Brazil's effective HIV prevention strategies

Davida volunteers in Rio de Janeiro, Brazil. (Image: UNAIDS/Daniel Ramalho)

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Story by Matt Ozug, "America Abroad"

Brazil has implemented effective and controversial strategies to reduce the spread of HIV. Specifically, these strategies include collaborating with those most at risk, which means in many cases public health officials are partnering with prostitutes.

Rio de Janeiro's Copacabana neighborhood is famous for its beaches, Bossa Nova sounds and increasingly, sex for hire. Prostitution is legal in Brazil, and the beachfront disco Help has become a favorite destination for Rio's sex tourists.

"My name is Val, and I'm a prostitute," said a woman at the club. "I was distributing condoms here. It's important for us to talk about prevention and about our rights."

Val is a volunteer for Davida, a local NGO organized to speak out for the health and safety for its members: 25,000 sex workers. One of main reasons for Brazil's relatively low HIV rate is that the Brazilian response has included organizations like Davida, and pushed for everyone -- from the President to prostitutes -- to practice safe sex.

Public health experts say Brazil's approach works because it doesn't discriminate. "The virus is very democratic," said Dr. Mariangela Simao, head of the National AIDS Campaign at the Brazilian Ministry of Health.

The Brazilian Ministry of Health has continued to work with groups like Davida even though it meant rejecting nearly $50 million dollars in US funding for AIDS.

"The US had started requiring countries to state that they oppose prostitution," said Simao. "And we can't do that in Brazil. When you criminalize prostitution, you add stigma and discrimination, and you add vulnerability."

Although Brazil's public health partnership with sex workers has been controversial, a World Bank evaluation says programs like these have had the largest impact on stemming the epidemic here.

In many countries, experts believe long-term solutions will come through condoms, fewer partners and fidelity in marriage. But in Brazil's more permissive culture, public health experts say focusing on condom use alone is a far more effective option, and they've aired some of the most explicit public service announcements in the world.

In one commercial, a man at a party ducks into a bathroom to have a talk to himself about the importance of using a condom, or "tiny hat," as they're called in Brazil. It's a two-sided conversation, with the dialog being filled out by a voice coming from the man's pants.

"The pillar of our prevention strategy is the promotion of condom use, and the government buys a large quantity of condoms," said Simao. "And we are buying right now 1.2 billion condoms."

That's 1.2 billion out of the 15 billion that's produced worldwide, according to Simao. The government has even built a condom factory in the Amazon to supplement global purchases.

Condom promotion would seem like an uphill battle in a country where three out of four citizens are at least nominally Catholic. But the Brazilian church as been relatively quiet on the issue. Although officially opposed to condom use, a historic leftist streak in the church has also allowed for some distance from the Vatican.

At Rio's Catholic University, Father Luis Lima walks a fine line. He councils his parishioners that there is room within church teachings for Catholics to use condoms.

"The Catholic church is against artificial birth control. It doesn't mean to be against the use of condoms to prevent AIDS. It's a subtle but very important distinction. If there is risk of contamination, people must use condoms."

And that's exactly what a large number of Brazilians have been doing: Using condoms. But Brazil's unique AIDS strategy extends beyond prevention, to also include guaranteed treatment for every AIDS patient. Brazil's 1988 constitution defines healthcare as a right for all and a duty of the state.

And this universal treatment makes prevention easier and more effective, says Pedro Chequer, founder of Brazil’s National AIDS Program. "If you provide treatment for free and at good levels, it's easier to convince people to be tested. Because if there's no hope for what's ahead, I'm going to be tested for nothing."

But Brazil's unique strategy is not for everyone. Because their prevention approach does not emphasize abstinence or fidelity in marriage, the Brazilian model has not been widely adopted internationally.

"No we don't work with abstinence," said Dr. Mariangela Simao at the Ministry of Health. "We think that we should help with information and that teenagers have to make their choices. Because they make their choices, whether parents like it or not. They decide when they're going to have their first sexual relation, and whether they are going to use a condom or not. And we want their decision to be informed."

Simao says, as a result, over the last two decades first-time condom among teens has jumped almost 60 percent. But the program also raised concerns from some quarters that preaching about condoms would make teens more sexually active.

Simao doesn't believe this is the case. "In '98, the median age to start sexual activities for boys was between 14 and 15, and for girls it was 15 to 16. In 2005, 2007 it was the same. It didn't change."

Despite successful programs like these, no one is claiming victory and major challenges still remain here. But what Brazil has shown is that, whatever the social context, it's impossible to imagine defeating HIV without two things: An acknowledgement of the realities of sexual behavior, and prevention strategies that are developed in partnership with those communities most at risk.

Dr. Chris Beyrer of the Johns Hopkins Bloomberg School of Public Health says Brazil's strategies have reduced its HIV infection rate notably in the last decade.

"If you look for example, at 1990, the HIV prevalence in Brazil was roughly one percent of adults," said  Beyrer. "The HIV prevalence in South Africa in 1990, was one percent of adults. And Brazil's population prevalence now is 0.6 percent, and South Africa tragically has gone in exactly the opposite direction. One is an example of what early prevention with a human rights-based approach can achieve, and the other is unfortunately what can happen if you ignore this."

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