This report joins Brazil to a growing number of countries demonstrating high levels of HIV prevalence among MSM.[3,18] These reports challenge the initial optimism for test and treat strategies for controlling and ultimately eliminating HIV.[19–22] Although successful treatment will increase prevalence there is evidence of increasing incidence and important gaps in prevention, including a fall-off in the promotion and use of condoms and other preventive behaviors. Available data on HIV prevalence and incidence from low, middle, and high-income countries suggest that the HIV epidemics among MSM are increasing due to stigma and discrimination, sexual behavior, and issues with adherence and care-seeking. From its onset, the HIV epidemic in Brazil has been a concentrated epidemic, with stable prevalence rates around 0.37%2 for the general population, and above 5% prevalence rates among MSM, FSWs, and illicit DU. Structural barriers, conservative social and religious movements in government and insufficient allocation of funds from local governments, may have contributed to the deficits in primary prevention programs reported in Brazil.
Our study shows higher levels of HIV prevalence among the MSM in the 12 cities (18.4%; CI95%: 15.4–21.7) we studied compared to the BBSS we conducted in 2009 in 10 cities (12.1%; 95%CI: 10.0–14.5) suggesting a potential increase in HIV incidence. In our discussion, we explore several potential reasons for rising seroprevalence.
Accounting for reasons for nation-wide changes in HIV prevalence across time is not a simple task. The causes of changes in the HIV epidemic are inherently multidimensional, involving environments of vulnerability and risk, stigma and discrimination for key populations, and changing behaviors, policies, and programs. During the period between our 2 surveys there have been major new strategies to address HIV/AIDS programs and important changes in the institutional, social, and political context in Brazil. Many of these changes – positive and negative – are well documented in Malta and Beyrer.
In addition to changes in these contexts, the changes in sexual behavior among the youth in our sample, shown in accompanying paper in this journal, is also concerning. In addition, the formative research for our study uncovered a catchphrase used by youth: “AIDS já não me assusta mais” (AIDS does not scare me anymore). Understanding this comment requires understanding the new scenario for AIDS created by antiretrovirals and the “treatment to prevention” initiatives[27,28] such as early treatment and preexposure prophylaxis. These initiatives have resulted in a medicalized approach that treats HIV infection as a lifelong chronic condition. In parallel, NGOs that addressed MSM and AIDS prevention have been defunded, removing spaces for community organizing around prevention and testing, and for generating solidarity among the MSM communities.[30,31] Growing support in the Brazilian government for the “Bullets, Beef, and Bible” caucus, in the most conservative congress in the Brazil democratic era, has led to a regressive gender and sexuality agenda and reduced support for programs that focus on MSM needs.[25,30,32] In fact, there have been major budget cuts or dismantling of programs in research, prevention, and treatment throughout the health sector.
Our 2016 sample is younger than the 2009 sample. Although HIV prevalence increases with increasing age due to cumulative incidence and improved survival, the much higher prevalence in 2016 is particularly notable. The trend toward rising new infections among youth is not isolated to Brazil. The US Centers for Disease Control report that in the US youth aged 13 to 24 account for 20% of all new HIV diagnoses, 81% of those occurring among self-reporting gay and bisexual males. Youth presents a special problem, reports CDC: they are the least likely to test or to use a condom, are more likely to drink or use drugs during sex, and have 4 or more partners during their incipient sexual careers. Other studies confirm these differences between younger and older MSM. Analyzing from a generational perspective, Méthy et al report for France that the younger generation of MSM are more likely to have their first sex with a man compared to the older generation of MSM, who were youth in the 1980s. Reports of oral and anal sex, and frequency of sex were lower for older generations of MSM, but are higher among the younger generation today. Interestingly, Wall et al note for the US similarities in this increased sexual frequency in both young MSM and heterosexuals.
This is a repeated sample among MSM in Brazil using RDS. Limitations of RDS have been well documented.[15,37,38] A recent publication has also criticized the reliability of RDS when repeated in the same population in a relatively short period of time. Because the sample selected through RDS is a product of a series of both theoretical assumptions and operational issues, such as seed selection, logistics, and control of “masking,” two consecutive samples could differ substantially. Khatib et al in discussing reproducibility refer to an earlier study in Zanzibar. In the latter study non-MSM IDUs masking as MSM entered the study and drove up the seroprevalence rate. For this reason, formative research and monitoring, applying a large design effect, adherence to STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) RDS guidelines, and RDS diagnostics are proposed. Until better methods are available, RDS will continue to be used to provide population estimates of hard to reach populations in the HIV epidemic. Even though our sample is different from the one in 2009, our findings move in the same direction as other sources of information.[2,44,45]
We take the opportunity in this paper to not just focus on our numbers, but advocate for a response. Our findings present a serious challenge to policy makers: how are we to address the increasing epidemic among MSM in Brazil? Our results argue for an invigorated prevention effort combining innovative approaches such as engaging communities in developing solutions and involving communities themselves in research, publication, and enhanced advocacy. Such strategies are part of a new sustainable development agenda, together with investment in science, innovative solutions, national and local leadership, and strong political commitment to achieve these targets. Parker terms this approach “prevention literacy” to complement treatment literacy, building on the strategy that used NGOs and community participation to promote prevention. Preventing AIDS makes sense on so many levels, but for governments actively shrinking health budgets, reducing transmission makes ultimate sense.
The authors thank the financial support provided by the Brazilian Ministry of Health, through the Secretariat for Health Surveillance and the Department of Prevention, Surveillance and Control of Sexually Transmitted Infections, HIV/AIDS and Viral Hepatitis. The authors also thank all the respondents and their enthusiastic participation in this troubled time for sexual minorities, without them this study would not be possible.
Conceptualization: Ligia Kerr, Carl Kendall, Mark Drew Crosland Guimarães, Adele Schwartz Benzaken, Cristina Pimenta, Ana Roberta Pati Pascom, Willi Mcfarland, Lisa Grazina Johnston.
Data curation: Ligia Kerr, Rosa Maria Salani Mota.
Formal analysis: Ligia Kerr, Mark Drew Crosland Guimarães, Rosa Maria Salani Mota.
Funding acquisition: Ligia Kerr.
Investigation: Ligia Kerr, Carl Kendall, Mark Drew Crosland Guimarães, Maria Amelia Veras, Ines Dourado, Ana Maria de Brito, Edgar Merchan-Hamann, Alexandre Kerr Pontes, Andréa Fachel Leal, Daniela Riva Knauth, Ana Rita Coimbra Motta-Castro, Raimunda Hermelinda Maia Macena, Luana Nepomuceno Costa Lima, Lisangela Cristina Oliveira, Ximena Pamela Diaz Bermudez, Regina Célia Moreira, Luiz Fernando Macedo Brígido.
Methodology: Ligia Kerr, Carl Kendall, Mark Drew Crosland Guimarães, Rosa Maria Salani Mota, Regina Célia Moreira.
Project administration: Ligia Kerr, Mark Drew Crosland Guimarães, Maria Amelia Veras, Ines Dourado, Ana Maria de Brito, Edgar Merchan-Hamann, Alexandre Kerr Pontes, Daniela Riva Knauth, Ana Rita Coimbra Motta-Castro, Raimunda Hermelinda Maia Macena, Luana Nepomuceno Costa Lima, Lisangela Cristina Oliveira, Ana Claudia Camilo.
Supervision: Ligia Kerr, Mark Drew Crosland Guimarães, Maria Amelia Veras, Ines Dourado, Ana Maria de Brito, Edgar Merchan-Hamann, Alexandre Kerr Pontes, Andréa Fachel Leal, Daniela Riva Knauth, Ana Rita Coimbra Motta-Castro, Raimunda Hermelinda Maia Macena, Luana Nepomuceno Costa Lima, Lisangela Cristina Oliveira, Regina Célia Moreira, Ana Claudia Camilo.
Visualization: Ligia Kerr.
Writing – original draft: Ligia Kerr, Carl Kendall, Luana Nepomuceno Costa Lima.
Writing – review & editing: Ligia Kerr, Carl Kendall, Mark Drew Crosland Guimarães, Rosa Maria Salani Mota, Maria Amelia Veras, Ines Dourado, Ana Maria de Brito, Edgar Merchan-Hamann, Alexandre Kerr Pontes, Andréa Fachel Leal, Daniela Riva Knauth, Ana Rita Coimbra Motta-Castro, Raimunda Hermelinda Maia Macena, Lisangela Cristina Oliveira, Adele Schwartz Benzaken, Gerson Pereira, Cristina Pimenta, Ana Roberta Pati Pascom, Ximena Pamela Diaz Bermudez, Regina Célia Moreira, Luiz Fernando Macedo Brígido, Ana Claudia Camilo, Willi Mcfarland, Lisa Grazina Johnston.
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Keywords:Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
Brazil; HIV prevalence; MSM; respondent-driven sampling