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Unprotected sex has no age

Unprotected sex has no age

People aged over 50 years of age are the target of a new campaign in Brazil to increase awareness of the risks of becoming infected with HIV. Claudia Jurberg reports.
In 1997 Beatriz Pacheco, a Brazilian lawyer, learned she was HIV positive. She had been ill for a year and had no idea what was wrong with her. “At that time, the doctors [in Brazil] did not associate HIV with someone like me – an elderly lawyer living with her husband,” she says. When the doctor asked her if she had any objections to undergoing the HIV test, Pacheco laughed, but she had the test and went to get the results unaccompanied. “I was certain that the test would be negative,” she says. She was wrong. She had been infected by her second husband, who had died of hepatitis after he had received many blood transfusions.

The doctor told her that she had only 18 months to live. Today Pacheco, aged 60, is still going strong, having spent the past decade as an AIDS activist, working for most of it alongside her third husband, who died of cancer three years ago: “My husband Carlos Aleixo said we should make sweet lemonade from these sour lemons,” Pacheco recalls. The first ‘lemonade’ they made was the Care Center for HIV Employees, which they established in 1998 to defend the rights of people who had been forced to leave jobs because they were HIV positive. Pacheco went on to establish two more advocacy groups in 1999: the Latin American and Caribbean Movement of HIV Positive Women and the National Movement of HIV Positive Women, Brazil.


Ricardo Barcellos
Beatriz Pacheco with other HIV/AIDS activists.

It was while working with these associations that Pacheco began to notice the number of older or elderly women infected with HIV. It was a fact never mentioned in government campaigns or official statistics. “In Brazil, there is a great deal of prejudice related to sexuality and age,” explains Ivo Brito, a technical adviser for the Brazilian programme for Sexually Transmitted Diseases (STDs) and AIDS at the Ministry of Health. “Many people do not think the elderly are sexually active; they regard AIDS as a disease of young people.”

The limited data available suggest otherwise. According to official government figures the annual incidence of HIV infection among Brazilians aged over 50 years doubled between 1996 and 2006, jumping from 7.5 to 15.7 cases per 100 000 inhabitants. Furthermore, the Gaffrée Guinle Hospital in Rio de Janeiro began to monitor the HIV status of patients in 2001 and noted a significant increase in seropositivity in patients aged 60 years and over. “We are like a barometer of what is happening in the Brazilian society,” says Dr Fernando Ferry, an HIV specialist at the hospital. “We have 3200 patients enrolled in the AIDS outpatient service at the hospital, around one-third of whom are older than 50.”

What exactly is happening in Brazil is unclear. As Veriano Terto, a coordinator with the nongovernmental organization known as the Brazilian Interdisciplinary Aids Association (ABIA), says: “We don’t know if the number of new recently reported AIDS cases increased among the elderly because diagnosis has become easier and more accessible in the last years, or because of a real increase of the number of HIV infections.”

Brito thinks that changes in the sexual behaviour of Brazil’s older citizens are among the factors that may be increasing exposure to infection: “Although there aren’t systematic studies on this subject, the experience of health professionals with the elderly population shows that this group is challenging prejudices and has more [sexual] interaction [than people realize],” Brito says, adding: “Many of them also seek to improve their quality of life and sexual practice.”

Some HIV specialists go as far as to correlate this change in behaviour with the arrival of drugs designed to treat erectile dysfunction in the country roughly 10 years ago. Sidenafil citrate – to give Viagra its generic name – and similar drugs from other manufacturers are easily available over the counter in Brazil and have certainly changed the parameters of sexual behaviour there. As Dr George Schmid, a medical officer at the World Health Organization, puts it: “Because of erectile dysfunction drugs, men, who would normally decrease or cease sexual activity as they age, have extended their sex lives.”

These changes in sexual behaviour bring with them certain risks. For one thing older people may not be as aware as their younger counterparts of the risks involved in having unprotected sex. “Older people became sexually active in a world where there was no AIDS,” notes Brito of the Ministry of Health. “They were not accustomed to using condoms.” The danger may be compounded by older men seeking out younger, sexually active women, which increases their chances of exposure to HIV. “[Erectile dysfunction] drugs can also be used for partying,” says Schmid, citing another cause for concern: that anti-impotence drugs may lead to sexual activity in unsafe conditions.


Ricardo Barcellos
Beatriz Pacheco with her daughter and grandchildren.

But the Brazilian spokesperson for Pfizer, the maker of one of the erectile dysfunction drugs, Viagra, rejects such talk as unfounded. “There is no evidence to link the use of Viagra with a growth of AIDS in older people,” says Dr João Fittipaldi, medical director of Pfizer’s Brazilian branch. On the contrary, Fittipaldi argues that these drugs may actually help to protect men, since it enables them to keep their condoms on by strengthening their erection.

Gaffrée Guinle’s Ferry is ready to admit that erectile dysfunction drugs are “not the only villains” in the putative HIV epidemic among Brazil’s elderly. He cites improved survival rates among Brazil’s seropositive population as an important factor. If fewer people are dying of AIDS, the number of people infected and the age of those infected will go up, even if new infections are on the decline. Finally, the overall health picture in Brazil is improving. Brazilians are living longer, healthier lives and are more likely to remain sexually active as a result.

In 1996, Brazil’s parliament passed a law providing free and universal access to treatment for HIV/AIDS through the public health sector. By the end of 2007 – more than 10 years later – with nearly 200 000 people on antiretroviral treatment, Brazil was providing this treatment to 80% of those in need. As a result, many Brazilians infected with HIV have increased their lifespan considerably.

Among middle-income countries, Brazil has led the way in terms of providing HIV/AIDS treatment to most of those in need. But not until recently was there any awareness that older and elderly people were also at risk of HIV infection. In recognition of that risk, the Brazilian STD/AIDS Program and the Ministry of Health launched a new campaign on World AIDS Day, 1 December last year (2008), under the slogan: “Sex has no age. Nor has protection.” The aim is to make older people more aware of the need to use condoms.

ABIA’s Terto welcomes the campaign, saying that it is essential to bring the words ‘elderly’ and ‘AIDS’ together in the public’s mind. For Beatriz Pacheco, the campaign is the first step on a long road: “The epidemic has been with us for many years and this is the first time that this issue has been addressed. It is very good, but the fight goes on. This is just the start...” ■


1997年,一位巴西律师比阿特丽斯·帕切科得知她HIV检测呈阳性且患病已有一年,其实在当时她对AIDS病是一无所知的。那个时候,巴西的医生并未将HIV与像她这样的人联系起来。一个上了年纪的律师,并且与丈夫住在一起。当医生询问她是否反对进行HIV测试时,帕切科大笑起来,但她做了测试,并且一个人去取了测试结果。她敢肯定测试结果会显示阴性,但结果出乎意料,她被她的第二任丈夫传染了,她的第二任丈夫在被大量输血后死于肝炎。

医生告诉她,她只能活18个月了。今天,帕切科60岁了,但仍然身体健壮,她利用过去十年的时间担任艾滋病宣传员,其中的大部分时间与她的第三任丈夫在一起共事,她的丈夫于三年前死于癌症。“我的丈夫卡洛斯·阿莱绍说,我们应当用酸柠檬来做出甜柠檬”,帕切科回忆到。他们所做的第一个柠檬就是HIV雇员护理中心。他们于1998年组建了这个中心来维护那些因HIV阳性而被迫离职的人的权利。帕切科继续于1999年又设立了两个宣传小组:拉丁美洲和加勒比海HIV阳性妇女行动和巴西全国HIV阳性妇女行动。

与这些社团共事时,帕切科开始注意到老年或中年以上感染HIV病毒的妇女的数量。这是一个在政府竞选和官方统计中从未注意过的事实。“在巴西,对于性别和年龄存在着极大的偏见”,卫生部巴西性传播疾病和艾滋病计划技术顾问伊沃·布里托解释提出,许多人认为年长者在性方面并不活跃,他们将艾滋病看作是年轻人得的病。

能够获得的有限的数据却显示出相反结论。根据政府的官方数据,1996至2006年间,在巴西50岁以上人群中,年度HIV感染发生率增长一倍,从每10万个居民中的7.5个增至15.7个。并且,里约热内卢的Gaffrée Guinle Hospital医院在2001年开始监督病人的HIV状况,并注意到60岁及以上年龄的病人中出现血清阳性的人数发生巨大的增长。“我们就是巴西社会众生万象的晴雨表”,该院HIV专家费南多•费瑞博士表示。“我们医院登记了3200位门诊服务的AIDS患者,他们中约三分之一的人都大于50岁。”

巴西到底发生了什么,我们并不清楚。据巴西跨学科艾滋病协会(ABIA)的非政府组织协调员维瑞诺•特图所说:“我们并不知道最近报告的新增艾滋病案例是否发生在年长者身上,因为在去年,艾滋病诊断已经变得简单和更加容易获得,或者说因为HIV感染的数量实实在在地在增长”。

布里托认为,巴西老年居民性行为的变化是使得感染的风险日益增加的一个因素。“尽管对于这一主题并没有系统的研究,但卫生专家所拥有老年群体的经验表明,该群体正在挑战偏见,他们的性交次数比人们所认为的要多。他们中的许多人还不断努力地想要改变其生活和性行为的质量。”

有些HIV专家目前将这种行为上的变化与该国约10年前开始使用治疗勃起障碍的药物相关联。枸橼酸西地那非——其通用名为伟哥,与其他制造厂商的类似药物在巴西的各个柜台可以很容易地买到,当然也改变了那里性行为的特性。正如世界卫生组织卫生干事乔治•史密德博士所说:“那些在变老后正常会减少或停止性行为的人们,由于勃起障碍类药物的作用,已经延长了他们的性生活”。

性行为上的这些变化为他们带来某些风险。首先,年长者可能不会像比他们年轻的对照人群那样了解发生无保护性性行为的风险。“年长者在没有艾滋的世界里对性行为更积极”,卫生部的布里托说到。“他们不习惯使用避孕套”。这种危险性可能还因年长者寻找年轻的性行为积极的妇女而变得更加严重,这会增加他们感染HIV的风险。壮阳药可能导致不安全状态下发生性行为。

但瑞辉(勃起障碍药物之一伟哥的制造商)的巴西发言人反对这种说法,认为这是没有根据的。“没有证据可以说明使用伟哥与年长者中艾滋病感染的增多有关”,瑞辉巴西分公司的医学总监费迪帕尔蒂博士说。相反,费迪帕尔蒂辩驳说,这些药物实际上有助于保护男人,因为它加强了勃起,使男人们能够戴上避孕套。

Gaffrée Guinle的费瑞准备承认勃起障碍类药物在公认的巴西年长者HIV流行事件中并非唯一的罪魁祸首。他引用巴西血清阳性人群生存率不断增加来作为一个重要因素。如果几乎没有多少人因艾滋病而死亡,那么感染人口的数量和被感染者的年龄将会提高,即使新的感染率在减少。最后,巴西整体的卫生状况在改善。巴西人越来越长寿,越来越快乐,因而更加可能保持性行为的积极性。

1996年,巴西国会通过了一项法律,规定通过公共卫生部门免费和广泛地提供HIV/AIDS治疗。至2007年底,也就是10多年前,已拥有约200 000名接受抗病毒治疗的人,巴西正在向80%需要接受治疗的人提供这一治疗。因而,许多感染HIV病毒的巴西人大大延长了寿命。

在中等收入国家中,对于向大部分需要治疗的人提供HIV/AIDS治疗方面,巴西处于领先。但直到最近才发现老年人和年长者也处于HIV感染的危险之中。为了确认这一风险,巴西性传播疾病/艾滋病计划和卫生部在2008年12月31日世界艾滋病日发起了一项新的运动,口号是无保护的性爱不分年龄,目的是使年长者更多地了解使用避孕套的必要性。

巴西跨学科艾滋病协会(ABIA)的特图欢迎这项运动,这项行动使公众在头脑中将“老年人”和“艾滋病”联系起来是必要的。对于比阿特丽斯·帕切科来说,这项运动只是万里长征的第一步:“这种流行病已经与我们共存了很多年,这还是我们第一次来面对这个问题。很好,但战斗还将继续。这只是开始... ...”

摘自http://www.who.int/bulletin/volumes/87/3/09-010309/en/index.html


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