISCUSSION
The Construction of the AIDS Space (1981)(1982)(1983)(1984) The epidemics arrived in Brazil in the early 1980s, when AIDS was not widely known and no efficient therapeutic response existed. From a political point of view, it was a period marked by the transition to democracy after the military dictatorship that started in 1964.
The first news reports about the disease were treated as a foreign problem by the media 2 and contributed to it being seen as a gay disease, the so-called "gay plague" l . The first cases, which were concentrated in Sao Paulo, were identified between 1982 and 1983, by dermatologist Valéria Petri. The patients had Kaposi's sarcoma, which is very unusual in young people. No blood tests existed; diagnose was clinical and therefore questioned by some physicans, according to the interviewed testimonial, "[...] some colleagues insisted I was lying" (E31, 6/20/2011). Despite the role of the press in giving the first reports on AIDS, only in 1983 were the first Brazilian cases reported 1,2 .
Despite first denying the disease, the gay movement was fundamental to recognize AIDS as a problem that required specific measures. The questioning stance on medical field was a result from the historical relationship of some physicians with homosexuality, who viewed it as a mental illness. k Collective Health, in its genesis, according to the findings from an empirical study conducted by Vieira-da-Silva and Pinell 25 (2013), analyzing the paths of 26 founders, could be interpreted as a social space that aimed to become a field but still did not have relative autonomy or a common habitus, found in consolidated fields, such as scientific, medical, bureaucratic, and political fields.  Afterwards, this group started reinforcing medical discourse, probably as a result from the exchange with foreign groups who brought reports of fear and death, and also because of the threat to the developing gay trade 14 The epidemic transformed the gay rights movement, by causing its sexual freedom proposals to lose momentum and reducing the number of groups 9 .
Besides diagnosing the first cases, physicians from different backgrounds took part in the initiatives that resulted in the first measures for control of the disease. Ricardo Veronesi (professor at Faculdade de Medicina of the Universidade de Sao Paulo, founder of the Brazilian Society of Infectious Diseases, and responsible for administering interferon as a treatment for AIDS in Brazil), n,o gathered gay activists in March 1983, warning them about the need for a response from the government.

Type of capital Description Source
Cultural Set of assets related to incorporated knowledge (being competent in a knowledge domain, being cultured, have a good mastery on language), owning cultural assets (books, dictionaries, instruments, machines) and, in its institutionalized state, to degrees, diplomas, and being approved in professional admission tests, that is, to the recognition of skills by the State.
Capital of relationships, regarding the gains associated with the existence of a network of real or potential connections, more or less institutionalized, of belonging to a group. Bourdieu 3 (1980) Symbolic Transmutation of the various species of capital into recognition capital by the agents in the social space Bourdieu 5 (1996) Political Related to the mobilization ability of an agent, it is a species of personally-obtained social and symbolic capital, which results from personal notoriety and popularity capital (being known and recognized), or by the delegation of an organization that holds this kind of capital, such as parties or sindicates. It can be achieved through the access to traditional political positions (positions in a party, in branches of power, in the network of companies related to parties, or by taking elective offices).

Militant
Set of knowledge and practices implemented in collective initiatives and struggles between or within parties; it is incorporated through techniques and dispositions to act, intervene, or simply obey. Under certain conditions, it can be a path to political capital when, for example, an agent is associated with the personification and disclosure of an initiative that allows them to convert their acquired militant notoriety into more institutionalized political investments, such as political parties.
Matonti and Poupeau 16 (2004) Garcia 12 (2005) Bureaucratic A capital that has power over other kinds of capital, it also corresponds to the power of nomination, controlling information and standardization, and also defining and imposing legitimate state categories. According to other studies 15,24 , the following contributed to the implementation of the AIDS Program at SES-SP: the first cases diagnosed; the demand for a group of militants, with support from a female physican; and the political conditions (democratic government, with sanitarians in strategic positions). The fear of the epidemic, the social group affected (an organized, upper class group of intellectuals with an important social capital), and the fact Sao Paulo had had a health care system with public health officer positions as of the 1960s should be added p , as well as the profile of the system' s director (a sanitarian and former member of the gay rights movement), a person with technical and political capability of dealing with stigmatized groups (E26).
Federal education and research institutions engaged by initiative of their professors and researchers. For example, Escola Paulista de Medicina, by physician Valéria Petri (E31), and Fiocruz, by its AIDS Research Laboratory. The latter was created in 1983, in Rio de Janeiro, by Bernardo Galvão, physician, master in Human Pathology, and PhD in Immunology, who became its coordinator, and Cláudio Ribeiro, a PhD in Immunohematology (E4).
The rise of Sao Paulo State AIDS Program confirmed the organization of a space to fight AIDS (AIDS Space). It was also a space for research and intervention, involving agents in the gay rights movement (militant space), in the medical field, teaching professionals, and researchers (scientific field), or staff in the state health care office (bureaucratic field).

The Response from the Ministry of Health (1985-1989)
In February 1985, federal government initiatives for controlling AIDS were initiated through Professional Training for Controlling Hospital-Acquired Infections Program, which was coordinated by Luiz Carlos Pelizari Romero, from the National Secretariat for Special Health Care Programs (SNPES) q . Fabíola de Aguiar Nunes, a sanitarian physician, took part in the program as a representative from the Ministry of Education and Culture (E10).
When Carlos Sant' Anna, a physician, congressman, and one of the liaison agents in Tancredo  Neves' presidential  The first measures taken by the MH were epidemiological surveillance, public health education and information, voluntary testing, and characterization of an epidemic that affected the whole population, to reduce stigma and discrimination of the most affected groups (E10, E11, E24).
Several social movements (homosexual, thalassemic, and hemophiliac) demanded a response from the government. The press insisted on the issue (E10, E26). Sao Paulo, Rio de Janeiro, and Rio Grande do Sul had already structured measures (E24), pressing the federal government to make a decision. The social representation of the disease, coupled with terror and fear, should be added to this.
In March 1985, meetings were held in Sao Paulo and Brasilia, to review and discuss the cases diagnosed. These meetings respectively resulted in the standardization of AIDS management procedures and the drafting of an ordinance by a panel of experts r . Epidemiological, clinical, and laboratory investigation were proposed, as well as public health education for suspected and confirmed cases, people in contact, and high-risk groups. The ordinance mentioned using condoms, disposable or individual syringes and needles, and controlling blood quality as preventive measures s . A training system was organized in Sao Paulo, for the states reporting their first cases (E10).
In January 1986, Fabíola Nunes invited dermatologist Maria Leide de Oliveira to DNDS (E10, E24). Miriam Franchini was responsible for STDs and sanitarian Lúcia Amaral, for AIDS, organizing an initial reporting system 19  The initiatives aimed at structuring the program and preventing AIDS. The implementation of activities started being centrally managed by the MH, in a way to invert the relationship with the states, which by then created and executed their specific programs 24 .
AIDS was included in Brazil's 8th National Health Conference, within "Epidemiological Surveillance" sub-topic. Later, the MH coordinated debates on "AIDS and Constitutional Convention" topic in the states, and this subsidized the national 1987 campaign, which discussed how the new health care system could solve the AIDS issue u,v,w .
The analysis of documents and interviews showed that Lair Guerra's administration was marked by NGO criticism related to the care of patients, to the campaigns, and to the official discourse, which was considered normative and medicalizing. Criticism was mainly given against 1988's campaign, which held individuals accountable for measures they were not capable of taking, such as controlling their blood quality, in a way to shift responsibility from the state to the people. Nonetheless, there were also people supporting the government campaign ( Table 5).
The relationship between the disease, sexuality, and use of injection drugs led its concept to be influenced by the religious discourse. Catholic tradition especially instilled the impression the disease was related to sin, moral transgression, and divine punishment, opposite to the discourse from homosexual groups x . This issue was mentioned by some subjects interviewed, and it shows the importance of analyzing the roles of agents in this field in setting the policy.
When it started being referred to as Acquired Immunodeficiency Syndrome (AIDS) (Síndrome da Imunodeficiência Adquirida -SIDA, in Portuguese), the foreign term was incorporated by physicians and the press in Brazil. Was the incorporation of a foreign word submission from scientific and cultural field agents to the USA, or simply a wish for better international communication in the scientific field? When asked, one of the interviewed subjects shows that, in the MH, its adoption was rationalized and formalized in a meeting for defining the term to be used. The associations that fight AIDS (NGO/AIDS), which rose from 1985, had a determining role for regulating the control of blood and blood products 23 and in the lobby in the constitutional convention for pushing the blood issue 20,y .
The empirical material showed that the main disputes between agents in the PNAids and in the association movement revolved around the preventive campaigns (target population, technical or popular language, what could be said, which terms to use, among other things).
And from the release of azithromycin (AZT), also regarding treatment.
During the whole period analyzed, the technical conception from the bureaucratic field prevailed in the official discourse. However, due to the influence from militant and religious fields, AIDS was considered to be a threat to society in general rather than restricted to specific groups.
Lair's international negotiations with the CDC and PAHO, as well as her management ability, contributed to the initial structuring and extension of PNAids. The Program also had important support from the Special Public Health Care Services Foundation for its interiorization, through its representative for transmittable diseases, sanitarian physician Pedro Chequer, who later was part of PNAids team 19 .
Getting PNAids attached to DNDS was under dispute, and this resulted from disagreements between agents from the medical field (Fabíola and Maria Leide) and AIDS Space, which was consolidating itself and seeking autonomy (Lair Guerra) (E10). In 1987, after Fabíola Nunes left SNPES, Brazil' s National STD/AIDS Division 19 was created. It was no longer part of DNDS and had autonomy regarding public health dermatology, a medical specialty. Its creation and transference to Brazil' s National Office of Basic Health Care Initiatives were made official in 1988. Lair remained in the management of the division until March 1990, during the early Collor administration.

AIDS Space: Its Agents and Sub-spaces
The following people affected by the epidemic engaged in AIDS Space: HIV positive people, people who were more vulnerable to AIDS (homosexuals, injection drug users, people Table 5. Some characteristics from the sub-spaces according to interviewed subjects and document analysis. Main disputes "Gapa's perspective leaned towards advocacy, ABIA had a concentration, a very high expertise to give information and guidance to specific groups" (E29, on 6/15/2011, Rio de Janeiro, RJ). "[...] the king ONGs were Gapa, Pela Vida, ABIA, and the others were all small" (E26, 5/3/2011, Sao Paulo, SP). "[...] The MSM category does not help anybody, nor does the prevention for bisexual individuals, not even to the queers and transvestites themselves, who often do not even consider they are men, then we protest against it, and still nowadays there are people defending it, but it is a misguided way as shown by the experience" (E20, on 3/23/2011, Salvador, BA). with hemophilia, sex workers); their parents and friends; professionals related to the epidemic, especially physicians and researchers. Those who enter this space for personal reasons, in general, joined the militant sub-space, had diverse educational backgrounds, and important cultural capital, with master's or PhD's degrees. In the bureaucratic and scientific sub-spaces, physicians predominated; the scientific field agents had graduate diplomas or were attending such courses (Table 3).

Sub-space Characteristic
Despite the importance of the gay movement in planning the first responses to the epidemic, the NGO/AIDS were created seeking get detached from this movement (E3, E20) ( Table 5).
The first NGO/AIDS were funded by the State: Aids Support and Prevention Group (Gapa) by SES-SP (E3, E26), and Brazilian Interdisciplinary AIDS Association (ABIA) by the National Social Security Institute of Medical Care (E29) and by Finep 20 , through public health militants taking over positions in these institutions, such as Hésio Cordeiro and Reinaldo Guimarães.
In this sub-space, the main issues were funding, structure, and liaison with the PNAids, living with HIV/AIDS, strategies for prevention and use of the technical formulation "men who have sex with men" (MSM). Disputes were also between the NGO/AIDS and groups in which AIDS was a cross-sectional topic, NGOs with more political perspectives (ABIA) and NGO focusing on care (Gapa) (E3, E12, E14, E18, E20, E29, E33) ( Table 5).
In the scientific field, young researchers and new PhD engaged themselves, seeking independent and original research lines. The main disputes were between generations or institutions. What was at stake was the recognition of the scientific authority or the position of state expert (E4, E7, E31) ( Table 5).
In the medical field, the disputes were between dermatologists, infectious disease specialists, tropical medicine, and infectious and parasitic diseases (E4, E31) ( Table 5).
In the bureaucratic field, the disputes were between State Health Secretariats and PNAids (E10, E26) ( Table 5). Some agents had priority insertion in this field, where agents from the remaining sub-spaces circulated through the CNAids or by taking over positions at PNAids or the remaining management levels.
The meeting of conceptions from the different sub-spaces on AIDS contributed to a broad construction of the problem and actions, based on the dignity of patients and human rights. CNAids, as the State commission that concentrated scientific and militant powers, transmuted into bureaucratic power, had an important role in planning the official discourse, which enabled negotiations between agents from different sub-spaces.

Political and Militant Path
Some of the agents involved in the genesis of the policy had a dominant political path, by occupying elective offices (Carlos Sant' Anna and Sérgio Arouca). Others had taken part in the sanitary movement (E9, E10, E26, E27), in the gay rights movement (E8, E18, E20, E26, E33), and in the fight against dictatorship, in clandestine parties such as Brazil's Communist Party (E4, E12), and Ação Popular (Popular Action) Party (E26) Most agents who had political capital to some extent stood out in the militant space, taking over dominant positions, such as the management of NGO/AIDS or other associative organizations (Table 3).

Final Considerations
This socio-historical analysis allowed explaining how the initial demand from militants to SES-SP took place, highlighting the role of the scientific field, from the start of the epidemic. It also recovered the initial formulation of the policy at the national level, which had rarely been described in the literature, identifying the main agents involved and showing the implementation of initiatives already in the last months of the military government. It also showed the importance of the participation of sanitarians who took over government positions at that time.
AIDS Space was historically constituted as a space for fighting for the organization of the response to the epidemic and public health care intervention. The authority to talk about the meaning of the disease, the methods to prevent, and treat it were under dispute, as well as strategies for controlling the epidemic. Its structure involved agents from the medical field, from "Collective Health Space", from the bureaucratic field, from the gay rights movement, and from the scientific field, influenced by political, religious, and juridical fields. Later, movements of people with hemophilia, people with thalassemia and sex workers, and NGO/AIDS, composing the militant sub-space.
The government response had the level of government that implemented the first initiatives as a specific aspect. Traditionally, the MH had a national policy, which was followed and enforced by the states. The initiatives against AIDS were started in the states, when MH denied the need for intervention. The national policy was implemented since 1985. The conditions that enabled including AIDS in the political agenda were the following: the democratic transition process; sanitarians taking over management positions at the MH; the quick spread of the epidemic; the existence of research groups of infectious and parasitic diseases, involving pathologists who became immunologists; the advancements in the medical field regarding the disease, and the development stage of the clinical and laboratory research; the organization of AIDS programs by some states; and the pressure from social movements and the press.
The comprehension of the historical reasons that allowed the initial planning of this policy and the analysis of the paths of agents and struggles common to AIDS Space and to the "Collective Health Space" empirically show the relationship between the policy and the sanitary reform movement and its assumptions. Its origin, during a time when the sanitary reform movement was rising and when there was no specific therapy, contributed to the initial prioritization of prevention. The dominance of the medical field and the constitution of the Brazilian Unified Health System (SUS) contributed to a connection between preventive measures and ensured treatment, a component that is necessary for implementing a policy that is based on integral care, which is internationally considered as an example.