“Disease requires medication, right? And children don’t, they’re for life”: HIV prevention according to low-income youth from five cities in BrazilAbstract
The increase in HIV incidence rates among young people contrasts with the discontinuity of educational actions and the invisibility of AIDS in public spaces. Based on socio-anthropological research, this article analyzes conceptions and practices regarding HIV prevention of 139 men and women, aged 15 to 24 years, mostly heterosexual and cisgender, from low-income Brazilian communities in Porto Alegre, São Paulo, Rio de Janeiro, Manaus, and Salvador. The study involved ethnographic observation, interviews, and focus groups. According to the findings, the knowledge about diagnosis and new technologies for prevention and treatment of HIV is limited. HIV transmission is still associated with gays, trans people, and individuals with many partners; the fear of the stigma of AIDS still persists; and there is rare contact with people with HIV. There is a prevailing self-perception that HIV infection is a very distant possibility, especially if condoms are used with strangers; the concern regarding an unintended pregnancy is far greater. The results point to the need for policies that address AIDS stigma and social, racial, and gender inequalities, as well as the need to create spaces for learning and dialogue in schools, health services, and social movements, updating successful experiences and exploring the potential of social networks.
Key words:
Prevention; Adolescent; HIV/AIDS; Poverty; Brazil
Resumo
O aumento da taxa de incidência do HIV entre jovens contrasta com a descontinuidade de ações educativas e a invisibilidade da Aids no espaço público. A partir de pesquisa socioantropológica, o artigo analisa concepções e práticas sobre prevenção do HIV de 139 homens e mulheres de 15 a 24 anos, majoritariamente heterossexuais e cisgênero, de comunidades de baixa renda em Porto Alegre, São Paulo, Rio de Janeiro, Manaus e Salvador. O estudo envolveu observação etnográfica, entrevistas e grupos focais. Segundo os achados é limitado o conhecimento sobre diagnóstico, novas tecnologias de prevenção e tratamento do HIV. A transmissão do HIV ainda é associada aos gays, pessoas trans e indivíduos com muitos parceiros/as, persiste o receio do estigma da Aids e há raro convívio com pessoas com HIV. Prevalece a autopercepção de que a infecção pelo vírus está distante do campo de possibilidades, principalmente se a camisinha for usada com pessoa desconhecida; há maior preocupação com a gravidez não intencional. Os resultados apontam para necessidade de políticas capazes de enfrentar o estigma da Aids e as desigualdades sociais, raciais e de gênero e de criar espaços de aprendizagem e diálogo, nas escolas, serviços de saúde, movimento social, atualizando experiências exitosas e explorando o potencial das redes sociais.
Palavras-chave:
Prevenção; Adolescente; HIV/Aids; Pobreza; Brasil
Resumen
El aumento de la incidencia del VIH entre jóvenes contrasta con la discontinuidad de las acciones educativas y la invisibilidad del sida en el espacio público. Con base en una investigación socioantropológica, este artículo analiza las concepciones y prácticas de prevención del VIH de 139 hombres y mujeres de 15 a 24 años, en su mayoría heterosexuales y cisgénero, de comunidades de bajos ingresos en Porto Alegre, São Paulo, Río de Janeiro, Manaus y Salvador. El estudio incluyó observación etnográfica, entrevistas y grupos focales. Según los hallazgos, el conocimiento sobre el diagnóstico, las nuevas tecnologías para la prevención y el tratamiento del VIH es limitado. La transmisión del VIH aún se asocia a personas homosexuales, transgénero e individuos con múltiples parejas, persiste el temor al estigma del sida y el contacto con personas con VIH es poco frecuente. Prevalece la autopercepción de que la infección por el virus es remota, especialmente si se usa preservativo con una persona desconocida; existe una mayor preocupación por los embarazos no deseados. Los resultados apuntan a la necesidad de políticas que aborden el estigma del SIDA y las desigualdades sociales, raciales y de género, y que creen espacios de aprendizaje y diálogo en escuelas, servicios de salud y movimientos sociales, actualizando experiencias exitosas y explorando el potencial de las redes sociales.
Palabras clave:
Prevención; Adolescentes; VIH/SIDA; Pobreza; Brasil
Introduction
Despite significant progress, AIDS remains a global public health problem1. In Brazil, the epidemic is characterized by the highest prevalence of HIV among men who have sex with men (MSM), transgender people, sex workers, and users of psychoactive substances2. From 2000 to 2018, there were significant reductions in the HIV incidence rate among people over 25 and among women, aged 15 to 24 years (5.0/100 to 3.2/100,000 inhabitants), but an increase among men in this age group (6.4/100 to 12.8/100,000 inhabitants)3.
These data are worrisome given the constraints on successful educational initiatives on sexual and reproductive health (SRH) in schools, which impact the learning about HIV4 and the mental health of young people. This scenario includes the conservative wave in the country, illustrated by the ban on the distribution of anti-homophobia kits in public schools in 2011, the Escola Sem Partido movement in 2016, the crusade against gender-based perspectives5, and the reduced presence of AIDS in the public debate.
The reduced visibility of the epidemic can be attributed to the greater emphasis on new biomedical technologies6,7 and the reduction in communication activities on prevention and care, coupled with the weakening of the social movement and the reduction in investment in research and behavioral and structural actions. The emergence of COVID-19 in 2020 and the restrictions on SRH and human rights policies imposed by the conservative federal government (2019 to 2022) also contributed to the invisibility of AIDS8.
We conclude that these factors and the temporary suspension of classes during the COVID-19 pandemic have contributed to young people’s distancing from AIDS. After all, what is the current view of youth groups regarding AIDS? A recent exploratory search of the national literature in the SciELO website highlights a lack of studies on this topic among heterosexual youth; the studies tend to address People Living With HIV/AIDS (PLWHA), gay men/MSM, HIV testing, and pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP)9.
This study aims to understand the current conditions of HIV vulnerability among heterosexual youth populations, given the setbacks and changes in the national context and the scarcity of recent research on the topic. Based on an analysis of the conceptions and practices regarding HIV prevention among adolescents and young people from low-income communities, we aim to reflect on the relationships between social and cultural contexts and vulnerability to STIs/HIV, focusing on gender relations and the territories studied. Our study included 139 men and women, aged 15 to 24 years, mostly heterosexual and cisgender (whose gender identity matches that assigned at birth), living in five communities located in five cities across the country.
Our study assumes that sexual exchanges between youth groups occur predominantly within their community. The term “community” is defined here as a geographic, social, and cultural space, configured as a territory where individuals share values, practices, situations of vulnerability, and access to health care10,11. It is our hypothesis that geographic and/or symbolic distance from the city center makes the territory relevant to youth sociability and networks. According to this perspective, it is in locations close to their homes, places of study, and work that youth groups access social services and establish affectionate and sexual interactions that can increase their vulnerability to HIV/other STIs.
Analyzing the implications of sociocultural and economic particularities and mechanisms in shaping youth social practices12 also guides the understanding of young people’s perception and appropriation of SRH discourses. Therefore, it is necessary to understand the life context, access to, and understanding of information, and the logic that informs young people’s SRH practices, including risk management.
Risk management is defined here as the use of strategies to deal with situations considered risky. In the health context, this term can be understood as the identification, assessment, and control of the risks of situations, aiming to reduce negative consequences and promote health. However, we share the understanding that there are distinct configurations in how people perceive risk discourses and incorporate them into daily life, influenced by knowledge about the phenomenon and by sociocultural and psychological aspects. In this sense, it is important to identify the knowledge, meaning, and experiences of the research population regarding the topic, considering the sociohistorical context. This perspective speaks to sociological approaches on the meaning of risk conception throughout history and its effects on representations, practices, and norms in health, and on how people perceive and deal with risks13-15. Furthermore, it converges with critical analyses regarding the limits of actions focused on disseminating information about risk behaviors and encouraging the adoption of preventive measures.
Methodological procedures
The research is guided by the contribution of social sciences to understanding the cultural significance of health and disease processes. This approach aims to understand the connections between cultural systems, social hierarchies, and access to material and symbolic goods in shaping social practices16.
This study is part of the project “Contexts of HIV Vulnerability among Low-Income Youth: a multicenter study in five Brazilian cities”, developed in low-income communities in Porto Alegre, São Paulo, Rio de Janeiro, Manaus, and Salvador, selected based on the team members’ networks with residents who mediated access to the respective communities.
Regarding the methodological strategies, the following were conducted in each location: 1) ethnographic observation, based on regular visits, lasting approximately 3 to 4 months, to map areas of youth social interaction in leisure, work, and daily activities; 2) individual interviews and focus groups with men and women, aged 15 to 24 years, regarding their social profile, concepts, and practices regarding reproduction, HIV prevention, and relationships with health services and intervention strategies. The field team consisted primarily of researchers with training and/or experience in social sciences and humanities.
The project was approved by the Research Ethics Committees (RECs) of the five participating institutions (CAAE: 36495120.7.0000.5327). All participants aged 18 or older signed a Consent Form. Those aged 15 to 17 signed an Assent Form. There was a favorable decision from the Ethics Committee to waive the need for an additional Consent Form signed by legal guardians of those under 18 years of age.
This study covered the pre-COVID-19 outbreak (2019), the pre-vaccination pandemic period (2020), and the vaccination of the majority of the population (2021). This entailed methodological adjustments, such as consulting websites and online testimonials from local stakeholders (youth, leaders, health and education professionals). In Rio de Janeiro, three residents took part of the fieldwork as assistant researchers, without increasing their exposure to COVID-19 and with the consent of RECs17. The search for adolescents and young people occurred through contact with local informants, health service professionals, and members of social organizations, in addition to approaching them while circulation in the community, aiming to randomly select participants in various settings.
The 137 interviews and 11 focus groups were conducted in locations agreed upon with the participants (social organizations, services, homes, squares, streets, stores), and were recorded after their consent. Only in Manaus were interviews conducted online, as the city became the epicenter of COVID-19. In general, cooperation among the young women and men predominated. Those from social projects distinguished themselves by their ability to express themselves and their knowledge. The boys’ lesser interest and embarrassment in discussing sexuality and gender can be attributed to the taboo surrounding these topics, which challenge research in this field, and to their educational gap. Furthermore, they were contacted in leisure spaces and interviewed by women from outside the community.
The study population, described in Chart 1, involved interviews with women and men, the majority between the ages of 15 and 19 years (N=107), female (79) and heterosexual (126), born in the communities and self-identified as being Black or Brown. The analysis prioritized data from the 126 young men and women defined by the authors as heterosexual and cisgender. A large proportion attend public schools, reflecting the expansion of education in the country. Some study and work; others had dropped out of school and worked in informal and precarious jobs, or were unemployed. There is greater pressure on young men to contribute to the family income, while young women tend to perform domestic activities. Among the older students, some are pursuing technical and higher education. A smaller group does not study and has no occupation. In the text, the testimonies are identified by their fictitious names, ages, and city acronyms: Rio de Janeiro=RJ; Manaus=MA; Salvador=SSA; Porto Alegre=POA; São Paulo=SP.
Field records and testimonies were categorized based on the stages of thematic content analysis, which involves an exhaustive reading of the data to identify, organize, and code core meanings18. The information was systematized using N-VIVO software, creating a single database. In this article, we prioritize knowledge and experiences related to the following categories: affectionate and sexual interactions, HIV protection logic, reproduction, and contraception. The interpretation of the results considered the study objectives and reflections from academic literature.
Results and discussion
Scenarios of affectionate and sexual interactions
The five locales, despite their specific geographic characteristics, diverse social projects, and ethnic-racial profile, share common characteristics, such as a predominance of low-income populations and precarious housing and sanitation conditions, which vary within each locality. Drug trafficking is common, generating tension and violence in daily life, stemming from armed conflicts between different commands (militia or faction) and security forces. This dynamic demarcates territories, restricts movement, and affects youth interaction, as one young man from Salvador describes: “We have to navigate this system, otherwise we end up being victims”. The “drug trafficking youth”, with their power and hierarchy, imposes rules and exerts dominance in the community. Given these collective experiences, residents develop a unique perception of risk; violence is so inherent that other “dangers” can be seen as less relevant given the urgency of surviving more serious and systemic threats.
In the five communities, there are public health services, public schools, collectives, and social projects led by government and non-governmental organizations, with varying degrees of reach. Another similarity concerns the spaces for youth socialization, both in open and closed places (squares, bars, fairs, funk dances, sound systems, parties), frequented primarily by local members, along with street walks and sidewalk conversations. In general, these are the contexts where adolescents and young people find romantic and sexual partners. Relationships can also begin through friendship networks, relatives, or childhood friends.
As reported, interacting with people from the local area, “from the same social circle”, or from the same class facilitates dating with greater complicity and intimacy, reflecting the impact of socioeconomic differences on social interactions. This finding echoes Bourdieu’s reflections12 on the relationship between taste and social standing, evidenced in studies of cultural preferences and practices among working-class, middle-class, and upper-class groups. According to this perspective, taste - defined as people’s seemingly voluntary choices and preferences - forms the basis of the lifestyle and social practices, which are closely related to the social standing of individuals.
In this regard, according to the testimonies, the limited movement of young people to other neighborhoods was due to transportation costs and fear of discrimination based on appearance, place of residence, and skin color. As already discussed19, racism and prejudice associated with poverty impact the mental health of favela residents, who are mostly Black, and create symbolic barriers that compromise their movement in social spaces, as exemplified in this account:
Outside the neighborhood, a girl sees me and crosses the street. Today, I see her and cross the street first, to protect myself from that gaze. It hurts; it may seem silly to those who don’t live there, but it does. My neighborhood is my fortress, where I feel good, where I feel alive (M_19_SSA).
Given the impact of social media in contemporary times20, it is worth noting that apps (WhatsApp, Instagram) and platforms (X, Facebook) are used for local flirting, serving to escape parental control and as a facilitator for shy people. According to field records, virtual flirting generally occurs with people already known on the street or in social spaces. Dating apps, such as Tinder, were rarely mentioned, being used for casual encounters. This situation can be attributed to the lack of individual cell phones, less access to quality internet, and less local interactions. As one interlocutor from Rio put it: “The street is the Tinder of young people”. This finding contrasts with the use of dating apps among young gay and trans people, which serve as zones for freedom and expression of their sexuality and the building of support networks21, which can increase vulnerability to HIV22.
The persistence of traditional gender relations23-25, characterized by greater female subordination, was observed in the accounts and field records regarding the flirting processes. In approaches, men/boys take on greater protagonism, with it being undesirable for women to take the initiative and for men to reject a sexual opportunity, even if they are “committed.” There were reports of abusive relationships (i.e., jealous and controlling partners). Some girls, like Carla (16_RJ), were not allowed by their families to socialize; their socialization was restricted to school and church. Field observations highlighted the impacts of religious affiliation on the social, emotional, and sexual interactions of young people, including their response to situations of violence, which could be addressed in future studies.
The data confirms the study’s premise that young people’s emotional and sexual encounters often occur among members of their own communities, permeated by gender hierarchies. It is in these local settings that HIV risk management and reproductive experiences, discussed below, occur.
Knowledge about STIs/HIV and proximity to AIDS
According to reports, the interviewees’ knowledge about AIDS is limited to the sexual transmission of HIV and condom use for prevention. Most are aware that there is a test to diagnose the virus. However, few have taken it, and there are questions about where and how to get tested, and misinformation about self-testing. Young people are unaware of PrEP and PEP, which are available through the public health system, despite the fact that PrEP was expanded in 2022 to “all sexually active adults and adolescents, aged 15 and older, at increased risk of HIV infection”26.
From the interviewees’ point of view, gay men, trans women, travestis, and people with multiple partners are more vulnerable to HIV. According to a young man from Manaus: “This AIDS thing is for gays.” Some reported having friends/relatives with HIV or who have died of AIDS; this interaction fosters knowledge about treatment for people with HIV. However, the subject is rarely discussed in the family and community, with silence prevailing due to prejudice, as reported:
A cousin of mine hooked up with a travesti and ended up contracting AIDS from her [...] He and I grew apart after that, [...] he only stayed with my aunt who looked after him [...] At family lunches we usually don’t even touch on that subject [...] He’s much better, he got really thin and then gained weight, he takes a lot of medicine [...] I learned a lot from those experiences, because [they were] things I didn’t even know about (Roberto_16_RJ).
Some young people still associate HIV infection with extreme physical weakness and a terminal stage, based on images on the internet or fake news. The persistent social representation of AIDS as a “deadly” disease is evident in the conversations about people with HIV: “He’s alone, his family only drops off food, he can barely walk, he’s so thin, emaciated, it’s a shame” (Ana Clara_15_MA). As for other STIs, most mentioned names (e.g., syphilis, gonorrhea) without indicating knowledge of symptoms and or of treatment. According to a health professional in Salvador, pregnancy tests and prenatal care are opportunities for young women and their partners to diagnose syphilis. Some of the girls mentioned “discharge”, a “woman thing” that can cause pain and discomfort. Some believe they are protected from HIV because they have been vaccinated against HPV.
For most, school was the source for information about HIV and other STIs. Some stated that parents and teachers discuss pregnancy prevention out of fear of repeating the mothers’ reproductive trajectories; when faced with any symptoms, doubts, or curiosity, they conduct random internet searches. The difficulties and lack of support in health services were discussed in greater detail in another article27.
The misinformation can be attributed to the lack of spaces for dialogue and learning about HIV/other STIs. Schools have not promoted discussions on sexuality and SRH in their curriculum28. The current School Health Program (Programa Saúde na Escola - PSE) has reduced its focus on youth participation29, SRH, and comprehensive sexual education4, that were present in the former School Health and Prevention Project (Projeto Saúde e Prevenção nas Escolas - SPE). As already noted, the dismantling of SRH and Human Rights policies, the absence of campaigns, and the invisibility of AIDS also contribute to this lack of knowledge. Misinformation about HIV diagnosis, transmission, and living with HIV contribute to an environment where vulnerability to AIDS is not made visible, impacting the logic of HIV protection.
HIV protection logic
The testimonies about HIV prevention methods indicate the updating of notions of protection, associated with the level of knowledge, familiarity, and loving bond with the person, attested in both historical23 and current24 studies. Following this logic, coexistence and commitment with the partner tends to generate trust that results in agreements, such as not using condoms, as illustrated by the report.
I don’t use condoms, because for me to be like that with someone, I get to know the person first, I even ask if they have anything. I get to know them well before getting into a relationship with someone, so that’s why I almost never use them (Yasmim_15_MA).
In HIV prevention practices, the logic that articulates the notion of protection from the known/familiar and the threat from the unknown/stranger/outsider suggests the persistence of the AIDS imaginary associated with the other and the connection of the symbolic cores of protection to the value of personal relationships. Following this line, protection from disease is also tied to the characteristics of a good-looking, well-dressed, clean, and perfumed partner, contrasted with the perception of danger associated with dirt and bad odor. Manoel_15_MA’s statement is suggestive: “Having sex in the light...you can see something, but in the dark you can’t [...] we look, you know, we open it [vagina] and if there’s something, we don’t do it, we smell it like this”. This description suggests the notions of purity and pollution/danger analyzed by Douglas15. According to the author, symbolic systems, deeply rooted in cultural practices and concerns with order and disorder, classify certain elements as pure or impure. In the quoted statement, visual and olfactory inspection acts as a control mechanism to ensure “purity” and avoid the pollution represented by potential STIs.
The cultural bias of the social constructions of the notion of risk formulated by Douglas15 is revealed not only in situations of violence in the social context experienced by young people, but also in the association of vulnerability to HIV/STI, with the image of the “street woman “ (i.e., sex worker); described by young people as a woman who has multiple partners and frequents places of intense unprotected sexual interaction (i.e., baile funk). She represents dangerous sex due to the possibility of transmitting diseases, contrasting with the trust and security attributed to the “woman of the house”, defined as a well-known, respected family woman, suitable for dating.
The dichotomy between “man of the street” and “man of the house” was rarely present, but it did appear in Katelyn’s (18, São Paulo) statement: “If he’s at the dance, he’s worthless. He must be a bum.” Some interviewees believe that heterosexual men do not perceive themselves as vulnerable; however, they can become infected and transmit HIV through the frequency of unprotected extramarital relations. They feel safer having sex with women; only one young woman from São Paulo addressed the vulnerability to HIV of in the context of sex between women.
Condoms, referred to as the primary means of preventing STIs/HIV, were described as a form of self-care that requires “sacrifice” for safety. However, despite free access at health clinics and sales in pharmacies, their use is irregular during vaginal intercourse and even less common during oral and anal sex, reiterating the low level of concern about STIs. As mentioned, protective strategies are more prevalent, based on the type of relationship with the partner, their appearance, and the location of the encounter.
Furthermore, condom use is influenced by gender relations and its effects on sexual pleasure30. Some of the interviewees said they expect men to have condoms or go out and buy them, leaving it up to women to request and demand their use. Thus, women do not always bring condoms to parties and social gatherings that may result in sexual interactions; this fact, combined with reports of embarrassment about picking up condoms at the health clinic, suggests women feel ashamed about carrying condoms.
It is important to note that, by assigning women the role of demanding condom use, young women indicate a willingness to negotiate with their partners, and a sense of responsibility for prevention, given that young men associate condoms with discomfort and reduced pleasure. As Guilherme (22_PoA) stated: “I feel more pleasure without [a condom], I think it’s uncomfortable [...] some are too tight, others are too big, it’s uncomfortable.” This view has been confirmed by various studies over the years. Some women also report this discomfort. Only one young woman stated that she liked using condoms because of the lubrication that eases the pain during sex: “Sometimes, you don’t even feel like it, you’re dry, and then the man goes in without a condom, sticking it all the way in, and it hurts me... It tears me apart!” (Athagna_18_SP). Discomfort during sexual intercourse is generally not discussed between couples. However, reports suggest that there are cases of dialogue about the use of STI prevention and contraceptive methods.
In short, despite young people having basic information about HIV transmission through unprotected sex, they appear not to perceive themselves as exposed to infection in interactions with familiar, “good-looking” people. AIDS seems distant from most people’s daily lives, and the greater risk of HIV infection is projected onto others, those “different”, associated with gay men, transgender people, and people with multiple partners, minimizing the perception of risk within their own group.
Contraception and the meaning of pregnancy
When asked about the meaning of pregnancy, it was common to say it was normal: “There are a lot of people like that here.” Many reported knowing young pregnant women or mothers in the community. This reality converges with indicators of higher pregnancy rates in low-income settings, compared to the rates among middle- and upper-income groups31.
The testimonies suggest that young women are more concerned about unintended pregnancy than about HIV/other STIs, due to the sociocultural context described. In the young women’s accounts, pregnancy is more feared and worrisome because it interrupts their studies, limits their social life, and is a “lifelong” responsibility, as Franciane (18_MA) puts it: “Disease requires medication, right? And children don’t, they’re for life”. Among men, the greatest fear of pregnancy lies in the financial responsibility, exemplified by Gabriel (15_MA): “I’m afraid of paying child support, you know!?” Concern about pregnancy translates into increased use of contraceptives, such as hormonal injections, the most cited method and considered the most reliable by respondents, followed by the oral pill, withdrawal, and the rhythm method. Gisele (18_RJ) reports that, in the beginning, she used condoms, “but nowadays, without anything, and I take injections [...] It’s a contraceptive, to avoid getting pregnant”.
Women’s greater responsibility for contraceptive use is noticeable, given that, when faced with an unwanted pregnancy, they tend to assume the consequences and do not always have the support of their partner or family32. We found reports of young men trying to buy the morning-after pill, usually at the pharmacy, to ensure the prevention of a potential pregnancy. The statements are illustrative:
I’ll tell them the next day, “Come get your pill” (Luiz Henrique_24_SP).
I used to buy the morning-after pill because what if the condom is broken or breaks (Gustavo_18_PoA).
We even used the morning-after pill twice. However, it was used in an unprepared manner, especially because the leaflet is huge, it was hard to read, and because the pharmacist didn’t know how to explain it properly; I don’t think he even had a degree. [...] He explained everything in a jumbled way, and said, ‘Oh, you can manage’ (Gustavo_19_RJ).
Of the 79 young women interviewed, 11 were mothers or pregnant. However, fears and doubts about terminating an unintended pregnancy were reported. The few cases of abortion mentioned indicated embarrassment, often expressed in shy speech, with the recorder turned off. The criminalization of abortion in Brazil contributes to shame and fear of moral condemnation, and to the use of natural remedies and herbs, or procedures in clandestine clinics when “the father has the money to pay for them”, which can result in complications and even death33.
It is important to note that the prospect of having a baby took on positive meanings in some statements, reiterating the symbolic value of motherhood25. Érica (17_MA) mentioned the love and expectation of a child’s support of their parents when they grow up: “He’ll help me, right, when I’m old”. Others see their child as a “gift from God”, a gift for life. Young women in Salvador revealed “awareness” and planning for their pregnancies, with their partners being older. Motherhood can also represent a network of support and complicity between friends and mothers, fostering greater self-care, as the young woman “is no longer alone”. In this context, the decision to have a baby results from a complex web of sociocultural and emotional values.
Final considerations
It is important to ask how the study’s results can inform prevention policies. For Grangeiro et al.9 (p.2), responses to AIDS for new generations must consider the transformations of recent decades, characterized by the redefinition of gender identity based on binarity and the adoption of new sexual and affective arrangements. Other changes concern the use of social media for sexual encounters, the expansion of youth collectives, and the LGBTQIA+ movement. In this sense, they argue that national AIDS policy should establish a hierarchy in the offering of preventive methods, prioritizing PrEP, especially for people most vulnerable to HIV. Furthermore, it must address the social determinants of the HIV epidemic, value the participation of youth segments, the intersectoral response, and the Health in Schools Program.
Regarding new ways of performing gender and sexuality, our results suggest that the views and practices of low-income heterocisgender youth point less to change and more to the maintenance of sexual and gender identities, except for some references to bisexuality among girls. Social media, in turn, serves more to supplement data on known local flirtations, not assuming a central role in partner identification, as identified in the MSM population. We also noted the predominance of hierarchical gender ordering in affectionate and sexual interactions, with greater control over women, despite advances in feminist agendas. Youth collective initiatives also proved to be not significant with the presence of various social projects being more common, with limited reach and little current focus on SRH.
Furthermore, the information gathered from the young people surveyed in this study concerning HIV is limited to sexual transmission, and vulnerability continues to be associated with MSM, transgender people, and people perceived as promiscuous due to having multiple partners and unprotected sex, updating initial views of the epidemic. The self-perception that HIV infection is a distant possibility if condoms are used with unknown and “untrustworthy” people prevails. Fear of the stigma of AIDS persists, and interaction with people with HIV is rare. PrEP and PEP are unknown, and there is little use or awareness of HIV testing. The testimonies express greater apprehension regarding pregnancy, identified by the high consumption of contraceptives by women, especially hormonal injections. Some young women mentioned positive aspects of motherhood; however, for most, pregnancy can compromise their studies and social life, and there is not always support from their partners and family. The young men expressed fear of the financial implications and responsibilities of fatherhood; some adopt surveillance measures to ensure their partner uses the morning-after pill.
In summary, the data suggest that the transformations highlighted by Grangeiro et al.9 may be more prevalent among the LGBTQIA+ population and segments of the middle class. The lesser expression of these changes among the young population in this study reiterates that youth profiles take on diverse configurations, resulting from sociocultural and economic differences, in interaction with other social markers such as sexual orientation, gender, and skin color34. Although these boundaries are not rigid, it is important to question the most appropriate prevention strategies for low-income heterosexual youth.
We argue that the research population’s lack of knowledge and distance from the perception of HIV vulnerability are related to its silencing in public debate, the failure to address AIDS stigma, the discontinuation of SRH initiatives in schools, and the effects of COVID-19. These factors are exacerbated by the persistence of social inequalities in the country and the structural deficiencies of the public health and education systems.
Given the lessons learned after more than 40 years of the AIDS epidemic, we believe that the development of public SRH policies must consider ways to mitigate the individual, programmatic, and social dimensions of vulnerability to HIV/other STIs. This perspective is illustrated by the results on the effects of government income transfer programs, such as Bolsa Família, on HIV/AIDS incidence, mortality, and case-fatality rates35. This means that policies are needed to address social, racial, and gender inequalities, as well as the stigma associated with AIDS and sexual diversity.
In this regard, in addition to offering biomedical prevention technologies, such as testing, PEP, and PrEP, it is essential to create spaces for learning and dialogue in schools, health services, and social movements, based on public policies and partnerships between government and non-governmental sectors, updating successful experiences and exploring the potential for dissemination of social media. Such initiatives should be developed with the participation of young people. And, as the interviewees suggest, they should be carried out in schools, health clinics, public and community spaces, NGO social projects, pharmacies (where there is less constraint), and the internet (e.g., creating blogs and using TikTok).
We are aware of the difficulties and challenges in implementing the suggested proposals, and the limitations of this study, as it fails to analyze the diverse profiles of youth and the specificities of the five communities. However, the results may contribute to the resumption of SRH policies in the current federal administration (2023-2026), in conjunction with other research involving youth segments that, like this study, were supported by the research call promoted by the Ministry of Health in partnership with the National Council for Scientific and Technological Development (CNPq).
References
- 1 Joint United Nations Programme on HIV/AIDS (UNAIDS). HIV response sustainability primer. Geneva: UNAIDS; 2024.
- 2 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Boletim Epidemiológico HIV AIDS. Brasília: MS; 2024.
- 3 Szwarcwald CL, Souza Júnior PR, Pascom AR, Coelho R, Ribeiro RA, Damacena G, Damacena GN, Malta DC, Pimenta MC, Pereira GFM. HIV incidence estimates by sex and age group in the population aged 15 years or over, Brazil, 1986-2018. Rev Soc Bras Med Trop 2022; 55(Supl. 1):e0231.
- 4 Paiva V, Antunes MC, Sanchez MN. O direito à prevenção da Aids em tempos de retrocesso: religiosidade e sexualidade na escola. Interface (Botucatu) 2020; 24:e180625.
- 5 Miskolci R, Campana M. "Ideologia de gênero": notas para a genealogia de um pânico moral contemporâneo. Soc Estado 2017; 32(3):725-748.
- 6 Monteiro S, Brigeiro M, Villlela W, Mora C, Parker R. Desafios do tratamento como prevenção do HIV no Brasil: Uma análise a partir da literatura sobre testagem. Cien Saude Colet 2019; 24(5):1793-1807.
- 7 Mora C, Nelvo R, Monteiro S. Government communication pieces on HIV pre-exposure (PrEP) and post-exposure (PEP) prophylaxis (2016-2019): analysis of their content and circulation among gay men, trans women/travestis, and sex workers Sau Soc 2022; 31(4):e210855en.
- 8 Brandão E, Cabral C. Justiça reprodutiva e gênero: desafios teórico-políticos acirrados pela pandemia de Covid-19 no Brasil. Interface (Botucatu) 2021; 25:e200762.
- 9 Grangeiro A, Ferraz D, Magno L, Zucchi EM, Couto MT, Dourado I. Epidemia de HIV, tecnologias de prevenção e as novas gerações: tendências e oportunidades para a resposta à epidemia. Cad Saude Publica 2023; 39(Supl. 1):e00144223.
- 10 Magnani JG. De perto e de dentro: notas para uma etnografia urbana. Rev Bras Cien Soc 2002; 17(49):11-29.
- 11 Monken M, Barcellos C. Vigilância em saúde e território utilizado: possibilidades teóricas e metodológicas. Cad Saude Publica 2005; 21(3):898-906.
- 12 Bourdieu P. Gostos de classe e estilos de vida. In: Ortiz R, organizador. Pierre Bourdieu. São Paulo: Ática; 1994. p. 82-121.
- 13 Castiel LD. Vivendo entre exposições e agravos: a teoria da relatividade do risco. Hist Cien Saude Manguinhos 1996; 3(2):237-264.
- 14 Luiz G, Spink MJ. O gerenciamento dos riscos no cenário da aids: estratégias adotadas por homens que fazem sexo com homens em parceria casual. Athenea Digital Pensamiento Investigación Soc 2013; 13(3):39-56.
- 15 Douglas M. Risk and Blame: essays in cultural theory. NewYork: Routledge; 1994.
- 16 Minayo MC. O desafio do conhecimento. Pesquisa qualitativa em saúde. 9ª ed. São Paulo: Hucitec; 2006.
- 17 Monteiro S, Fonseca V. Trabalho de campo com pesquisadores locais: relato de experiencia em uma favela do Rio de Janeiro. In: Valente P, organizador. História oral e questões de ciência e saúde: Atravessamentos. São Paulo: Ed. Letra e Voz; 2024. p. 37-57.
- 18 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011.
- 19 Cecchetto F, Monteiro S. Discriminação, cor e intervenção social entre jovens na cidade do Rio de Janeiro: a perspectiva masculina. Estud Feministas 2006; 14(1):119-218.
- 20 Castells M. A sociedade em rede. A era da informação: economia, sociedade e cultura. Rio de Janeiro: Ed. Paz e Terra; 2017.
- 21 Christ A, Hennigen I. Apenas um perfil no Grindr? Montando um corpo marcado. Sex Salud Soc 2022; 38:e22200.
- 22 Magno L, Medeiros DS, Soares F, Grangeiro A, Caires P, Fonseca T, Westin MR, Dourado I. Factors associated to HIV prevalence among adolescent men who have sex with men in Salvador, Bahia State, Brazil: baseline data from the PrEP1519 cohort. Cad Saude Publica 2023; 39(Supl. 1):e00154021.
- 23 Monteiro S. Qual prevenção? Aids, sexualidade e gênero em uma favela carioca. Rio de Janeiro: Editora Fiocruz; 2002
- 24 Knauth D, Pilecco F. Aids e prevenção do HIV entre adolescentes e jovens em seis municípios brasileiros. Sau Soc 2024; 33(1):e230789pt.
- 25 Heilborn ML, Aquino EML, Bozon M, Knauth DR, organizadores. O aprendizado da sexualidade: reprodução e trajetórias sociais de jovens brasileiros. Rio de Janeiro: Editoras Garamond e Fiocruz; 2006.
- 26 Brasil. Ministério da Saúde (MS). Protocolo Clínico e Diretrizes Terapêuticas para Profilaxia Pré-Exposição (PrEP) de Risco à Infecção pelo HIV. Brasília: MS; 2022.
- 27 Monteiro S, Leal A, Barbosa R, Magno L, Neves A, Honorato I, Knauth D. Saúde sexual e reprodutiva de adolescentes e jovens: identificação de demandas e experiências a partir de estudo qualitativo em comunidades de cinco cidades brasileiras". Cad Saude Publica 2025; 41(4):e00047824.
- 28 Magno L, Marinho L, Zucchi E, Amaral A, Lobo T, Paes HC, Lima GMB, Nunes CCS, Pereira M, Dourado I. School-based sexual and reproductive health education for young people from low-income neighbourhoods in Northeastern Brazil: The role of communities, teachers, health providers, religious conservatism, and racial discrimination. Sex Education 2022; 23(4):409-424.
- 29 Bueno DR, Köptcke LS. A participação juvenil no Programa Saúde na Escola (PSE): uma reflexão sobre o papel da gestão federal. Saude Debate 2022; 46(n. esp. 3):29-44.
- 30 Nascimento IR, Neves A, Rodrigues P, Teixeira E. Representações sociais de masculinidades no curta-metragem "Aids, escolha sua forma de prevenção". Cien Saude Colet 2020; 25(3):879-890.
- 31 Assis T, Martinelli KG, Gama S, Santos Neto ET. Pregnancy in adolescence in Brazil: associated factors with maternal age. Rev Bras Saude Mater Infant 2021; 21(4):1055-1064.
- 32 Miura PO, Silva ACS, Lima EFO, Galdino EBT, Santos KAM, Menezes SKO, Costa GC. Gravidez na adolescência e as experiências da vida escolar. Psicol Esc Educ 2023; 27:e238700.
- 33 Diniz D, Medeiros M, Madeiro A. National Abortion Survey - Brazil, 2021. Cien Saude Colet 2023; 28(6):1601-1606.
- 34 Mello L, Gonçalves E. Diferença e interseccionalidade: notas para pensar práticas em saúde. Cronos 2010; 11(2):163-173.
- 35 Morais GAS, Magno L, Silva AF, Guimarães NS, Ordoñez JA, Souza LE, Macinko J, Dourado I, Rasella D. Effect of a conditional cash transfer programme on AIDS incidence, hospitalisations, and mortality in Brazil: a longitudinal ecological study. Lancet HIV 2022; 9(10):e690-e699.
Acknowledgments
The study was supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq/MS-DCCI) (process 442618/2019-0) and the Fundação de Amparo à Pesquisa do Estado do Amazonas (FAPEAM) Grant No 01.02.016301.001618/2022-44.
The data sources adopted in the research are indicated in the article’s body.
