|DR. ARTUR KALICHMAN|
Dr. Artur Kalichman, the coordinator of the sexually transmitted disease and AIDS program for the state of São Paulo's health department, shares his thought on the progress Brazil has made in its efforts to keep HIV from devastating the country.
The NewsHour Health Unit is funded by a grant from The Henry J. Kaiser Family Foundation.
| SUSAN DENTZER: Describe for me
first the course of the epidemic here in São Paulo, since the first case
was found in the early 1980s.
DR. ARTUR KALICHMAN: Well, the HIV virus arrived here in São Paulo in the beginning of the '80s. During the '80s, the main cause of infection was male-to-male relationship infection in gay men population, homosexual and bisexual. In the late '80s the IV drug users became a very important problem. And in the '90s IV drug use became the main cause of infection in the state of São Paulo.
Along with that, a lot of humans became infected because they were using drugs or because they are partners of IV drug users. And so the epidemic that in the '80s was mainly among men became also among women. And just to give a figure, in the '80s, the male-female ratios were more than 20:1, and nowadays we're at 2:1. And among the asymptomatic HIV patients 1:1.
So, nowadays, not only São Paulo but in Brazil as a whole, what is on the rise is heterosexual transmission. So, we still have a very important epidemic among men having sex with men, although it has now plateaued nowadays, but in a very high plateau.
The epidemic at least in São Paulo among IV drug users went down, mainly because of the harm reduction strategy that we are implementing; and also because with the arrival of crack, a lot of heavy drug [users] moved from IV drug user to crack, so it's not as much related to HIV as IV drug use. And the epidemic rise through heterosexual transmission.
The epidemic is growing among women, it's a kind of feminization of the epidemic. The epidemic is also spreading throughout the state, and becoming more concentrated in the big cities of the state of São Paulo. And now it's spreading through the interior of São Paulo. But not to rural areas like in Africa, but small and medium cities, and in the interior of the city of São Paulo.
The epidemic always reaches the various social classes ... And nowadays we have a kind of mature epidemic here in the state of São Paulo. And the only situation, the only real situation that is on the rise is heterosexual transmission.
Men have sex with men has stabilized. IV drug user has fallen. And along with this increased number of cases among women, we've begun to have maternal-to-child transmission, as a very important part of HIV/AIDS among children. And nowadays 90 percent of the cases among children under 13 years old is related to mother-to-child transmission.
SUSAN DENTZER: You've had your first instance recently of the second generation mother-to-child transmission ... What is the lesson of that?
DR. ARTUR KALICHMAN: Well, the lesson of that is we have a generation of people, men and women, who were born infected by HIV. They have grown up. They are having an active sexual life. And this is good, because they are having the opportunity in their lives to experience that.
But the lesson is we have to enhance the prevention strategies, and not necessarily to avoid them to get pregnant, but try to give them access to mother-to-child prophylaxis; and if it fails, try to treat this child that was born now as good as we treated her mother or his mother. Because I don't know the sex. For him to be alive as long as his mother was, and be able to marry, to have children, and have a happy life.
|Brazil's HIV prevention strategies|
SUSAN DENTZER: You feel very strongly as do many here in Brazil about the importance of condom use. Why is that so important?
DR. ARTUR KALICHMAN: Well, based on the evidence available through all of the studies... using condoms is the most effective way to avoid HIV infection. And the most feasible way.
I mean from an individual point of view, anyone has the right to decide to be abstinent, to have only one partner. But in terms of a public health message, what we feel and what we believe based on the existing data that is more effective, is to send a message to use condoms...
And I believe that we avoided 600,000 infections mainly because of the increasing use of condoms in this country.
SUSAN DENTZER: As you know in the United States, many organizations and many people feel that no money or only a limited money should go to organizations that preach anything other than abstinence. They want the abstinence message to be the primary one. What do you think of that?
DR. ARTUR KALICHMAN: I think to deal with sexual behavior is not easy. To change sexual behavior is not easy. But I believe that it's more feasible that people still do have sex using condoms, than people stop [having] sex. I don't believe it's feasible as a public health message to promote abstinence. In fact, it didn't work...
And so it's not an ideological discussion I'm doing here. I'm just talking very practically, very pragmatically. Based on the evidence available and all over the world, abstinence could be an individual choice. And it's very respectable. I cannot disagree with somebody who decides to be abstinent; it's okay for sure. And it works. But as a public health message, I don't believe that it's feasible, and I don't believe it works. Not ideologically, based on evidence data available all over the world.
|Ongoing challenges for Brazil|
SUSAN DENTZER: What is the biggest challenge facing this nation in its ongoing battle against HIV/AIDS?
DR. ARTUR KALICHMAN: Well, I think you have to keep and reinforce the prevention strategies that we are implementing here in Brazil, to try to [increase] the use of condoms, try to... avoid infection through IV drug users, which was the main path to heterosexual transmission.
So if you disregard the IV drug users, you end up with a lot of women and children [who are] HIV infected. So we still have to promote prevention among this population. I think to work among the disfranchising people, it's still a big challenge. Inmates in prisons, it's a big challenge. We have to reinforce the mother-to-child prophylaxis, which is a very feasible and effective strategy. And we can do better in that.
And we have to keep on going on the strategy of treatments, and try to deal with the challenge related to that. The ones related to the managing, clinical management of anti-retroviral therapy, adverse effects, compliance, and enhance the quality of public health services to support patients... And I must say that Brazil has figures as good or as bad as the rest of the world in terms of... compliance, we are doing at the same pace as everybody else.
And a problem also would be the prices of the medicines, of the drugs. Not only to Brazil but all the developing world. So we have to come up with negotiations, ideas, strategies that put public health higher than commercial interests. We have to respect they are legitimate also, the commercial interests. But you have to end up with a balance that prioritizes the public health interests, the life of the people, and that we can have affordable prices for the drugs, to maintain the sustainability of the treatment policy.
SUSAN DENTZER: Is Brazil a model for even less-developed nations as they seek to fight AIDS and HIV?
DR. ARTUR KALICHMAN: It's very hard to get a model from a country to another country. I mean I think Brazil, the way we are organizing our efforts against HIV/AIDS could be used to learn a lesson, to learn which are failures, to learn what will succeed. But maybe the principles could be used for other countries in terms of, we believe here in Brazil that health is a right of the citizen and a duty of the state. It's in our constitution...
Not a model. I think Brazil is more an example. I mean if we can do here, why people cannot do other places? Not necessarily in the way we are doing, with the same way, because the reality may be very different from Brazil or other countries. But we are more than a model. I think we are a reference, or an example that things can be done...