FAPESP Week France

By Maria Fernanda Ziegler in Paris  |  Agência FAPESP – The number of people infected by HIV is falling globally, as is the number of deaths due to AIDS, but official statistics show the decline occurring unevenly across countries and social segments. Among adolescents, for example, the risk of HIV infection has risen significantly in recent years.

“The problem of AIDS is far from over. Talk of imminent victory over the disease is counterproductive. It distracts us from the harsh reality,” said Vera Paiva, one of the coordinators of the University of São Paulo’s Center for AIDS Prevention Studies (NEPAIDS-USP) in Brazil. Paiva was speaking at FAPESP Week France, a symposium held November 21-27, 2019, in Paris and Lyon.

The 2016 International AIDS Conference, considered the largest and most important global forum on the epidemic, pointed to adolescents as a key population among the groups that is disproportionately affected by AIDS. This age group has therefore become a priority for public policy, alongside other populations historically considered most vulnerable to HIV infection and AIDS-related mortality, such as users of injectable drugs, men who have sex with men, transgender people and sex workers.

“The particular vulnerability of adolescents to HIV is a global trend. Over 2 million adolescents and young adults [15-24] are currently infected. This is the only group in which the infection rate continues to rise, with a 50% higher relative risk than other age groups,” Paiva said.

“As stressed by Gunilla Carlsson, Deputy Executive Director of UNAIDS [the Joint United Nations Program on HIV/AIDS], it’s unacceptable that 6,000 adolescents, girls and young women are infected by HIV worldwide every week because their reproductive and sexual rights continued to be denied,” said Paiva, who leads a research project on adolescence, HIV and dating violence in Brazil. The study is supported by FAPESP via a thematic grant.

According to Paiva, the rising vulnerability of adolescents to AIDS in Brazil is all the more alarming at a time when public spending on health promotion is being cut in the country, despite the right to education and health enshrined in the constitution, which also establishes the separation of religion and the state.

Inequality matters

Women are the most affected in low- and middle-income countries, Paiva noted, whereas in the rich countries, the most vulnerable groups are transgender, bisexual, and gay people and the nonwhite indigenous population.

“This inequality must be taken into account when programs to combat AIDS are formulated,” she said. “The current abandonment of public policies based on the promotion of human rights is one of the main obstacles in Brazil.”

The policies implemented in Brazil between 1993 and 2013 are internationally considered a success case. “The success was supported by the implementation of the right to health and to prevention, as well as sex education projects, and above all, by a secular state that literally produced a national response based on scientific evidence and not on moralistic preaching and rules about good behavior,” Paiva said.

In her view, several factors were crucial to controlling the epidemic in previous decades, especially public access to healthcare, including the right to prevention methods and treatment with effective drugs, as well as equity-based actions to offset social inequality involving cooperation by various players such as NGOs and local governments to prevent the disease.

“These effective actions include sex education and prevention, which are part of the school curriculum in all of Brazil’s 26 states and the Federal District,” she said. “This alliance resulted in a decline in AIDS for two generations and in the 2000s, also produced an important nationwide debate on sexual diversity and gender inequality.”

In her presentation to FAPESP Week France, Paiva highlighted the consistent results of these programs. “In the 1980s, the use of condoms among 14- to 19-year-olds was almost zero. By the end of the 1980s, 48% were using condoms. In 1998, the proportion was 54%, and since 2013, it has reached 62% to 69% in secondary schools. The age of sexual initiation in Brazil has remained between 14 and 15,” she said.

Paiva also highlighted innovative research conducted in this period on health, the social sciences and education. The findings strengthened the perception that sexuality is not confined to hormones and emphasized the importance of understanding the impact of gender inequality and taking sexual, cultural and religious diversity into consideration.

“These are central principles of the programs implemented and coordinated by the SUS [Brazil’s national health system] and based on human rights and evidence,” she said.

“One of the challenges for research is how to monitor and understand the impact of the current situation in which human rights-based policies are under attack, and not just in Brazil.”

Investment in public health, education and science has been cut in Brazil since 2016 in the name of austerity, she noted. “As in other parts of the world, these cuts are accompanied by a political movement fueled by religious and anti-science rhetoric. Guaranteeing sexual and reproductive health for young people therefore requires new ideas that assure the sustainability of programs based on evidence and not on moral preaching,” she said.

The religious and anti-scientific speech that has become more frequent, she continued, runs counter to the discourse that produced the successes achieved over two decades, returning to approaches that demonstrably failed at the start of the epidemic.

“If you keep saying that the family alone should talk about sex with young people, not schools, you’re ignoring important changes in sexual culture and socialization for sex now mediated by the internet: 93% of adolescents in low-income homes access the internet by cell phone,” she said.

These cultural and political changes should be a priority for the research agenda to contribute to a renewal of prevention actions. “The dismantling of prevention policies and cuts to funding for research to monitor their results, provide feedback and correct the techniques and practices that don’t prove effective indicate negligence in the promotion of the right to prevention, especially for the young,” Paiva said.

Epidemiological analysis shows that young people who were born in the 1990s and became sexually active in the 2000s are three times more likely to be HIV positive than people born in the 1970s whose sexual initiation occurred before the AIDS epidemic began to be controlled by access to retroviral medication and mass HIV/AIDS prevention programs.

Data for 2018 show that the proportion of the 15-19 age group with AIDS in São Paulo State has risen from 2% to 7%. There has also been a rise in the number of cases among black people, while the proportion of white people with AIDS has fallen. “An intersectional analysis is crucial when inequality is a key variable. This is so in the case of the techno-scientific discourse designed to prevent differences from becoming inequalities,” she said.

FAPESP Week France took place thanks to a partnership between FAPESP and the University of Lyon and University of Paris. More news about the event can be found at www.fapesp.br/week2019/france.