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The policy responses to human immunodeficiency virus/acquired immune deficiency syndrome (AIDS) in the Brazil, Russia, India, China and South Africa (BRICS) nations have played out amid radically different political environments that have shaped state-civil society relations in critical ways. In contrasting these different environments, this article offers the first comparison of the policy response to AIDS in the BRICS nations and seeks to understand the way in which political context matters for conditioning the response to a major epidemic. Using a comparative historical approach, we find that while collaborative state-civil society relations have produced an aggressive response and successful outcomes in Brazil, democratic openness and state-civil society engagement has not necessarily correlated with an aggressive response or better outcomes in the other cases. Response to the epidemic has been worst by far in democratic South Africa, followed by Russia, where in the former, denialism and antagonistic state-civil society relations fuelled a delayed response and proved extremely costly in terms of human lives. In Russia, a lack of civil societal opportunity for mobilization and non-governmental organization (NGO) growth, political centralization and the state’s unwillingness to work with NGOs led to an ineffective government response. Top-down bureaucratic rule and a reluctance to fully engage civil society in democratic India substantially delayed the state’s efforts to engage in a successful partnership with NGOs. Nevertheless, China has done surprisingly well, in spite of its repressive approach and narrow engagement with civil society. And in all cases, we find the relationship between state and civil society to be evolving over time in important ways. These findings suggest the need for more research on the links between democratic openness, political repression and policy responses to epidemics.