The development of new methods for the prevention of HIV infection has caused major changes in acquired immune deficiency syndrome (AIDS) policies as to the United Nations stating that the world is facing the end of the epidemic11. Joint United Nations Programme on HIV/AIDS. 90-90-90: an ambitious treatment target to help end the AIDS epidemic. Geneva: Joint United Nations Programme on HIV/AIDS; 2014. p. 33., as the pool of available technologies is widely accessible to the population and in the regions most affected by the disease. This optimism is supported by the high degree of protection of the new and traditional preventive methods22. Kurth AE, Celum C, Baeten JM, Vermund SH, Wasserheit JN. Combination HIV prevention: significance, challenges, and opportunities. Curr HIV/AIDS Rep 2011; 8(1): 62-72., with the possibility of using them in different exposure situations and by people and social groups within a wide range of profiles and needs. In these 30 years of responses to AIDS epidemic, there has been a vast knowledge about effective interventions to promote, both at individual and collective level, access to prevention technologies, safer practices, and reduction of the infection incidence33. Coates TJ, Richter L, Caceres C. Behavioural strategies to reduce HIV transmission: how to make them work better. The Lancet 2008; 372(9639): 669-84..
The new set of methods comes at a crucial time. Even in high- and middle-income countries, which over the years have developed bold prevention and care policies, incidence rates in specific groups remained high and often returned to grow, marking an upsurge of the epidemic44. Wilson DP. HIV treatment as prevention: natural experiments highlight limits of antiretroviral treatment as HIV prevention. PLoS Med 2012; 9(7): e1001231.. This is the case of homosexuals and young people in different parts of the world, including Brazil. In the metropolitan regions of South and North Regions, the epidemic takes alarming contours, as there may be a prevalence of more than 1% in the general population in some of the cities55. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento Nacional de DST AIDS e Hepatites Virais. Boletim epidemiológico - AIDS e DST. Vol 1. Ano III. Brasília: Ministério da Saúde; 2014.. These rates are even higher than 5% in the most vulnerable populations to human immunodeficiency virus (HIV) infection, such as prostitutes, drug users, and homeless people in different urban centers of the country66. Malta M, Magnanini M, Mello M, Pascom AR, Linhares Y, Bastos F. HIV prevalence among female sex workers, drug users and men who have sex with men in Brazil: A Systematic Review and Meta-analysis. BMC Public Health 2010; 10(1): 317..
The experience and the knowledge accumulated show that the availability of preventive strategies and devices is only part of the solution of health problems. Historically, the existence of drugs was not enough to end epidemics. Tuberculosis and leprosy are good examples. The mortality and incidence rates of these diseases remain high in many regions, despite the existence of effective treatments to cure and prevent their transmission77. Lindoso JAL, Lindoso AABP. Neglected tropical diseases in Brazil. Rev Inst Med Trop S Paulo 2009; 51: 247-53.. This is because the determinants of an epidemic are numerous. Structural barriers, difficulties in access to services, and individual perceptions are just some of the factors that maintain social groups in more vulnerable conditions.
To reflect on the nature of challenges in the context of the HIV epidemic in Brazil, theRevista Brasileira de Epidemiologia gathered in this special issue articles that review the knowledge of HIV prevention methods, its limitations, and potential use within the Brazilian Public Health System (SUS), as well as their impact on services and populations most affected by the epidemic.
The degree of protection offered by biomedical methods based on the use of antiretroviral (ARV) and traditional methods, many of which developed as a community response, was revised by Kuchenbecker and Grangeiro et al.; Kuchenbecker used the number needed to treat to compare the benefits of preventive strategies and methods, showing that counseling and ARV treatment potentially offer better results in reducing the incidence of HIV; Grangeiro et al. showed the limits and specificities of each method, and argue that their ranking exclusively based on effectiveness data hampers an effective policy to fight the epidemic. Offering combined and complementary preventive methods can result in a greater impact. The review of preventive methods is also the subject of Dourado et al., who revisited studies on the male condom. The authors analyzed the frequency and factors associated with the use of such preventive method in the Brazilian population and specific groups, as well as the most successful interventions using this technology, which are those related to adherence and support groups for assuring availability.
Ferraz and Paiva showed no evidence indicating disinhibition of sexual practices due to the supply of new preventive technologies but pointed out that preventive policies must be designed taking into consideration sexuality and human rights, guided by the needs of vulnerable groups. Community mobilization and the right to decision making were taken by Maksud et al. to address the challenges inherent to the organization and the health care structure in offering new methods. Completing this set of articles, Bastos and Veloso Filho reflected on the significant changes in the drug consumption scenario and its impact on harm reduction policies.
The set of preventive tools were analyzed from the perspective of the groups most affected by the epidemic. The specificities of women were treated by Villela and Barbosa and those of men by Leal et al. Both works are pointing out that men and women include different identities. Whereas Villela and Barbosa discussed the impossibility of separating contraception and HIV prevention, Leal et al. showed the invisibility of heterosexual men in policies and studies on AIDS. Terto Jr. used ethnographic reports to reflect on how homosexual men adapt preventive speeches to their reality, desires and sexual practices, refleting on whom, when, and why new methods will be used in the context of homosexuality. The literature on serodiscordant couples was reviewed by Hallal et al., who identified four effective strategies to reduce the risk of infection in this group.
The Revista Brasileira de Epidemiologia pays posthumous tribute to Gabriela Silva Leite (1951-2013), a prostitute and a leading Brazilian activist for the rights of prostitutes during the three decades of the AIDS epidemic in Brazil. Gabriela was a pioneer in founding the Brazilian Network of Prostitutes, the NGO Davida - Prostitution, Civil Rights and Health, and the Daspu design clothes, dedicated to the visibility of the causes of prostitutes through fashion. Gabriela is author of the text entitled "The Couple is Odd: Reflections on Risk Management Potential for STD/HIV/AIDS Prevention in Contexts of Prostitution", which is also signed by Laura Murray and Flavio Lenz, and it was published as a special article in this edition. With peculiar candor and pragmatism, Gabriela and her colleagues reflected on prevention strategies for prostitutes while highlighting one of the characteristics that marks the Brazilian response to AIDS: Human Rights.
Mathematical models define scenarios where the AIDS epidemic can be controlled from combined strategies and access to diagnosis, prevention, and treatment. In this context, the collection of articles aimed to highlight that interventions to increase the autonomy of individuals and vulnerable groups are a strategic and fundamental axis for the best use of prevention methods. The integration of of health care, prevention, and epidemiological surveillance, under the principles of SUS are critical to a successful response to the AIDS epidemic in Brazil.
To the National Department of STD, AIDS and Viral Hepatitis of the Ministry of Health, the Pan American Health Organization (PAHO) and Health Institute of the São Paulo State Department of Health (FAPESP nº 2009/53692-1). These institutions have played a key role in the development of the papers published, by conducting forums, a seminar, and giving technical and financial support to discuss and deepen the various topics addressed here with managers, leaders of non-governmental organizations, and researchers.
To Dulce Ferraz and Gabriela Calazans, who actively integrated the group that organized and coordinated the forums and the seminar that discussed the papers published.
- 1Joint United Nations Programme on HIV/AIDS. 90-90-90: an ambitious treatment target to help end the AIDS epidemic. Geneva: Joint United Nations Programme on HIV/AIDS; 2014. p. 33.
- 2Kurth AE, Celum C, Baeten JM, Vermund SH, Wasserheit JN. Combination HIV prevention: significance, challenges, and opportunities. Curr HIV/AIDS Rep 2011; 8(1): 62-72.
- 3Coates TJ, Richter L, Caceres C. Behavioural strategies to reduce HIV transmission: how to make them work better. The Lancet 2008; 372(9639): 669-84.
- 4Wilson DP. HIV treatment as prevention: natural experiments highlight limits of antiretroviral treatment as HIV prevention. PLoS Med 2012; 9(7): e1001231.
- 5Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento Nacional de DST AIDS e Hepatites Virais. Boletim epidemiológico - AIDS e DST. Vol 1. Ano III. Brasília: Ministério da Saúde; 2014.
- 6Malta M, Magnanini M, Mello M, Pascom AR, Linhares Y, Bastos F. HIV prevalence among female sex workers, drug users and men who have sex with men in Brazil: A Systematic Review and Meta-analysis. BMC Public Health 2010; 10(1): 317.
- 7Lindoso JAL, Lindoso AABP. Neglected tropical diseases in Brazil. Rev Inst Med Trop S Paulo 2009; 51: 247-53.
- Publication in this collection