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Print version ISSN 0034-8910
Rev. Saúde Pública vol.41 n.3 São Paulo Jun. 2007 Epub Mar 22, 2007
Patricia Neves GuimarãesI; Denise MartinII; José QuirinoIII
de Saúde Mental e Saúde Coletiva. Universidade Estadual de Montes
Claros. Montes Claros, MG, Brasil
IIPrograma de Mestrado em Saúde Coletiva. Universidade Católica de Santos. Santos, SP, Brasil
IIIDepartamento de Psiquiatria. Escola Paulista de Medicina. Universidade Federal de São Paulo. São Paulo, SP, Brasil
To describe behaviors facilitating HIV/AIDS exposure in rural population. METHODS:
A qualitative study was conducted comprising 52 patients who attended a STD/AIDS
outpatient clinic in 2002 and 2003. In-depth open and semi-structured interviews
were carried out with subjects (30 males, 22 females) at the clinic or at home
in rural municipalities in the northern area of Minas Gerais state, Southeastern
Brazil. Interviews were transcribed and analyzed considering categories such
as disease, work, social life, prior HIV/AIDS knowledge, and lifestyle. Content
analysis was used for result interpretation.
RESULTS: Interviewees perceived AIDS as a "big city disease", an "outsider's disease", dissociated from local culture. They were all infected through either heterosexual or homosexual sex. Rural-urban migration is a major factor for HIV infection in the area as people migrate to search for jobs.
CONCLUSIONS: Popular beliefs about HIV/AIDS disease contributes to HIV vulnerability of this population. There is a need to apprehend their cultural beliefs to better understand their ways of thinking and to focus on these local beliefs when disseminating HIV/AIDS information.
Keywords: Acquired Immunodeficiency Syndrome. Rural population. Health knowledge, attitudes, practice. Qualitative research.
In the last 10 years, AIDS epidemics in Brazil has been characterized by pauperization, feminization, and interiorization.2,4,6,8,19 There are few epidemiological studies on the process of AIDS epidemic interiorization in Brazil4,8,19,20 and scarce qualitative research studies have focused on the epidemic in rural Brazilian population. Alves1 (2003) investigated HIV/AIDS perception and sexual practices among rural men in inland Pernambuco state (Northeastern Brazil). Kerr-Pontes et al14 (2004) addressed belief, behavior and social representation in groups of migrants from the Brazilian northeastern region focusing on their ability to put up HIV prevention measures. Both studies stressed the challenges of prevention in rural populations. There is a need for new knowledge about the different social and cultural background of HIV/AIDS in rural Brazil.
The study of HIV/AIDS in rural populations allows exploration of the distinctive traits of the epidemics in this environment and to broaden knowledge and better management of preventive actions.
The growth of HIV/AIDS in the northern area of Minas Gerais State (Southeastern Brazil) reflects a general trend of the disease in Brazil in terms of its expansion towards small-size municipalities and inland areas. This area is marked by poverty and lack of resources.*
The objective of the present study was to describe behavior facilitating HIV/AIDS exposure in a population living in rural localities.
A qualitative study was conducted comprising patients who attended a STD/AIDS outpatient clinic in the municipalities in the northern area of Minas Gerais State. This area covers 89 municipalities and a total population around 1.5 million inhabitants. Eighty-four municipalities have less than 50,000 inhabitants.18
Selection of subjects was intentional, counting on their availability to participate in the study and appropriate place of residence (only those living in rural localities).
The inclusion criteria in the study were the following: HIV-positive or living with AIDS; aged 18 years or more; living in rural localities in the study area; being under treatment or clinical care, at the time, in the outpatient clinic of STD/AIDS. The exclusion criterion was living in Montes Claros, the urban heart of the area.
Interviews were carried out by an ethnographic approach.10,16 Field work focused environmental and social background of subjects. The ethnographic approach10 allowed close inspection of subjects' daily life as well as their social relations with the family and community.
The data was collected between January 2002 and January 2003. In-depth open and semi-structured interviews were carried out with 52 subjects (30 males and 22 females) both at the outpatient clinic, and at home. Subjects were approached between medical visits at the clinic and were fed the study main lines, in which confidentiality and privacy of information were assured. Interviews were conducted using guidelines including work, lifestyle, perceptions and prior knowledge of HIV/AIDS, social life, marital relations and treatment. Two individuals refused to participate in the study because they feared their status would become clear to their neighbors.
Interviews were recorded, ending when they reached saturation. They were then transcribed and analyzed. In the transcription, subjects' names were coded: the prefix H being used for males and M for females, followed by identification digits. The analysis produced categories that were grouped as follows: common perception of HIV/AIDS, local perception of sexuality (homo and hetero) and migration due to looking for a job. Bardin's3 (2004) content analysis was used for result interpretation.
The study was developed in compliance with the Ethics Committee of Universidade Federal de São Paulo, all interviewees being briefed and agreeing to freely endorse a signed consent.
RESULTS AND DISCUSSION
All subjects came from the following rural counties: Porteirinha, Janaúba, Januária, Itacarambi, Taiobeiras, Rio Pardo de Minas, São João da Ponte, and Salinas. Main activities are food crops, occasional seasonal jobs, and non-market trading of produces. Ages ranged from 25 to 70 years. Most completed elementary school (four years).
AIDS perception and its implication to HIV spread
Locally, AIDS was considered to be a disease from "outside the area" where they live, a "big city" disease not recalling villages or rural areas.
"I didn't believe it can come to this small town". (H25, 38 years old)
"I thought this thing would not infect me. I thought it [AIDS] was a thing of big city, these places, that is. I thought people would change. And that we can see that people has it; but many peoples with this thing is no different, ain't they? They are the same". (H15, 37)
All interviewees were indifferent to HIV/AIDS information they received through the press media. It was understood as "a big city disease" not linked to them in any way.
"I have heared this HIV was a thing from they say it was there, in those parts in the United State..., at that time when it's start'd, people was not afraid, it didn't get into their heads it could go aroun' and and and contraminate them, see? No one car'd. I myself did not even think about it." (H10, 40).
"I have heared people talking [on TV]. I didn't pay any attention, I didn't even care. I used to say: Uh, here we don't have it". (M18, 34)
Their beliefs of "nearness and distance" showed a system classification of that can be very useful in the analysis of their patterns of thought.
The disease is part of what locals considered as not belonging there or the neighboring areas. In their reasoning, there is no need to worry about AIDS as it is part of what they perceive as "distant," i.e., everything that is not part of their immediate sphere of knowledge. The notion of a geographic and a cultural distance was present here, in the sense shown by Evans-Pritchard11 (1978) for Africa, the notion of time and space being linked to the physical environment, being essentially based on seasonal variation of social activities.
Local notion of distance would include things or people not acknowledged as belonging to the group. They regarded as "close" those people living in the area or small cities who were defined as alike, i.e. belonging to the same social group and sharing the same set of standards. Following this reasoning, people living in rural areas would be free of the AIDS threat. The belief of distance would include strangers, "outsiders," regarded as not belonging to the same social group and thus potentially harmful to them and likely to be HIV infected.
Subjects also hardly perceive or identify AIDS because it is not seen. There is no clear symptom that can be attributed to HIV infection either in the asymptomatic period or in the symptomatic period when AIDS typical conditions can be mistaken for others. People do not recognize the disease as physical. Besides, the status of asymptomatic infection makes it difficult to acknowledge the disease and more, that it is there and anyone can be infected.
In spite of having heard about AIDS by the media, some persons declared they did not either think about it, or even that it could be a non-healing disease. Some say AIDS is like any other disease they were familiar with and that could be easily cured like gonorrhea, which was the most referred sexual disease by them.
According to the interviewees, the disease is detected only when a patient has significant weight loss, which is the single symptom acknowledged as being related to AIDS.
"Yeah but not me I didn't believe it because it was the first sample. I said: Uh, this got to do with the guys there in the laboratory. My wife also didn't pay no attention to that... yeah. I didn't believe it. And not even now I'm taking this medicines I don't believe it. I myself let it run free. I don't give a damn." (H08, 32)
From the subjects' viewpoint, the expression "your test is positive" is an abstract statement as it cannot be associated to signs and symptoms. This makes patients doubt the diagnosis and sometimes postpone treatment, and they are very likely to carry on spreading the virus.
Why do you think you don't have it [AIDS]? "Because I feel nothing, see? Peoples say it sometime takes time for AIDS to develop, doesn't it? sometime some peoples has a body has a strong body and it doesn't develop, you know? The virus doesn't develop but I don't think I have it". (M01, 34)
"I used to hear people saying AIDS... AIDS, I thought it was a disease so that we get treated and then we were cured fast. I thought so." (M04, 31)
These data show that the population studied behaves according to standards of reasoning related to their local culture which are quite different from the disease nature and progress, according to scientific conceptions. It makes therefore prevention meaningless to this population since to them the disease does not exist, rending people more vulnerable to infection.
Migration and return to the source community
Epidemiological data from the Brazilian National Program on STD/AIDS7 (2004) show 362,364 AIDS cases reported in the period between 1980 and 2004, of which 42.2% were reported in the State of São Paulo. It was verified the migration of interviewees and their family from the study area to urban and rural areas in search for jobs and better living conditions. The State of São Paulo was the most referred destination of this migratory movement.
Some studies5,9,12-14 point out migration as a major factor for HIV dissemination in rural areas. These authors claim that migration per se does not lead to infection but actually behavior and sexual practices arising from this process does.
In the present study, migration was mostly reported among male subjects who sought to earn elsewhere a livelihood for their family or better life opportunities. More people migrate especially during the particular harvest seasons of crops such as soy, coffee and sugar cane when men leave the area to look for jobs. They seasonally worked in the States of Minas Gerais, São Paulo, and Goiás. They often traveled to the city of São Paulo to trade typical products from their area.
"I live there for quite a while. I've worked there for a long time... there in the State of São Paulo..." Inland? "Yeah, inland. It is within Ribeirão Preto, Pontal, Sertãozinho, in those plant there all over I worked". In the plant, isn't it? "Yeah. I worked in the plant, in the backwoods plantation, yeah... sugar cane harvest." (H10, 40)
There were 22 women interviewed, of whom 13 were infected by their husbands and partners who worked in São Paulo. The remaining reported they were likely infected by their partners who worked in other Brazilian regions or in the study area.
"My husband came. He came and we start'd to like each other and didn't want to stay at my mother's like that. I want'd to have a house, see? Take care of myself, my child. So his family, see, made an extra effort for us to be together. But, see, they didn't tell me he had the disease. He lived in São Paulo." (M19, 30).
Women also migrated but less frequently than men. Some female interviewees went to São Paulo under special circumstances to go along with their husbands. Working there is still a life goal aspired by both men and women.
Migration to other Brazilian regions is key to understanding HIV infection in the northern area of Minas Gerais as well as a major element for prevention actions.
Sex and HIV infection
All interviewees were infected through sexual exposure, confirming a worldwide trend.21 Most men reported being infected through heterosexual exposure especially in whorehouses. They vehemently denied homosexual intercourse, which can be an artifice for not having to admit homosexuality, a morally unacceptable practice in the communities studied. Some interviewees either married or not, suggested having both heterosexual and homosexual exposure, especially during the time they were away from home working in other Brazilian regions.
"Well, as I said I was drunk in the New Year's eve and the kid ask'd me to go to his place. See, people are goin' to my place to eat snacks, a stew and such and such, when I arrived there he..." Did he pay you? "No. He put a tape in the VCR to seduce me and that's it." What was this tape about? "Sex. Between men. Uh! I was really drunk then I went with someone but didn't use this condom. Because a year later he died! With a condition. One only [homosexual intercourse]. That is what makes me furious." (H25, 38)
"In downtown São Paulo. Praça da República, Estação da Luz, there in the city downtown. So, you're a young guy, nice, see, so those queers, those guys who prostitute there, find you interestin', want to go out with you, you know? So you don't give a damn, you go out with them, you know?" (H05, 35)
Likely homosexual relationships were explicit in speeches where subjects reported experiences predisposing them to this sort of contact such as men who offered them money in exchange for sex.
"He want'd and want'd me to stay with him, he wasn't and has never been my kind, see! They gave, he gave me money, so he seemed to be rich... whatever..." Did he offer you money? "Money, so much money! But he wasn't my kind. I never was, it has never been and it is not". (H17, 45)
Many times. Many, many men have stopped their cars near me offering me money, everything, for us, for me to go out with them. But I never, you know? I dont know, I never, never liked that kind. To me men are like me, I dont, I dont desire men at all, understand? So I did never go out with homosexuals. (H24, 30)
Interviewees generally had moralistic arguments to deny homosexual behavior, pejoratively referring to openly homosexual men. Homosexual practice is not accepted in their social environment. Subjects speeches show a moral duty to desire women.
I think it is underhandedness... uh, I think they are not men... men have to desire women... (H01, 35)
Interviewees often referred to homosexuality as a devilish behavior, a kind of supernatural force alien to ones own will that would make people commit acts against their own will and nature. They believed homosexual behavior is an anti-natural act or a deviation from normality; and normality meant subjecting oneself to the established social convention.
Oh, let me tell you, I neither agree nor disagree, I dont know why someone why it happens and I dont know why, but only as a contrast, see? I wont discriminate no one because I aint God to judge people, am I? In contrast, uh it would be good if I think it [homosexuality] is more devilish. I think it is an evil spirit that gets into people. Im positive thats it! (H02, 34)
The denial of contact with same sex partners was explicit but some subjects minimized this behavior by giving it a superfi cial connotation. For instance, some said they have had only one homosexual intercourse in their lifetime, making it a distant act of minor relevance. Subjects were concerned about self-affi rming their maleness and did not want to be fi tted as homosexuals.
Parker17 (1991) showed that sexual interactions between men are conceived within a male-female relationship construction, and their sexual role, active or passive, is more relevant than the choice of sexual object to defi ne sexual identity and values.
Some interviewees managed to express their true sexual practices but they argued they did not see themselves as homosexuals. For example, one subject explained that homosexuals are only those individuals who, during intercourse, play a passive role. As he played the active role, he was not part of this group.
It was the fi rst thing. It was the fi rst time. A quick thing but what I really liked was striptease, lookin for women. I used to go a lot to red-light districts, to those meeting places there... but with women, such thing has hardly ever happened with men, but it happened with women. I had once [anal sex with men]. That time I played the active role. (H05, 35)
With men, never... I dont know..., I have rubbed against but only once. It was a long, long time ago. (H09, 29)
Many subjects women believed their partners and husbands were infected through contacts with street women, an argument accepted in their community, which reproduces traditional gender relations as well. Women did not see any chance of their husbands having homosexual exposure.
Uh, this disease was contracted and catched in the state of São Paulo, see? Yeah. Those women there... Uh, Ive heard it is transmitted by having sex, isnt it? by having sex with women people catch it. (H10, 40)
Both men and women reported that, even though they were aware of their HIV status, they continued to have sex without using condoms. None of the subjects in the study was used to condoms and many reported they had never tried to use a condom.
Even he has even said to me: this is my like, you think Ill spend the rest of my life having sex with you with condoms? You think Ill... Ill never have the pleasure of being with you without a condom, never? This is my life, Ill do whatever I like, he has even said that to me, see? So it was so much so much pressure that I eventually I used to come for the checkup and cried and cried.... (M05, 29).
Male subjects believed backwoodswomen posed no risk of sexually transmitted diseases as they were upstanding, family women who did not like to go out partying. Following this reasoning, condoms were not needed. Also, not using condoms was based on the trust they placed on their partners.
Sometime I would fi nd one, see.... but that I knew there was no problem, you know? How did you know there was no problem? cause sometime they were family women who perhaps not even liked much partying, see? This thing. So you would know, you dont know, I think they didnt have it. This bush woman who lived there in those bushes. I think she didnt have it, didnt have anything. (H15, 37).
It can be said that behavior arising from rural to urban migration are likely facilitators of HIV spread in the study area. Subjects and their families moved between several Brazilian cities looking for jobs and the State of São Paulo was the most common destination.
Although subjects have heard about AIDS through communication media, advertisements broadcasted targeting prevention do not appear to be reaching this population for they are restricted to a cultural background quite different from that of rural communities. This may be an obstacle to their understanding of AIDS. Bearing in mind cultural issues while disseminating HIV prevention can be thus a facilitator to raising these individuals awareness of their HIV susceptibility. In this sense, information provided through communication media would be more meaningful and more easily absorbed in the cultural background of target populations.
The present study stresses regional characteristics that should be further explored and taken into consideration while devising HIV/AIDS prevention policies and campaigns. The study fi ndings highlight guiding tools for future AIDS prevention campaigns in Brazil.
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Patricia Neves Guimarães
Rua Agapito dos Anjos, 636 Cândida Câmara
39401-040 Montes Claros, MG, Brasil
Based on a Masters
dissertation by PN Guimarães presented to the Department of Preventive
Medicine, Unifesp, in 2003.
Study conducted in the STD/AIDS outpatient clinic of Universidade Estadual de Montes Claros.
* Guimarães PN. Aids no Brasil rural: um estudo etno-antropológico da contaminação. [Master's dissertation]. São Paulo: Unifesp; 2003.