Healthcare professionals are worried about the silent march of AIDS. The most recent cause for concern are the results of a survey interviewing 1,217 patrons at bars, movie theaters, and nightclubs in República and Consolação, two neighborhoods in downtown São Paulo. The study found high rates of infection with the HIV virus, which causes AIDS, especially among young gays. It also revealed situations that leave these individuals very vulnerable to infections and detected gaps in prevention strategies for a disease that remains a public health challenge, with 37,000 new cases appearing in Brazil every year, 7,000 in the state of São Paulo alone.
Of interviewees between the ages of 18 and 24, 6.4% were infected with the HIV virus – a rate about 50 times greater than the national average for this age bracket. Among interviewees in the 18- to 19-year-old range, the infection rate was 5%, suggesting that these individuals were infected during their first two years of sexual activity. Looking at all age brackets, the overall infection rate was 15% for HIV and 18% for syphilis, another sexually transmitted disease (STD).
The artist José Leonilson Bezerra Dias was born in Fortaleza, Ceará, in 1957. The overriding theme of his work became AIDS in 1991, when he discovered he had HIV/AIDS. Leonilson died in 1993.
“These are unacceptably high numbers,” states Maria Amélia Veras, professor at the School of Medical Sciences at São Paulo’s Santa Casa Hospital and one of the research project coordinators. Known as SampaCentro, the study has brought together researchers from Santa Casa’s School of Medical Sciences, the São Paulo State Department of Health, the State University of Campinas (Unicamp), the University of São Paulo (USP), the Adolfo Lutz Institute, the Oswaldo Cruz Foundation (Fiocruz), and nongovernmental organizations (NGOs). “What we saw reflects what is also happening in other regions of the city and in other cities,” says Gabriela Calazans, professor at Santa Casa, researcher at the São Paulo State Department of Health’s Reference and Training Center on Sexually Transmitted Diseases and AIDS, and another coordinator on the project.
The Ministry of Health has recorded an increase in the infection among gays between the ages of 17 and 22 – from 0.56% in 2002 to 1.2% of the total number of infected individuals in 2007 – but, according to the research coordinators, the social and sexual habits of gays and bisexuals have not been examined in depth in São Paulo since the Bela Vista Project, about ten years ago.
The locations surveyed in the study are patronized mainly by gays (80% of those interviewed). These areas are also frequented by men who have sex with other men but do not consider themselves homosexuals, as well as men who have relations with women. This highlights the need for specific preventive initiatives among all groups. Statistical records indicate 608,230 cases of AIDS in Brazil from 1980 to June 2011, with a growing incidence among women, who are primarily infected through heterosexual contact. According to the Ministry of Health, there was one case of AIDS among women for every 26 among men in 1985; by 2010, the proportion had shifted to one case among women for every 1.7 among men.
Fear and discrimination
Thirty years after São Paulo and other states registered their first cases, AIDS is now less visible, as it is no longer an incurable disease with a high mortality rate. In many ways, however, little seems to have changed. While there is no more talk of “risk groups” – a public health concept that in the early days of the epidemic incited discrimination even among those who were not infected – the groups now referred to as “more vulnerable” are still victims of discrimination at school, at work, within their families, and among their circles of friends, as this study bears out. There is continued concern over the risks of HIV infection but prevention does not always seem possible. People who might have the infection tend to put off being tested for the virus out of fear of suffering the consequences of a disease whose treatment remains an arduous ordeal. Condom use is still the safest and cheapest way of avoiding infection, but it isn’t always promoted and therefore isn’t always adopted by young people and other segments who are more exposed to the infection.
Almost half (43%) of those interviewed said they had at least a college education, indicating that they did not catch the virus or run the risk of doing so because they lacked access to information. Almost all interviewees recognized that there is a high (69%) or moderate (28%) risk of contracting HIV during gay sex, but awareness of this risk did not always translate into actions that could avoid infection: almost one-third (29%) of those interviewed reported that it was difficult to use a condom when they were in love, and 13% find it hard to tell their partner that they want to use a condom.
“In the context of life and relationships, there isn’t always room to adopt the prevention measures that can keep the virus from being transmitted to other people,” says Calazans. She draws a parallel with the prevention of diseases like high blood pressure, diabetes, or obesity: “Even though we know we should change our diets and engage in physical activities, it’s not always easy to incorporate these changes into our lives.”
In most of the 73 places visited, interviewers found no posters or materials on methods for preventing infection or recommending screening tests for HIV or other STDs. “Several managers said that the public needs to know more about AIDS prevention measures,” Calazans pointed out. “A few said our work would bother their business and they wouldn’t let the interviewers in, arguing that their customers were there to have fun and didn’t want to hear about sickness. Barriers like this were more common in places catering to higher socioeconomic classes.”
From November 2011 to January 2012, 34 interviewers usually worked from about 10 pm to 2 am to get to know the habits and fears of gays, heterosexuals, and bisexuals. When they approached someone, they would ask a simple question – “Can you take part in a survey?” – followed immediately by an incisive one: “Have you ever had anal or oral sex with a gay or transvestite?”
After the interview, which averaged 45 minutes, the interviewers invited the interviewees to give a finger-stick blood sample to check for HIV. Of the 1,217 interviewees, 778 took the test but only 282 picked up the results at the Department of Health’s Reference and Training Center on STDs and AIDS, in Vila Mariana. Of the 235 who took the syphilis and hepatitis B and C tests, 172 went to get their results. “Many of the participants agreed to have the test as a way of contributing to the production of knowledge that might redirect the development of public health policies for the group, but they said up front that they weren’t interested in picking up the results, in many cases because they already knew what they’d be, but also because they were afraid,” Calazans says.
“Mainly among men who have sex with men, the fear of knowing that you’re positive appears as the biggest reason for not having the test or not wanting to know the result,” stated Veras when she presented the study’s findings on the morning of August 30 at a congress on AIDS prevention in São Paulo. “If the test result is positive, it can augment discrimination and social isolation.”
“Today’s young people hadn’t seen the face of AIDS when we started prevention work at schools,” says Vera Paiva, coordinator of the Nucleus for AIDS Prevention Studies (NEPAIDS) and professor at USP’s Institute of Psychology. Anyone born post-1990 has probably only heard tell of the terror of the early days of AIDS, in the 1980s, when neither doctors nor patients knew what the disease was or what caused it. There was no medicine for it until the mid-1990s, and so when people with AIDS got to the hospital, they knew they’d be placed in an isolation wing and would die within a few weeks or, at most, months.
“At the onset of the epidemic, in the midst of the panic, as women teachers, parents, and members of the clergy grew convinced of the need for psycho-educational work that fostered prevention, it was easier to work with schools,” says Paiva. “But many administrators today restrict prevention efforts at schools, even though 97% of Brazilians, from all social groups, have expressed support for educating adolescents in school about the use of condoms. It was also the work at schools that achieved the celebrated stabilization of epidemic growth.”
For Paiva, the notion promoted by the Ministry of Health that the epidemic has been stabilized “shouldn’t be commemorated, especially not to the extent that it is.” “We wanted to get rid of inflation, not control it,” she offers as way of comparison. “We can’t be content seeing infection rates at high levels. The misguided celebration of stabilization, today’s homophobia, and the intensification of religious discourse can undo decades-long mobilization and prevention work.” Activists, people with AIDS and their friends and family, researchers, and physicians relentlessly and successfully worked together to stem the epidemic’s advance through prevention methods until the late 1990s, when the first AIDS medications began to be distributed.
At the same time, numerous teams worked steadfastly at research institutes and universities to help fight the epidemic. One of the milestones in this endeavor was identification of the HIV virus in Brazil in 1987, as a result of work by immunologist Bernardo Galvão, a native of the state of Bahia, and his team at the Oswaldo Cruz Foundation (Fiocruz) in Rio de Janeiro (see Pesquisa FAPESP nº 118). In the years that followed, other groups started identifying the most common HIV subtypes in the country, thus contributing to the enhancement of medical treatment.
On August 21, the manifesto “AIDS no Brasil hoje – o que nos tira o sono” (AIDS in Brazil today: what keeps us awake) began circulating on the Internet and was later debated at the congress held in São Paulo. The title was an allusion to a comment made by Dirceu Greco, director of the Ministry of Health’s Department of STDs, AIDS, and Hepatitis. At the international AIDS conference held in Washington DC, he remarked that he wasn’t losing any sleep over the disease in Brazil.
The document – which in just a few days had nearly 370 signatures, headed by that of Vera Paiva, of NEPAIDS – declared: “The affirmation that the AIDS epidemic is under control in Brazil is not only fallacious, it has compromised our national response, depoliticizing the discussion and discouraging international investments. If in the past affirming that we had the world’s best AIDS program legitimized audacious decisions that were previously a mark of the Brazilian program and yielded so many benefits for the public, what we have today is, inversely, an outdated program, whose components are not enough to address the epidemic’s national profile.” The document showed a 10% rise in the number of AIDS deaths (from 11,100 in 2005 to 12,073 in 2010) and of 12% in the number of cases (from 33,166 in 2005 to 37,219 in 2010).
“It seems like different actors grew resigned in their responses to the epidemic,” observed Ivo Brito, coordinator of the prevention unit of the Health Ministry’s national STD and AIDS program, at one of the congress debates. “We were looking at general trends, not at specificities or micro-areas, which very often revealed quite different data. AIDS is not a single epidemic; it’s a set of epidemics, a mosaic, displaying unique features.”
And now what do we do?
“You can’t tackle the prevention of sexually transmitted diseases without recognizing that there is a broad diversity of behaviors, sexual orientations, and ways that people satisfy their desires,” Veras emphasizes. She reports that her team has been meeting with representatives of the government and NGOs to ensure that their analyses help to guide initiatives that are able to curb AIDS and other STDs. “We have to be creative and expand prevention actions,” she says. Veriano Terto Junior, general coordinator of the Brazilian Interdisciplinary AIDS Association (ABIA), one of the area’s oldest NGOs, agrees: “A single prevention strategy – recommending condom use – has not been enough.”
Experts recognize the urgent need to broaden access to condoms, testing, and healthcare services and reinforce counseling efforts on how to prevent infection and expand prevention strategies. One of the latest ideas, heavily debated in recent months, is the use of antivirals that could be taken before or shortly after exposure to situations where there is a risk of infection. Experts stress, however, that this potential new preventive treatment is still under evaluation and it is not clear what groups might best be served by it or how it would effectively work.
Working more intensely with groups that are more vulnerable to HIV infection seems to be a priority once again. Paulo Roberto Teixeira, advisor to the state STD-AIDS program in São Paulo, had made this recommendation right at the outset of the epidemic, as noted in the book AIDS – A epidemia (AIDS – The epidemic), published in 1987. On the last day of the AIDS congress in São Paulo, he stated: “We’re all dissatisfied with what we’ve managed to accomplish so far.”
Over the past ten years, according to Teixeira, there has been no change in prevalence, which remains high among gays, men who have sex with men, and prostitutes. “In the last ten years, since the epidemic acquired its current profile of pauperization, interiorization, and heterosexualization, have preventive measures suffered? Has the effort to de-characterize risk groups and say that AIDS belongs to all of us reduced intervention among more vulnerable groups? We have to re-assess.”
Another substantial challenge is how to identify and treat women with HIV/AIDS. Marli Cassamassimo Duarte studied the prevalence of STDs in 184 women with HIV between the ages of 18 and 67 seen at the infectology clinic at the Botucatu School of Medicine of São Paulo State University (Unesp). Of the total, 84% had been infected by their current or previous partner; 83% presented the human papillomavirus (HPV), which causes cervical cancer; and 24.6% had chlamydia, a bacterial STD. “The high rate of STDs is indicative of unprotected sex and promotion of the transmission chain,” concluded Duarte. As these microorganisms increase the risk of HIV infection, she suggests: “Screening for sexually transmitted diseases should be reinforced at basic healthcare units.”
Sexual behaviors and practices, access to prevention, and the prevalence of HIV and other sexually transmitted infections among gays, transvestites, and men who have sex with men (MSM) in the central region of São Paulo (nº 09/53082-9); Grant mechanism Public Policy Research for the National Healthcare System (SUS); Coordinator Maria Amélia de Sousa Mascena Veras – School of Medical Sciences of Santa Casa Hospital in São Paulo; Investment R$359,124.00 (FAPESP).