Reality or utopia: eradication of the AIDS epidemic in Guinea-Bissau by 2030

e20190137 http://dx.doi.org/10.1590/0034-7167-2019-0137-2019-0137 4 of ABSTRACT Objectives: to reflect on the implementation of an integrated strategy to eradicate the Acquired Immunodeficiency Syndrome (AIDS) epidemic in Guinea-Bissau by 2030. Methods: a reflective study. Reflection: Guinea-Bissau is a Portuguese-speaking country located in Sub-Saharan Africa, in constant political and economic instability. Among its characteristics are sociocultural diversity and high rates of morbidity and mortality from causes related to infection by the Human Immunodeficiency Virus. In the quest to eradicate the AIDS epidemic by 2030, instituted especially by the United Nations, it is noted that political and sociocultural factors transformed eradication of the AIDS epidemic by 2030 into a utopia. Final Considerations: international strategies, although ambitious, are considered opportunities for countries to propose and build public policies capable of changing the existing reality. Descriptors: Guinea-Bissau; Acquired Immunodeficiency Syndrome; United Nations; Social Determinants of Health; Public Health Nursing.


INTRODUCTION
Utopia is there on the horizon. I approach two steps; it takes two steps away. I walk ten steps, and the horizon runs ten steps. As much as I walk, I will never reach. What is utopia for? It serves so that I don't stop walking (1) . (free translation from the version in Brazilian Portuguese) Throughout the existence of the Acquired Immunodeficiency Syndrome (AIDS) epidemic, different strategies have been launched by international organizations, in particular by the United Nations (UN), with a view to controlling the disease in all countries. Among them are the Millennium Development Goals (MDGs), launched in 2000 for the 196 member countries. Of the eight MDGs, the sixth aimed to combat the Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS), malaria, and other diseases. To achieve this objective, three goals were outlined, two of them related to HIV/AIDS, such as reducing HIV incidence and transmission by 2015 and universalizing access to antiretroviral therapy by 2010 (2) . Fifteen years after the launch of MDGs and still not fully reaching the goals, the UN launched Agenda 30. This Agenda includes the 17 Sustainable Development Goals (SDGs) compiled in 169 goals, in addition to detailing actions to achieve development in the social, environmental and economic areas by 2030. The third SDG seeks to ensure a healthy life and promote well-being for all people, at all ages, and presents as one of its goals ending the AIDS epidemic in the world by 2030 (3)(4) .
Pari passu, the Joint United Nations Program on HIV/AIDS (UNAIDS), disseminated and called on different political actors to achieve zero HIV infection, zero discrimination and zero AIDSrelated death. This program converged with Agenda 2030 with regard to ending the epidemic. Among the efforts of UNAIDS, 90-90-90 goal, in 2013, to start in 2015 and reach by 2030 stands out. This goal, with an ambitious character and with a definite tendency, seeks that 90% of people living with HIV know their diagnosis; 90% of people diagnosed with HIV receive antiretroviral treatment without interruption; and 90% of people on antiretroviral treatment get viral suppression (5)(6) .
Considering the highlighted international goals, it became relevant to reflect on the situation of some countries, especially Africans. It is known that since the beginning of the AIDS epidemic, in the early 1980s, the African continent has been the most affected, mainly in the sub-Saharan region. Guinea-Bissau is based in that region and belongs to the Community of Portuguese Speaking Countries (CPSC), and was created in 1996 to broaden links between member countries that have Portuguese as their official language (Angola, Brazil, Cape Verde, Guinea-Bissau, Mozambique, Portugal, São Tomé, Timor-Leste, and Equatorial Guinea). Located in West Africa and covering 36,125 km 2 , it is a former Portuguese colony that became independent in 1973. It is characterized by religious, linguistic and ethnic diversity, with between 27 and 40 ethnic groups distributed throughout the territory. Each group has a region of predominance, habits, customs, and different dialects (7) .
In 2015, its population was approximately 1,844,000 inhabitants, and 60.4% lived in rural areas. It is a country with a 0.420 Human Development Index (HDI); life expectancy is 48.6 years old; education rate is 50.5% among girls and 70.4% among boys; infant mortality rate is 54.5 per 1,000 inhabitants; about 40% of the population of Guinea-Bissau is under 15 years old and women account for 51.6% of the population. It is considered a country of low income and low level of human development. In 2013, it presented its Gross Domestic Product (GDP) in US dollars (USD) of 1,090 per capita, and it ranked 177 th on HDI out of 187 countries (8) .
When analyzing the AIDS epidemic in Guinea-Bissau, there was a total of 36,000 infected people and a prevalence of 3.3% in the general population, with 3% being affected in urban areas. Among those infected, 12,000 were on antiretroviral treatment. Moreover, the country is experiencing the event of the feminization of the disease, as the prevalence among women is 5%, reaching 6.9% in women between 15 and 49 years old and 5% among pregnant women (5) . Therefore, the epidemic in Guinea-Bissau is widespread, i.e., HIV infection is present in several population segments. The case differs from the concept of a concentrated epidemic, which has a high prevalence in specific populations, with a considerable difference from the general population (9) .
After a brief characterization of the scenario (HIV/AIDS) in Guinea-Bissau and presentation of the international objectives and goals for ending the AIDS epidemic in the world, the question arises: will Guinea-Bissau be able to eradicate the AIDS epidemic by 2030? What factors could negatively influence the achievement of this goal? How important is the target for the country? In view of the questions raised, the objective is to reflect on the implementation of an integrated strategy to eradicate the AIDS epidemic in Guinea-Bissau by 2030.

METHODS
A theoretical-reflective approach was carried out to construct this study. The guiding themes for the readings and analyzes were the goals established in MDGs, SDGs, 90-90-90, conditions and Social Determinants of Health (SDH).

REFLECTION
It is possible to observe initiatives to build alliances such as CPSC and/or cooperation with other countries, as in the case of Brazil. Brazil supplies antiretroviral agents (ARV) to the Guinean government to contribute to the control of this epidemic and, consequently, to achieve 90-90-90. However, it is clear that eradicating the AIDS epidemic in Guinea-Bissau by 2030 depends on multiple factors that, for the most part, are internal (national) and belong to the political, social, and cultural fields.
It is observed that, in recent decades, Guinea-Bissau has been experiencing constant political and economic instability, favoring impunity and corruption. This reflected in the impossibility of defining and implementing policies in the long term, which reflected in the fight against AIDS in the country, being exemplified by the difficulty in guaranteeing continuous availability of ARVs in the public network. According to the German broadcaster Deutsche Welle (DW), there was a disruption in the supply of ARVs to those infected for more than four months due to the lack of financial resources from the Guinean government to transport ARVs from Brazil to Guinea-Bissau (10) . This situation, of Reality or utopia: eradication of the AIDS epidemic in Guinea-Bissau by 2030 Sanca AM, Silva DAR, Rocha CMF, Riquinho DL.
which seems to be recurrent in recent years, compromises the second axis of the 90-90-90 cascade (90% of people diagnosed with HIV receive antiretroviral treatment without interruption) and favors virus reproduction, its resistance to ARVs and the evolution to the AIDS picture. With regard to HIV testing and care for people living with the virus, services are available on the public network. However, the country has a high rate of direct payment for health services, especially in the year 2016 among West African countries (11) , which prevented the majority of infected people and family members from accessing formal health services. Search for care in the popular sector, where payment is low cost and occurs through other goods, money is not necessarily used frequently by the population. Easy access to health care in the popular sector and cultural aspects of belief hinder the practice of carrying out the HIV screening test, contributing to the late diagnosis of the disease.
In a study conducted by Hønge et al. (2016), with people undergoing treatment for HIV/AIDS in one of the most important hospitals in Guinea-Bissau, it was found that most people infected with HIV obtained late knowledge of their HIV status. Among these, the majority had advanced disease and had a mortality almost four times higher (12) .
Among the socio-cultural factors, Female Genital Mutilation (FGM) and Male Circumcision (MC) stand out as one of the main responsible factors for the spread of the virus. FGM practice belongs to certain Muslim groups and rural people in some African countries and is considered to be an attack on human rights, with several worldwide movements in favor of its eradication (13) . In Guinea-Bissau, FGM is very low and criminalized, but MC is not. A study carried out in the country pointed out that MC is prevalent in the country and acts as a protective factor against HIV. However, the authors point out that, when performed in religious rituals, without adequate hygiene and safety conditions, there is a risk of HIV infection (14) . The need to modify such cultural practices stands out, as well as (re) formulation and implementation of policies and actions that consider other aggravating factors in the fight against AIDS in Guinea-Bissau. Among them are the lack of a culture of condom use; existence of polygamy; male chauvinism; patriarchy; inequalities that affect women; female submission; gender-based violence; inability of women to negotiate safe sex; belief that HIV can be transmitted through witchcraft and/ or supernatural forms; resistance to treatment, for believing in traditional cure more than conventional cure, among other factors that also contribute to the scenario.
Furthermore, it becomes opportune to dialogue with SDH to reflect on the general context of the country and to understand the multiple factors that maintain the AIDS epidemic. SDH are understood as economic, social, cultural, ethnic-racial, psychological, behavioral, political and environmental factors that are related to the health conditions of individuals and populations. Such factors can contribute to understanding the barriers to achieving the goals in question and to overcoming the major public health challenges.
SDH can be classified into macro and micro determinants. The macro level context is influenced by global trends and events, namely global climate change and financial crises. More generally, there are concerns about globalization, deindustrialization, immigration, and inequality. National and local responses to these macro-level influences affect the conditions in which people live and, therefore, influence health effects (15) . In this case, take as an example the difficulty that Guinea-Bissau had in the fight against AIDS due to the financial crisis of 2008, which directly influenced the capacity of partner countries to provide inputs for actions in the country.
Concerning the micro level, SDH involve the economic, social, cultural and environmental structures of a society, in addition to those determinants linked to life condition and work (people's daily lives) such as workplace, access to health services, education, food, housing and transportation. Individual aspects that are related to people's free will are also considered, such as how to live their lives, diet, physical exercise, alcohol use, among others that, in a way, are influenced by the culture/society where the person lives.
It is important to highlight that health is not limited to a biological-natural fact and to the use of epidemiological schemes, it is part of the coexistence of individuals in society and access to socioeconomic networks and essential services. The social context and the individual and community life history will influence positively or negatively on health, which is an eminently human phenomenon (15) . It would be necessary to remedy the problems already identified and to promote mechanisms to reduce social inequities. The international institutions themselves recognize the existence of these problems and suggest partnerships, public and/ or private, of national and global character, supported by the spirit of solidarity, to the poorest and to people in vulnerable situations.
When raising this debate, even though succinctly, linked to some provocative and relevant concepts for constructing public health policies, it is thought that the proposal to eradicate the AIDS epidemic by 2030 has become a utopia. However, there are incentives to think that international organizations, by proposing ambitious goals such as those set out in this text, provoke nations to keep this objective on their agendas on a permanent basis. Therefore, regardless of the barriers currently encountered, at some point AIDS eradication may be a reality.
For the eradication to be achieved, commitment of political actors and health professionals, particularly nursing, will be fundamental, as it is an indispensable category in the fight against the HIV/AIDS epidemic and for its possible eradication. Nursing must act as a care manager in the various spheres of health and contribute to elaboration of policies and actions through care practice, whether for health promotion, disease prevention or rehabilitation of the sick. Therefore, it is believed that this practice should incorporate the debate in order to participate in the process of facing AIDS, with attention to SDH inclusion.

FINAL CONSIDERATIONS
When thinking about the eradication of the AIDS epidemic by 2030, mainly in countries like Guinea-Bissau, it is imperative to know and consider the specificity of the population and the SDHs present within that society. Factors such as political and economic instability; lack of definition and implementation of public health policies in the long term; direct payment rate for health services; greater access to care in the popular than formal sector; late HIV testing; belief that HIV can be transmitted through witchcraft and/or supernatural forms; difficulties in ensuring continuous availability of ARVs in the public network; lack of the culture of condom use; gender-based violence; FGM; MC and among other factors contributed to the proposal to eradicate the AIDS epidemic by 2030 become a utopia. However, it is important to highlight and consider that all strategies (be they local, national or international), even though they may seem ambitious, represent opportunities for countries to propose and build public policies capable of changing the existing reality and, preferably, reduce some of the ills that afflict their populations.
Concluding, it is noteworthy that this reflection did not seek to raise formulas or proposals to make feasible the fulfillment of international goals, but to highlight the challenges to reach and the possible catalyzing factors of the HIV/AIDS epidemic in Guinea-Bissau. Thus, we aimed to awaken and promote debates to find viable solutions capable of transforming walls that, at times, seem insurmountable, into safe bridges, perhaps not only to eradicate the AIDS epidemic in this country, but at least to bring more citizenship, dignity, and quality of life for this population.