Between 2010 and 2020, cases of HIV infection in Rio Grande do Norte grew by 93.1%, rising from 3,190 to 6,158 in the decade analyzed. The data are included in the most recent HIV/AIDS Epidemiological Bulletin of the State Department of Public Health (Sesap/RN) and were analyzed by medical and multidisciplinary preceptors at the Santos Dumont Institute (ISD), in Macaíba. In the state, the document details an increase in case records in all age groups, in both sexes, as well as among pregnant women and in the occurrence of deaths due to the infection. On Wednesday, December 1, actions around the world were dedicated to World AIDS Day, a disease that has already killed approximately 33 million people since its discovery, in the early 1980s.

The Bulletin in question was prepared by the State Program for Sexually Transmitted Infections (STI), AIDS and Viral Hepatitis. It presents an epidemiological analysis of confirmed cases of AIDS in adults and children, mortality from the disease, HIV infection, infected pregnant women and children exposed to the virus. As explained, between 2010 and 2020, Rio Grande do Norte had 6,232 cases of AIDS. Of these, 70 were in children under five years of age; 6,158 cases of HIV infection; 995 pregnant women infected with the human immunodeficiency virus. The number of deaths from the disease, in the period analyzed, reached 1,365.

In percentage terms, only the virus detection rate in children under five years of age fell during the period: 43%. The others increased significantly. HIV detection increased by 18.6% (from 14.0 to 16.6 cases per 100,000 inhabitants). The occurrence of pregnant women infected with HIV increased by 1,42% (from 1.2 to 2.9 cases per thousand live births). The number of children exposed to the virus had the most dramatic increase: 8,77% from 2010 to 2020. The occurrence of deaths caused by AIDS increased, in the same period, by 15.7% throughout Rio Grande do Norte.

“It is a disease that is difficult to control. It depends on people’s behavior. There has been a decrease in condom use, especially among young people. In 2020, there was a decrease in the number of tests and an increase in the identification of cases. It depends a lot on each person. Educational actions in schools for adolescents are very important. The more information, the better the prevention. This has not been done in public and private schools, for example. The state is prepared for this increase in demand for cases, for care for patients with HIV and AIDS, with free distribution of medicines sent by the Ministry of Health. The ideal, however, is to raise awareness among the population about prevention. Just because AIDS no longer kills like it used to, does not mean that people should lose their fear of contracting the disease,” emphasizes Amanda Dantas, technician of the State Program for STIs, AIDS and Viral Hepatitis of Sesap/RN.

In the decade in question, 4,441 cases were recorded in men (71.3%) and 1,791 cases in women (28.7%). Sesap found an increase in the sex ratio in 2020, with 3 cases in men for every 1 case in women. The highest concentration of HIV occurrence between 2010 and 2020 was observed in individuals aged 30 to 39 years (31.1%). The main route of transmission, in the period analyzed, was sexual, in 53% of the cases. Among men, the predominant exposure category was homosexual/bisexual with 27.5%. Among women, the highest occurrence is among heterosexuals, with 55.6%. In men, the age group that showed the greatest variation was 60 years and over (100%) and, in women, the greatest growth was observed in the age group of 30 to 39 years.

ISD infectious disease preceptor Manoella Alves warns about the increase in HIV infection cases among young people. “Unfortunately, in the state, as in the country, we have a large number of young people becoming infected. An age group between 20 and 29 years old, in which I have made many diagnoses. Which is a shame. In addition to all the work to protect these young people during sexual intercourse, there is PREP, which is Pre-Exposure Prophylaxis. This program exists within the Unified Health System (SUS),” she emphasizes.

Reference

The Anita Garibaldi Health Education and Research Center (Anita), one of the ISD units, is a state reference for the Unified Health System (SUS) for care for pregnant women infected by the virus. From 2018 to 2020, the number of HIV-infected women undergoing prenatal care at Anita increased by 45,45% – rising from 11 to 16. From January to September this year, 12 patients in this condition had started multidisciplinary treatment, with a team composed of by an infectious disease specialist, gynecologist and obstetrician, psychologist, nurse, social worker and biochemical pharmacist.

“All pregnant women who enter Anita, at some point, will take a rapid test for HIV, syphilis and viral hepatitis. The Ministry of Health's protocol defines that tests are carried out in the first trimester of pregnancy, at the beginning of prenatal care and another in the third trimester of pregnancy. At the time of delivery, the mother is tested again for HIV and syphilis. Data from the current Sesap Bulletin points to a reflection of the increase in the number of cases among this population. Screening during pregnancy is very efficient”, points out Carla Glenda Souza da Silva, multi-professional psychologist preceptor at ISD. She highlights, however, that in addition to cases of HIV infection, there is a prevalence of syphilis among pregnant women, which can result in irreversible consequences for the baby, such as serious neurological diseases, if not treated in a timely and skillful manner.

Among the HIV-positive pregnant women being monitored by Anita professionals, there is a 15-year-old teenager, corroborating the statistics from Sesap/RN. “She was infected at 13, during her first sexual intercourse with her first boyfriend. There is a profile of the women we serve today: they have low levels of education, do not have access to adequate information, live in a situation of economic vulnerability, and are submissive to their partners for various reasons. Many do not accept the use of condoms. It is difficult to empower women in these conditions, because they feel cornered,” says Carla Glenda Souza da Silva.

To support women in these circumstances, the Social Service Sector of the ISD develops intervention work that involves coordination with the intersectoral network, formed by several areas such as health, security, education, labor, among others. It aims to ensure that consultations are completed, that tests are performed, that patients are transported in cars from the respective municipal governments to which their addresses belong, and that they receive antiretroviral medication without interruption. The theme of this year's campaign for World AIDS Day, developed by the Pan American Health Organization (PAHO), linked to the World Health Organization (WHO), is: “End inequalities. End AIDS. End pandemics”. According to PAHO/WHO, this date is an opportunity to support people involved in the fight against HIV and to improve understanding of the virus as a global public health problem.

“It is extremely important for people living with HIV/AIDS to be monitored by multidisciplinary teams, since care requires diverse and complementary perspectives. Caring for these people requires specialized professional action that can promote an improvement in their quality of life and the achievement of their rights. The articulations with other services that make up the municipal and state care networks seek to meet demands that go beyond medical and drug treatment, especially with regard to prejudice and difficulty in accessing basic services such as education, work, culture, leisure, among others,” says Alexandra Lima, the multidisciplinary preceptor and social worker at ISD.

DATA

AIDS in Children

110 cases in children under 13 years of age (between 2010 and 2020), of which 70 were diagnosed before the age of five;

Mother-baby binomial

142% increase in HIV detection rate in pregnant women;

117% in the number of cases of pregnant women infected with HIV;

77.3% of contaminations in this age group occur through vertical transmission (mother-baby during childbirth);

Deaths from AIDS in RN

1,365 deaths from AIDS in RN in the decade analyzed (977 men and 388 women), with a predominance in people aged 40 to 49 (28.7%);

15.7% increase in deaths in the period analyzed;

Profile of infected people

70% of the cases of infection registered in RN until December 2020 occurred among men; with a concentration in the age group of 20 to 29 years (35.3%) of the registered cases;

38 million is the number estimated by the World Health Organization (WHO) of people living with HIV in the world;

920 thousand is the number estimated by the Ministry of Health of people living with HIV in Brazil.

Sources: Sesap/RN, World Health Organization (WHO) and Ministry of Health (MS)

Wcontamination

So it goes:

Vaginal sex without a condom;

Anal sex without a condom;

Oral sex without a condom;

Use of syringe by more than one person;

Transfusion of contaminated blood;

From an infected mother to her child during pregnancy, childbirth and breastfeeding;

Non-sterile piercing or cutting instruments.

This doesn't work:

Sex as long as the condom is used correctly;

Masturbation for two;

Kiss on the face or mouth;

Sweat and tears;

Insect bite;

Handshake or hug;

Soap/towel/sheets;

Cutlery/glasses;

Bus seat;

Pool;

Bathroom;

Blood donation;

By air.

Source: Ministry of Health

INTERVIEW

“We are still experiencing the HIV epidemic”

Manoella Alves

Infectious disease medical preceptor

In a didactic way, what is HIV and what is AIDS?

When someone is infected with HIV, the most common form of infection is through unprotected sex, the virus enters the body and begins to kill the immune cells. This can happen quickly or slowly. But little by little, it kills these immune cells. There comes a time when these immune cells are so low that we say the person has AIDS. When someone is infected with the virus, at that moment, they often don't feel anything. In some cases, there is a fever and weakness, but it goes unnoticed. Sometimes, a few years later, the patient will actually become ill and receive a diagnosis of HIV and AIDS.

Why is testing important?

Yes. That's why we run a huge campaign to get people tested. Because anyone can have the infection and not know it. The sooner a person knows they have the infection, the better. Because they can start treatment for free and prevent it from reaching the stage we call AIDS.

Is receiving an HIV diagnosis still a taboo subject today?

Absolutely. Despite all the campaigns emphasizing that HIV is now a treatable disease, that people shouldn't die from it, and despite the fact that we can't cure it but we can control it, people are still very afraid to get tested for fear of being diagnosed. And it's not just a question of "I'm going to die from HIV." There's also the issue of prejudice involved when you think about what others will think. This certainly keeps people away from getting tested. The primary health care network does testing, but people feel inhibited from getting tested in their neighborhoods. There's a whole dynamic that we need to increasingly think about ways for people to get tested and not be afraid of the result. It's a challenge.

In Rio Grande do Norte, how have you been monitoring the progress of the disease?

Rio Grande do Norte, in general, follows the dynamics of the country. Unfortunately, we are still experiencing the HIV epidemic. Even though we try to reduce the number of people who become infected, we can only achieve this by trying to make people aware of the risk they run if they have unprotected sex, and by trying to diagnose as many people as possible who already have the virus. When I identify a person with the virus, we start treatment, and when they are taking the appropriate and regular HIV treatment, there comes a time when this person can no longer transmit HIV through sexual contact. Unfortunately, there is still no cure, but if the person takes the medication correctly and has what we call an undetectable viral load, when the medication is really working and the patient has been taking the medication stably for at least six months, the virus becomes undetectable. This means that the person can no longer transmit the virus, which is what we call untransmittable. For those who didn't know this, it is always important for anyone who has HIV and is undergoing treatment to talk to their doctor and find out if they are, in some way, untransmissible. This is super important.

Are many young people being infected in Rio Grande do Norte?

Unfortunately, in the state, as in the country, we have a large number of young people becoming infected. An age group between 20 and 29 years old, in which I have made many diagnoses. Which is a shame. Today, in addition to all the work to protect these young people during sexual intercourse, we have PREP, which is Pre-Exposure Prophylaxis. This program exists within the Unified Health System (SUS).

How does it work?

There are some groups that we call vulnerable groups, which are made up of people who have a higher chance of becoming infected due to their sexual behavior. These groups can receive, free of charge, medication that greatly reduces the chance of becoming infected with HIV through unprotected sex. I am talking about PREP so that people are curious about it, so that they look for informative material that is available on the website of the Ministry of Health. In Rio Grande do Norte, there is a PREP laboratory at the Giselda Trigueiro Hospital. If someone is interested in learning more, they can schedule an appointment, ask any questions they may have and see if they can be included in the free PREP program. However, it is important to point out that despite the use of PREP, condoms and several other ways to prevent infection, which is what we call today the prevention mandala, we still have a significant number of young people who continue to become infected. We do not want that. When someone becomes infected, they acquire a disease that is still chronic today, and despite the fact that treatment is free, it still causes morbidity.

Have young people lost their fear of contracting HIV or is there a lack of sexual education policies that show the risk of this contamination?

I may not be able to fully explain the reason. In fact, there are several studies that seek to understand these perceptions of risk. Perhaps the fact that we now have a treatment for HIV, that people no longer die from the disease if they so wish, because they have the medication for free, so these are factors that influence. People lose their fear of the disease, which no longer kills as it used to. But there are several other associated behaviors involving drinking and drugs that alter perceptions of risk and, during sexual intercourse, make people careless. As for the issue of awareness campaigns, talking about HIV and AIDS, I think this is a subject that will never be discussed enough. The more we talk about sexually transmitted infections, the better it will be. It is a subject that can be talked about every day, every hour, not just in December. When someone has another STI, this increases the chance of acquiring HIV. Working with all populations on the risks of infection, expanding testing sites, facilitating access, will never be enough. We have to work on this every day. When we talk about STIs, we are not just talking about HIV, but all the others that affect men and women. These infections cause miscarriages, birth defects... Ideally, everyone should get tested, treated and prevent all infections.

We also have a significant increase in HIV cases among pregnant women. What is the reason for this?

Rio Grande do Norte behaves like the rest of the country, with a large number of pregnant women diagnosed. There is, in a way, an increase. However, it is important to keep in mind that we try, as much as possible, to have 100% of pregnant women tested for HIV. So, this means that I have a large number of diagnoses of women made during pregnancy, since most of these women were not tested before pregnancy.

The HIV/AIDS Epidemiological Bulletin from Sesap shows an increase in cases among heterosexual men aged 60 and over. Is this due to the fact that these people are using more dating sites and sexual stimulants?

Probably yes. In fact, this change has been happening for a few years now. At first, when we saw this curve of positive diagnoses in this age group, we attributed it to these stimulants. But humanity as a whole, Brazil fits into this. People are reaching older ages in good health. We consider a person who is 60 years old to be elderly, but this is something that needs to change. People have vitality and an active sex life, and this certainly contributes to people in this age group starting to get infected because they have an active sex life. The important thing is that we not only approach young people about the prevention of sexually transmitted infections, one of which is HIV, but that we also approach all age groups from adolescence onwards.

The number of cases among children has also increased. What is the most common form of HIV infection in this age group?

When we talk about vertical transmission, the moment when it occurs most is during childbirth. What has been happening over the last few years, with effective prophylactic schemes that are being implemented, is a huge campaign to get women tested at the time of childbirth, and if they test positive, they should take prophylaxis to prevent transmission to the child. With this, we have managed to reduce this transmission to practically zero. What has been happening is that some postnatal diagnoses can occur, for example, during breastfeeding. If a woman tests negative at birth, but becomes infected while breastfeeding, there is a chance that she will transmit the infection to the baby through breastfeeding. It is extremely important to educate and tell these women that while breastfeeding, they need to continue to protect themselves against HIV. In fact, they need to always protect themselves, seeking all ways to avoid HIV infection. But I emphasize that, while a woman is breastfeeding and becomes infected, she runs the risk of passing it on to the baby. This is another form of infection. There is also sexual abuse, which is also a form of infection. But the mother-fetus binomial allows this transmission when the mother is infected.

How is prenatal care carried out for an HIV-positive pregnant woman?

For pregnant women who are HIV positive, the goal is to determine the viral load to be undetectable. We look for the virus in the blood and find none. This is achieved by giving them antiretroviral therapy, specific medication. A woman who is HIV positive and wants to get pregnant, with highly potent therapy, her viral load is undetectable, she becomes pregnant and the pregnancy can be managed, with a very low chance of infection. The difference between an HIV-positive woman and a non-HIV-positive woman during prenatal care is that pregnant women with HIV need to be closely monitored regarding the dosage of the virus in their blood. My wish is for her viral load to be undetectable in all trimesters of pregnancy. This happens when women with HIV decide to get pregnant and adhere to regular treatment and are able to have a very uneventful pregnancy. When HIV is discovered during prenatal care, antiretroviral therapy is started in order to quickly reduce the viral load. The earlier we can detect the virus and start treatment, the lower the chance that the mother will transmit it to her baby. We aim to ensure that the viral load is undetectable at the time of delivery.