The worst of the AIDS epidemic may yet to come, says former director of the national program

The worst of the AIDS epidemic may yet to come if the number of young people infected with HIV continues to increase, warns sociologist Alexandre Grangeiro, a researcher at the Department of Preventive Medicine at USP’s Faculty of Medicine.

Former director of the Ministry of Health’s national HIV/AIDS program (2003-2004) and now coordinator of studies with PrEP (pre-exposure prophylaxis) for adolescents and adults, he says that the new generation of HIV-positive people is already contributing more to the epidemic than the first generations, now 60, 70 years old.

“If this trend continues, that is, if each new generation contributes with a greater number of cases, we will have a very dramatic situation ahead, reversing all the gains that have been made so far”, says Grangeiro, 56.

Data from the most recent epidemiological bulletin on HIV/AIDS by the Ministry of Health, released on Wednesday (1), reveals that young people are the ones with the highest incidence of the disease. Of the cases registered between 2007 and June 2021, 53% were among young people aged 20 to 34 years.

For Grangeiro, there was a change in generational behavior that policies cannot keep up. “There is a huge gap between what is being responded to and the change in behavior experienced by the population.”

Mr. says the worst of the HIV/AIDS epidemic may still lie ahead. Why? In very long-term illnesses like HIV/AIDS, it is very important to look at the generations because there are so many changes over time. These generations in their 60s and 70s were heavily affected by HIV and were the ones who contributed the most to the number of cases over the years.

The generations that were born with the disease already established and with its clearer impacts, with more widespread knowledge, managed to curb the epidemic and this led to the stabilization of the disease’s growth, reduction in the number of hospitalizations and deaths.

But generations born from 1995 onwards, who began to have sex with the epidemic already under the influence of antiretrovirals and with the disease apparently less serious, began to be more affected, to the point that today they contribute more to the epidemic than previous generations of 50, 60, 70 years.

In a number of cases, they contribute more than triple. If this trend continues, that is, if each new generation contributes with a greater number of cases, we will have a very dramatic situation ahead, reversing all the gains that have been made so far.

Even with all the advances made in HIV prevention, diagnosis and treatment methods? Yes, even with everything available today. Many people attribute this increase in cases among young people to the fact that they have not lived the scale of the epidemic. In part, yes, but it doesn’t fully explain.

In reality, there has been a generational change in behavior that policy cannot keep up. There is a big mismatch between what you are having in response [das políticas públicas] and the change in behavior experienced by the population.

What is the mismatch? There are different situations. Today, the main methods to contain the epidemic are based on the use of antiretroviral drugs. People who make a timely diagnosis, start treatment and stop transmitting the disease. PrEP and PEP [profilaxia pós-exposição] are prevention methods dependent on health services. They depend on awareness and education of these people. It is knowledge that would need to be passed on by institutions.

Schools, for example? Yes. Schools reduced their educational actions, and health also reduced their prevention actions. We have almost an institutional silence facing these new generations, who are making them as incapable of maintaining prevention as older generations. We are starting to retreat from the point of view of knowledge, skill, autonomy.

And the role of families? Many parents prefer sex education to be done at school because they don’t know how to approach the subject, they feel embarrassed. But even those who talked about the subject leave condoms on the table. And now with PrEP? Are you going to leave the medicine on the table? It does not give? Necessarily, today you have to go to the health service.

How is the use of new prevention therapies among young people? The more you reduce the age, the lower the proportion of use. Those who use PrEP the most are those who are 30, 40 years old, that is, generations who have already been sensitized about HIV and are already motivated to prevent it. We see an almost explosive scenario in relation to the new generations.

Regarding risky behavior, what changes in this younger generation? They are having more sex and are being less informed and motivated to do it safely. The problem is not getting laid. It’s doing it in an unprotected way. Condom use is not ingrained as a habit in Brazilian culture, it is only used when people are motivated to prevent it. And it’s falling into the new generations.

In qualitative research with MSM [homens que fazem sexo com homens] and trans women, we notice that there is concern about HIV, they know they need to prevent themselves and do not want to become infected, but the references are still those of grandparents. They are not aware of new prevention methods.

What is the impact of the Covid pandemic on the AIDS epidemic? It’s still a big question mark. Apparently there was a decrease in sexual activity, most of the younger people say they have reduced the frequency of sexual intercourse, are having sex more with people from their close cycle, are in a stable affective relationship or with partners they already know.

However, there was also a reduction in the offer of services, many PrEP/PEP services closed, interrupted the offer of new prophylaxis. The result of all this is still unknown. But the incidence of the virus in young people has not decreased. The pre-pandemic infection rate was 0.9% to 1%. It is now at 1.3%.

These young people who are becoming infected now will live with the disease for 60, 70 years. Unless a cure for AIDS emerges, we are going to live with this contingent of infected people for five, six, seven decades. This has a high cost, demands health services, these people can transmit the virus again if they are not adhered to the treatment.

And how can public policies face this new reality? The responses through public policies developed over the last 40 years are no longer adequate. The availability of new preventive methods alone does not guarantee their use. We have to motivate younger people to use PrEP.

The response to HIV has aged along with the epidemic. These new generations have less weight in social movements and also in health services. It is necessary to rejuvenate the answers, as the new generations are accumulating cases.

How is it possible to do this? New prevention methods are heavily service-dependent, impractical and do not favor autonomy. You need to go to the health service five times a year, you need the doctor to prescribe, you need to be tested all the time, this conflicts with everyday life.

You have to change the way you offer these methods. They have to leave health services and be offered more and more in the community, being close to people, with remote follow-up, over the internet.

X-RAY

Alexandre Grangeiro, 56

Graduated in Social Sciences at PUC, he has a specialization in public health. He was director of the national HIV/AIDS program between 2003 and 2004 and of the Health Institute in São Paulo, in 2007 and 2008. He is currently a scientific researcher at the USP School of Medicine and coordinates studies with PrEP for adolescents (Prep15-19 ) and adults (Combines).