1. “Consultation on Strategic Information and HIV Prevention among Most-at-Risk Adolescents” Brazil’s Experience Geneva, 2-4 September 2009 Nara Vieira, Brazilian National STD/AIDS Program Daniela Ligiéro, PhD, UNICEF Brazil

2. Brazil Presentation 1.Background 2.Causes of vulnerability and risk 3.Strategic information gathered 4.Current response 5.Challenges

3. 1. Background Data: Concentrated epidemic: 506,000 AIDS cases since 1980 and 35,000 new cases per year Incidence in 2007: 19/100,000 inhabitants Prevalence in general population: 15-49 years of age = 0.61% (stable since 2000) Male prevalence = 0.80% Female prevalence = 0.42% MSM prevalence = 4.5% to 10.8% CSW prevalence = 2.6% to 8.0% IDU prevalence = 15% but only 10% of total cases Estimated number of people living with HIV 630,000

4. Trends—what we know: Increase among adolescent MSM Increase among adolescent girls Increase among Afro-descendant populations Increase in resource-poor settings: North and Northeast Decrease among IDU

5. Trends—what we don’t know : Adolescent HIV Prevalence Adolescent CSW? HIV+ adolescents? Street children and adolescents? Recent RDS (IDU, CSW, MSM) = 18 and older

6. Backrgound history... Human rights approach — focus on vulnerability (individual, social & structural) vs. “at risk groups” Who are MARA in Brazil? Fundamental aspect of public health system is “participation” Representation of civil society at Municipal, State, and Federal level “AIDS councils” Response based on civil society participation and mobilization -- 1994 Brazil was one of the first countries to offer free ARV treatment to all who need it due to “grass roots” movement.

7. Difficulty in access to information (particularly in certain regions of the country). Difficulty in access to health services and prevention supplies (e.g., male condoms). Very little recognition of the sexual and reproductive rights of adolescents and young people. 2. Causes of vulnerability and risk for young people and adolescents:

8. Stigma and discrimination (gender, gender identity, sexual orientation, race/ethnicity, HIV status, etc.) Very little dialogue with families, especially around sexuality. Low utilization of health services by adolescents and young people. Poverty Sexual exploitation and abuse

9. Research AdvocacyProgramming Advocacy 3. The cycle of strategic information gathered about adolescent vulnerability to HIV OR Why we know what we know...

10. Epidemiological Bulletin: SUS information system—yearly. Research study about knowledge, attitudes, and practices related to STDs and HIV/AIDS (PCAP)—every four years. School Census to ascertain HIV prevention practices in schools—every two years and PENSE—Health in Schools every two years. Strategic Research: e.g. MSM, IDU and CSW RDS; Armed Forces, etc. 3. Strategic information gathered about adolescent vulnerability to HIV:

11. Epidemiological bulletin: AIDS Cases among MSM 13-19 year olds MSMheteroIDUbloodMTCT

12. Epidemiological bulletin: Adolescent male to female ratio of AIDS cases

13. Research study about knowledge, attitudes, and practices related to STDs and HIV/AIDS (PCAP)— every four years—15-24 year olds -Home-based study of the Brazilian population aged 15-64. -Higher condom use -Higher number of casual partners -High levels of information regarding HIV transmission Proportion of individuals who began sexual relations before the age of 15: 31,4 % Mean age at first sex (years): 15,3

14. Strategic Research with 17-21 year old men in the Armed Forces 2002 & 2007 35,460 young men and adolescents participated 3.2% of informants described MSM experiences HIV prevalence for MSM was 5.79%, while in the total sample it was 0.88%. (p<.001).

15. 4. Current Response: National Plan to prevent HIV among MSM 2007-2011 Includes campaigns, information, condom distribution etc. targeted at both adolescent and adult MSM

17. The process Seminars and workshops – governments and CSO – Jan./June 2007 Public Consultation – on the internet for a month Negotiation and approval – Tripartite Comission (MoH, state and city health secretaries) – November 2007

18. Workshops - with State Secretaries and City Health, CSO to build states plans Discussion during the States and the National LGBT Conference 1st Forum “National Plan to fight STD/Aids among gays, other MSM and transvestites - Florianópolis, June 26 Expected results: inclusion of activities in all 27 states plans to fight STD/Aids by the end of 2009 Activities led by the MoH - 2008

19. “Not more, not less – equal rights” “Não menos, não mais – direitos iguais” National GLBT Conference Brasilia – June 5 - 8, 2008 600 delegates 14 countries as observers

20. 4. Current Response: Health and Prevention in Schools Partnership between Ministry of Health, Ministry of Education, UNFPA, UNESCO, and UNICEF Human rights based approach—homophobia, gender based violence, sexual rights, etc. Schools are the second place where 15-24 year olds access condoms (more than NGOs & pharmacies) 63% of Brazilian schools address HIV prevention, and 50,214 schools now have HPS (out of 198,507). 21% of Brazilian high-schools distribute condoms— information alone doesn’t work

21. Adolescents as participants in their own assessment of risk—Strategic information for one’s own benefit.... Adolescent Empowerment! -1 million questionnaires – test for the test distributed nationally 2008-2009 (to assess at-risk adolescents and encourage HIV testing) --pre and post study of HIV testing trends for adolescents

22. Pilot program in the 4 largest Brazilian cities (Partnership with UNICEF and UNODC) 4. Current Response: HIV prevention among street children and adolescents –focusing on services first

23. Partnership with UNFPA, UNIFEM and UNICEF. 4. Current Response: National Plan to Prevent the Feminization of HIV— including focus on CSW

25. 5. Challenges - Who are MARA in Brazil? More data... What are the networks that exist and how do we reach them. -Out of school children and adolescents -Health services not prepared to respond to adolescent demands, increasing access to services for MARA -HIV+ adolescents as entry point to MARA

26. 5. Challenges - Strengthen programs directed at adolescents, with joint strategies, that take into account sexual and reproductive health in schools, adolescent participation and access to prevention supplies. -Ethical and legal issues

27. Some decrease in condom use among 15- 24 year olds... Condom use 20042008 Valor de p During first sexual relation 53,260,90,0000 In the last sexual relation in last 12 months 38,436,80,0999 In the last sexual relation with a casual partner in the last 12 months 67,059,90,0000 In all sexual relations, in the last 12 month with any kind of partner 25,321,50,0000 In all sexual relations, with fixed partners, in the last 12 months 24,920,30,0000 In all sexual relations with casual partners in the last 12 months. 51,546,50,0054

28. More casual partners for 15-24 year olds... Indicator 20042008Valor de p Sexual relations in the last 12 months 81,479,00,0004 Over 5 casual partners in the last 12 months 4,09,30,0000

29. OBRIGADA! THANK YOU! MERCI!

30. Nara Vieira nara.vieira@aids.gov.br +55.61-3306-7092 Ministério da Saúde Secretaria de Vigilância em Saúde Departamento de Vigilância, Prevenção e Controle das DST e Aids Unidade de Prevenção Daniela Ligiéro, Ph.D. dligiero@unicef.org +55.61.3035.1905 UNICEF Brazil