Fórum: desafios da prevenção das DST/AIDS em países africanos de língua oficial portuguesa: contribuições da pesquisa social e do recorte de gênero. Introdução
Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
This forum on the challenges of preventing STD/AIDS in Portuguese-speaking African countries contains three articles and a postscript. The first paper reviews academic production on the topic from the fields of the social sciences and of health, with special attention on how local cultural and socioeconomic factors impact the dynamics of the epidemic. Based on an ethnographic study of a region in southern Mozambique, the second paper analyzes the notion of 'tradition' within the context of Mozambique and how it affects perceptions of the local population's vulnerability to STD/AIDS. The third and final article discusses common ground and differences between government and civil society in gender approaches by community HIV/AIDS projects in Mozambique. Their observations suggest that important mistakes have been made in STD/AIDS prevention discourse and initiatives in African countries because the unique features of local development models and cultural systems have not been taken into account.
Sexually Transmitted Diseases; Acquired Immunodeficiency Syndrome; Disease Prevention; Africa
Esta introdução apresenta o Fórum sobre os desafios da prevenção às DST/AIDS em países africanos de língua oficial portuguesa, constituído por três artigos e um posfácio. O primeiro trabalho traz uma revisão da produção acadêmica no campo das ciências sociais e da saúde sobre o tema, focalizando as implicações dos fatores culturais e sócio-econômicos locais para a dinâmica da epidemia. A partir de um estudo etnográfico numa região do sul de Moçambique, o segundo texto analisa a noção de "tradição" no contexto moçambicano e suas conseqüências para a percepção da vulnerabilidade às DST/AIDS da população local. O terceiro artigo discute pontos de aproximação e de desencontro entre o governo e a sociedade civil na abordagem de gênero de projetos comunitários de enfrentamento do HIV/AIDS em Moçambique. As reflexões revelam que os discursos e ações de prevenção das DST/AIDS em países africanos apresentam equívocos importantes por não considerarem as particularidades dos modelos de desenvolvimento e os sistemas culturais locais.
Doenças Sexualmente Transmissíveis; Síndrome de Imunodeficiência Adquirida; Prevenção de Doenças; África
Despite efforts and advances in the political, social, and biomedical spheres, the HIV/AIDS epidemic remains a critical public health problem, especially in contexts where socioeconomic inequality and social marginalization are prevalent. This means that groups at a social disadvantage because of poverty, lower educational levels, and a lack of access to social goods and healthcare services are more vulnerable to STD/AIDS. These factors gain greater saliency when they come hand-in-hand with gender inequalities and engagement in the socially stigmatized behaviors associated with sexual diversity and drug use. Of special interest here are the data recently released by the Joint United Nations Programme on HIV/AIDS (UNAIDS). According to the UNAIDS report, the HIV-positive population worldwide has held steady in percentage terms since 2000, while the overall number of those living with HIV has grown, owing both to new infections and to the benefits of antiretroviral treatment. The region hardest hit by HIV continues to be Sub-Saharan Africa, where 67% of the globe's HIV-positive population lives and where 72% of global AIDS deaths occurred in 2007. Elsewhere around the world, HIV has hit injecting drug users, men who have sex with men, and sex workers.
Given that investments in the development of a safe, effective AIDS vaccine have yet to meet with success, controlling the epidemic depends upon effective initiatives in prevention and assistance that will be capable of addressing the social exclusion factors that underlie greater vulnerability to STD/AIDS in the global context. This in turn means that addressing the epidemic will require an improvement in the human rights situation around the world, by achieving greater gender equality, combating stigma and discrimination, and ensuring access to social goods and the means of prevention, treatment, and care.
The articles comprising this forum are a contribution to the discussion about what has worked and what has not in STD/AIDS prevention policies in African nations and as such they play an important role in analyzing the vulnerability of social groups within these settings. These texts rely on the social and health sciences to better understand local cultural systems regarding gender, sexuality, and healthcare and their interdependence with socioeconomic conditions.
Bearing in mind the African continent's socio-cultural, economic, and political diversity, the chosen focus was on social research from a gender approach on Portuguese-speaking African countries, known by the acronym PALOP (for "países africanos de língua oficial portuguesa"), and on Mozambique in particular. This choice reflects Brazil's technical and scientific collaborative agreements with the Portuguese-speaking community in Africa, which in health care encompass epidemiological surveillance, technical and professional training, and antiretroviral drugs. Two examples of such initiatives are the Oswaldo Cruz Foundation's current partnership with Mozambique and Angola in the area of graduate teaching and the Second Congress of the Community of Portuguese-Speaking Countries on STDs and AIDS, held in Rio de Janeiro in April 2007, with scientific coordination provided by the Oswaldo Cruz Institute. The three papers in this forum were presented at the latter event.
Simone Monteiro's article examines academic production from the social science and healthcare fields on STD/AIDS prevention initiatives in PALOPs. Based on a bibliographic survey of the SciELO, PubMed, and Sociological Abstracts databases from 1997 to 2007, the study was organized along two lines. The first describes research that explores how vulnerability to STD/AIDS may be influenced by local cultural and socioeconomic factors linked to gender, sexuality, color/race, religion, and health care dynamics. Complementary to this focus is a look at evaluations of mistakes that have been made in the STD/AIDS educational messages sponsored by governments and international agencies. Also discussed are the impacts of systems of traditional medicine and of the post-colonial civil wars on the STD/AIDS situation in the African nations under research.
Luiz Henrique Passador's text analyzes the notion of "tradition" in the context of Mozambique and explores how it affects perceptions of social groups' vulnerability to STD/HIV/AIDS. Based on an ethnographic study of a rural region of southern Mozambique, the author offers his thoughts on the "traditional" definition of a person in this context and how this understanding shapes local gender relations and the universe of disease. In his view, HIV/AIDS has been perceived from a social-cultural perspective that sees diseases as actions taken by social subjects that place people at risk, thereby creating a situation in which women are cast in a vulnerable role as promoters of disease. These factors have determined not only how people experience the epidemic but have also influenced discourse and public policy on STD and HIV/AIDS prevention and treatment within this setting.
Wilza V. Vilella & Rosemary Barber-Madden's article examines where government and civil society agree and disagree in their approaches to gender within community HIV/AIDS projects in Mozambique, based on an evaluative study conducted there in 2006, encompassing 160 of the 1,124 NGO projects undertaken with the support of the country's national AIDS council, known as Conselho Nacional de Combate ao SIDA (CNCS). The authors point out that the gender approach in community projects most often finds expression in initiatives to mitigate the economic impact of the epidemic on widows. Initiatives aimed at men and at the population as a whole generally do little to address power relations between men and women or their affect on the epidemic. The article stresses the importance of painstaking translation and adaptation to local cultural standards when transferring Western analytical and interventionist technology on the HIV/AIDS epidemic to regions of the African continent.
Employing distinct yet complementary methodological approaches, these three articles offer analyses of the local cultural logic regarding gender dynamics, health practices, and the interpretation of preventive discourses by governments and international agencies in PALOPs. Their observations suggest that important mistakes have been made in STD/AIDS prevention proposals and initiatives, which have been characterized by the import of programs that fail to take into account each place's unique characteristics, as far as their development models and cultural systems. The arguments offered in these pages point to a need to arrive at effective, creative solutions that will reduce poverty and work to integrate the logic systems defined as traditional and modern. The sometimes exaggerated emphasis on male circumcision as a way of controlling the AIDS epidemic in African societies suggests that an ill-advised process of medicalization of prevention is taking place. This perspective seems to stand in contradiction with struggles and victories in the field of rights, led by world leaders, the scientific community, governments, and activist groups, characteristic of the social response to AIDS around the world in recent decades.
1. Cáceres CF, Aggleton P, Galea JT. Sexual diversity, social inclusion and HIV/AIDS. AIDS 2008; 22 Suppl 2:S45-55.
2. Joint United Nations Programme on HIV/AIDS. Report on the global HIV/AIDS epidemic 2008: executive summary. Geneva: Joint United Nations Programme on HIV/AIDS; 2008.
3. Fauci A. 25 years of HIV. Nature 2008; 453:289-90.
4. Monteiro S. STD/AIDS prevention in Portuguese-speaking Africa: a review of the recent literature in the social sciences and health. Cad Saúde Pública 2009; 25:680-6.
5. Passador LH. "Tradition", person, gender, and STD/HIV/AIDS in southern Mozambique. Cad Saúde Pública 2009; 25:687-93.
6. Villela WV, Barber-Madden R. The gender approach in community AIDS projects in Mozambique: agreement and disagreement between government and civil society. Cad Saúde Pública 2009; 25:694-9.
7. Potts M, Halperin DT, Kirby D, Swidler A, Marseille E, Klausner JD, et al. Public health. Reassessing HIV prevention. Science 2008; 320:749-50.
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Submitted on 25/Aug/2008
Approved on 04/Nov/2008