Vera Paiva

A Critical Analysis of the Brazilian Response to HIV/AIDS: Lessons Learned for Controlling and Mitigating the Epidemic in Developing Countries

The Brazilian National AIDS Program is widely recognized as the leading example of an integrated HIV/AIDS prevention, care, and treatment program in a developing country. We critically analyze the Brazilian experience, distinguishing those elements that are unique to Brazil from the programmatic and policy decisions that can aid the development of similar programs in other low- and middle-income and developing countries.Among the critical issues that are discussed are human rights and solidarity, the interface of politics and public health, sexuality and culture, the integration of prevention and treatment, the transition from an epidemic rooted among men who have sex with men to one that increasingly affects women, and special prevention and treatment programs for injection drug users.

Idade e uso de preservativo na iniciação sexual de adolescentes brasileiros

OBJETIVO: Analisar a idade e o uso do preservativo na iniciacao sexual de adolescentes brasileiros em dois periodos: 1998 e 2005. METODOS: Amostras representativas da populacao urbana brasileira foram entrevistadas em inquerito domiciliar por duas pesquisas, realizadas em 1998 e 2005. Dentre os entrevistados, 670 jovens (16 a 19 anos) sexualmente ativos foram selecionados para o estudo, 312 de 1998 e 358 de 2005. Para analise dos dados ponderados foram utilizados o teste qui-quadrado de Pearson e o teste exato de Fisher (±<5%). RESULTADOS: Em 2005, 61,6% dos jovens entrevistados tinham iniciado-se sexualmente, cuja idade media foi 14,9 anos, sem diferencas significativas para os jovens entrevistados em 1998. O uso de preservativo na primeira relacao sexual aumentou significativamente em relacoes estaveis (48,5% em 1998 vs. 67,7% em 2005) e casuais (47,2% em 1998 vs. 62,6% em 2005) em quase todos os segmentos. Persistiram as diferencas relacionadas a iniciacao sexual e ao uso de preservativos segundo genero, cor da pele e escolaridade, tal como observado em 1998. A diminuicao no uso de preservativo entre os jovens que se iniciaram sexualmente antes dos 14 anos, em todos os contextos de parceria, foi expressiva na regiao Sudeste e entre os mais escolarizados. CONCLUSOES: Como em outros paises, observou-se tendencia a estabilizacao da idade da iniciacao sexual entre jovens de 15 a 19 anos. O adiamento do inicio da vida sexual, mais frequente entre os jovens mais escolarizados, deve ser tema discutido no planejamento da educacao dos adolescentes para a sexualidade e prevencao das IST. Quanto a diminuicao da vulnerabilidade ao HIV, e relevante e significativo o incremento no uso de preservativo na iniciacao sexual.

Reproduction and sexuality in HIV-positive women, Brazil

OBJETIVO: Estudar questoes relativas a sexualidade e a saude reprodutiva de mulheres HIV-positivas, seu acesso as praticas de prevencao, sua aderencia a tratamentos e a possibilidade de fazerem opcoes conscientes quanto a gravidez. METODOS: Estudo exploratorio realizado, em 1997, em um ambulatorio de um centro de referencia na area de doencas sexualmente transmissiveis e Aids localizado na cidade de Sao Paulo, Brasil. Foi estudada uma amostra consecutiva, nao-probabilistica, constituida de 148 mulheres HIV-positivas. Foram excluidas as menores de 18 anos e as fisicamente debilitadas. Os dados foram colhidos por meio de entrevistas estruturadas. Foram aplicados os testes de chi² e t-Student. RESULTADOS: A media de idade das mulheres pesquisadas foi de 32 anos, sendo que 92 (62,2%) tinham ate o primeiro grau de escolaridade, e 12,2% chegaram a cursar uma faculdade. A mediana do numero de parceiros na vida foi quatro, e metade das entrevistadas manteve vida sexual ativa apos infeccao pelo HIV. Do total das mulheres, 76% tinham filhos, e 21% ainda pensavam em te-los. Um maior numero de filhos, maior numero de filhos vivos e de filhos que moravam com as maes foram os fatores mais indicados como interferencia negativa na intencao de ter filhos. Nao foi encontrada associacao entre pensar em ter filhos com as variaveis como percepcao de risco, situacao sorologica do parceiro, uso de contraceptivos e outras. Os metodos contraceptivos mudaram, sensivelmente, na vigencia da infeccao pelo HIV. CONCLUSOES: A intencao de ter filhos nao se alterou substancialmente nas mulheres em consequencia da infeccao pelo HIV. Mulheres HIV-positivas precisam ter seus direitos reprodutivos e sexuais discutidos e respeitados em todos os servicos de atencao a saude. A adesao ao medicamento e ao sexo seguro sao importantes, mas dificeis, requerendo aconselhamento e apoio. Sao necessarios servicos que promovam ambiente de apoio para essas mulheres e seus parceiros, propiciando as pessoas com HIV/Aids condicoes de conhecer, discutir e realizar opcoes conscientes no que concerne as decisoes reprodutivas e sua sexualidade.

Vulnerability, Human Rights, and Comprehensive Health Care Needs of Young People Living With HIV/AIDS

We sought to identify and understand the health care needs of young people living with HIV/AIDS, particularly in terms of their psychosocial well-being. We conducted a qualitative analysis of HIV-positive young people and their caregivers, focusing on the implications of an HIV diagnosis for health care needs. Stigma was a recurrent issue that arose in the interviews conducted with the respondents, and it was evident that youths had been denied many rights related to health. We concluded that young people living with HIV need comprehensive care based on a human rights approach. In this regard, we offer some practical recommendations for health programs.

The right to love: the desire for parenthood among men living with HIV.

Abstract Drug regimens and procedures now exist that will prevent parents from transmitting HIV to infants, and the ethical and legal obligation to promote and protect the reproductive rights of those living with HIV should form part of training for HIV/AIDS care and prevention. This paper reports a study that investigated issues of sexuality and reproduction with 250 Brazilian men living with HIV in São Paulo. We asked whether they wished to have children and whether health professionals in HIV/AIDS treatment clinics that they attended were supportive of their wishes. Health professionals were not considered by most participants to be supportive enough or even impartial about HIV-positive people having children, and paid little attention to mens fathering role. 80% of the men had sexual relationships, and 43% of them wanted children, especially those who had no children, in spite of expectations of disapproval. Few of the men received information about treatment options that would protect infants, however. In previous studies with HIV-positive women attending the same clinics, by comparison, greater knowledge about prevention of perinatal HIV transmission was reported, but women had fewer sexual relationships, fewer desired to have children, and they expected even more disapproval of having children from health professionals. We conclude that the rights of those with HIV to found a family depend as much on curing the ills of prejudice and discrimination, including among health professionals, as on medical interventions.

Sexuality of women living with HIV/AIDS in São Paulo

The social and cultural setting which increases female vulnerability to HIV does not disappear when women living with HIV/AIDS discover that they are infected. Following diagnosis, new challenges arise in their emotional lives, an issue which has received little attention in the literature. This study interviewed 1068 women living with HIV/AIDS using a questionnaire consisting of both open and closed questions, aimed at describing aspects of their sexual and reproductive lives and how they perceive counseling at Reference Centers in two cities in the State of São Paulo, where they have access to free antiretroviral therapy. Of the women with stable sexual partners, 63% used condoms in all their sexual relations, or three times the national average; 43% of the partners were HIV-negative and 14% had unknown serological status; 73% of the women had children and 15% were considering becoming pregnant. Knowledge on mother-to-child transmission was less than expected, and the interviewees complained of limited space and receptiveness for discussing sexuality, especially with regard to their childbearing wishes. Counseling on sexuality should be a continuing process and requires interdisciplinary training for the professional team working in health care services, with an emphasis on sexual and reproductive rights.

The right to prevention and the challenges of reducing vulnerability to HIV in Brazil

The study evaluates the Brazilian response to the targets established by UNGASS for the prevention of HIV/AIDS. The analysis was based on national research, documents and information from the National Program STD/AIDS and on state-level action plans and targets. Brazil relies on various prevention policies to attain the UNGASS targets proposed for 2005. These include: addressing discrimination issues, promotion of HIV testing, distribution of condoms, needle exchange programs, discussion of sexuality in schools, prevention initiatives for sex workers and homosexuals and prevention in the workplace. These have resulted in increases in testing and condom use. Various challenges are discussed, including: overcoming discontinuity in action plans (particularly with more vulnerable groups), training prevention teams, increasing monitoring of quantity and quality of preventative actions and overcoming regional, racial and gender inequalities. It is concluded that the right to prevention is not a public priority, nor is it on the social movement agendas. This contrasts with the right to better HIV treatment. In order to increase the efficacy of these programs, it is suggested that they be understood and incorporated based on the promotion and guarantee of human rights, thereby advancing the ethical/political debate at local and national levels.

Putting sexuality (back) into HIV/AIDS: issues, theory and practice.

Abstract After more than twenty years of programming and activism aimed at stemming the sexual transmission of HIV (and addressing the needs of those most vulnerable to infection) the HIV/AIDS epidemic continues to grow worldwide. Taking up this concern, this paper argues that one of the reasons why HIV prevention has had limited success is because of inadequate conceptualization of human sexuality in such work. Giving sexuality a more prominent position in responses to the epidemic raises a range of issues, including theorization of gender, understanding of sexual subjectivity, the significance of pleasure (or lack of pleasure) in sexual decision-making, and conceptualization of sexual behaviour and culture. Taking these themes forward entails asking significant questions about the underlying paradigmatic and methodological commitments of mainstream HIV/AIDS research, especially the tendency to reproduce accounts of human sexuality as if it were a measurable form of conduct only. Advocating new approaches that take the meaning and symbolic value of sexualities into account complicates established orthodoxies in the field whilst offering potential for more effective HIV prevention strategies.

A revelação do diagnóstico na perspectiva dos adolescentes vivendo com HIV/AIDS e seus pais e cuidadores

The purpose of this study was to identify relevant issues in the disclosure of HIV-positive status in children and adolescents, aiming to improve the quality of their healthcare. A qualitative study included adolescents living with HIV/ AIDS and their parents and caregivers at AIDS reference services in Sao Paulo and Santos, Brazil. In-depth interviews and focus group were used. The main reasons for disclosure were: poor treatment adherence, sexual maturity, adolescents request, and inadequate procedures by medical staff. Disclosure was a critical moment for adolescents, with a strong impact on their life plans and horizons. Adolescents infected through sexual transmission and drug use reported the most problematic scenes involved in disclosure. Despite its initial negative impact, disclosure resulted in improved healthcare and better dialogue among the adolescents, caregivers, and healthcare providers. The adolescents also requested clear, no-nonsense, honest information. The authors conclude that health services need to actively provide an adequate approach to facilitate disclosure of HIV-positive status to children and adolescents, realizing that it is a long-term process supported by the family and a multidisciplinary team.

Aids, estigma e desemprego: implicações para os serviços de saúde

OBJETIVO: Analisar o efeito do processo de estigmatizacao e discriminacao no ambiente de trabalho sobre os cuidados cotidianos a saude e o bem-estar de homens vivendo com HIV/Aids. METODOS: Estudo qualitativo com 17 homens vivendo com HIV, realizado em 2002. Foram estudados os depoimentos em grupo para discutir as dificuldades sobre discriminacao no ambiente de trabalho, utilizando analise das praticas discursivas. O grupo, proveniente de centro especializado em HIV/Aids da cidade de Sao Paulo, representou segmento de pesquisa anterior. RESULTADOS: O debate entre os participantes indicou que o tratamento anti-retroviral exige idas frequentes aos servicos de assistencia medica, que implicam em faltas ou atrasos no trabalho. A apresentacao de atestados medicos para justificar ausencia no trabalho, mesmo sem indicar Aids, pode resultar em demissao. Desempregados, muitos sao barrados nos exames medicos e tem o direito ao sigilo de sua condicao violado. Como ultimo recurso, o pedido de aposentadoria implica em cenas de humilhacao ou discriminacao na pericia medica. CONCLUSOES: A assistencia planejada com o envolvimento dos pacientes consegue ampliar a atencao psicossocial e considerar as necessidades do paciente trabalhador ou desempregado, reconhecendo que o estigma limita o cuidado, afetando a saude mental e a evolucao da infeccao. Mitigar o efeito do estigma e da discriminacao requer articulacao politica intersetorial e contribuira para atingir metas globalmente reconhecidas como fundamentais para o controle da epidemia.