Artigos

Conteúdo (article):

What prevention approaches and technologies are we using?
Analysing HIV and AIDS communication campaigns in Brazil


AUTHOR:
● Ádria Albarado (adria.albarado@gmail.com) - Programa de Pós-graduação em Saúde Coletiva e Laboratório de Informação, Educação e Comunicação em Saúde da Universidade de Brasília
ORCID: https://orcid.org/0000-0003-2519-7690

COAUTHORS:
● Maria Beatriz Ruy (beatrizruy@gmail.com) - Secretaria de Estado da Saúde do Distrito Federal
ORCID: https://orcid.org/0000-0001-6509-4392;
● Ana Valéria Machado Mendonça (valeria.mendonça@unb.br) - Departamento de Saúde Coletiva da Faculdade de Ciências da Saúde da Universidade de Brasília
ORCID: https://orcid.org/0000-0002-1879-5433


ABSTRACT: Health campaigns have been carried out for a century in Brazil to prevent diseases, including HIV and AIDS. But what approaches and technologies are used in these actions? Our aim was to identify and discuss prevention strategies in HIV and AIDS campaigns run by the Ministry of Health between 2012 and 2022. This is a qualitative-quantitative exploratory study based on thematic content analysis and descriptive statistics. The primary, secondary, tertiary and quaternary categories of prevention were discussed in the light of the relevant literature. It was observed that the campaigns use approaches and technologies from the primary (81%) and secondary (93%) levels in the pieces analysed. The tertiary and quaternary levels only appear in 8% and 32%. The campaigns mention prevention methods without explicit information about each one and mostly deal with biomedical interventions. There is positive action to encourage barrier methods and mass testing, and information gaps regarding treatment as prevention, the response to social determinants and combination prevention. The campaigns need to be evaluated and improved as a health communication strategy adopted with the aim of providing information for HIV and AIDS prevention, especially among key and priority populations.

KEYWORDS: HIV; AIDS; Health Surveillance; Prevention; Health Communication.



INTRODUCTION

There are approximately 39 million people living with HIV or AIDS in the world1. Of these, around one million live in Brazil, with 70.5% of reported cases in men and 29.5% in women. The percentage distribution of registrations by race, colour and ethnicity shows that black and brown people account for 34.2% and white people for 32.2%. In 2022, 62.8% of new cases occurred in the black population. In terms of education, 43.9% have less than nine years of schooling and in terms of age - between 2007 and June 2023 - 62.3% of the cases are concentrated among young men aged 15-34 and 48.9% among women2,3.
Between 2012 and 2022, the detection rate of HIV infection in pregnant women increased from 2.4 to 3.12. In the same period, a total of 52,415 young people living with HIV, aged 15 to 24, of both sexes, developed AIDS, highlighting the need to promote initiatives for linkage to health services and adherence to antiretroviral therapy (ART). Brazil currently has 731,000 people on ART, of whom 95 per cent are virally suppressed3. To achieve the goal of eliminating the HIV and AIDS epidemic as a public health problem, Brazil needs to diagnose 4% more of the nearly one million people living with HIV in the country - who do not know their serological status - and increase treatment of those diagnosed by 14%. Only the viral suppression target has been achieved1.
Achieving these goals is inextricably linked to prevention and, in the case of HIV and AIDS, involves all levels of prevention. The dictionary defines prevention as a set of measures or advance preparation aimed at avoiding a harm. In health, there are harms - in the plural - and they are infections, diseases and illnesses. Prevention aims not only to prevent the onset of these infections, diseases and illnesses, but also to reduce their incidence and prevalence in the population, to eliminate them as public health problems or even to eradicate them6,7.
In this sense, primary prevention is based on actions aimed at avoiding or eliminating people\'s exposure to risk before pathologies develop7. Examples include the use of technologies such as condoms or HIV pre- and post-exposure prophylaxis (PrEP and PEP), which act as barriers to infection with the virus. Secondary prevention aims to identify a health problem at an early stage and prevent it from becoming more serious. An example of this is early and timely diagnosis of HIV infection, because in positive cases, treatment can be started immediately, which in turn can prevent the development of AIDS, as well as transmission to sexual partners or vertical transmission in the case of pregnancy.
Tertiary prevention focuses on reducing the social and economic costs of illness through rehabilitation and reintegration, including improving people\'s functional capacity. It concerns particularly chronic diseases and aims to treat and control them7. In the case of HIV, an example is the treatment of the infection, which prevents AIDS and the development of opportunistic diseases.
Quaternary prevention includes technologies and interventions aimed at avoiding or minimising excessive medical intervention. It also aims to empower people under the care of health professionals by providing them with information on the advantages and disadvantages of preventive or therapeutic methods, so that they can make autonomous and informed decisions7,8, as is the case with the combination prevention strategy. This strategy consists of the simultaneous use of different prevention approaches, applied at different levels, in order to respond to the specific needs of certain populations and modes of HIV transmission9.
In Brazil, communication campaigns are traditionally and seasonally used to encourage the prevention of infectious diseases10,11. Campaigns are strategic communication management tools that aim to ‘achieve a defined goal by integrating a series of instruments and actions within a predetermined timeframe and with a clearly defined objective’ (p. 7)12. In the context of health surveillance, this objective is to protect and promote the health of the population and to prevent and control risks, complications and diseases, including through the dissemination of information13.
Communication campaigns seek to prevent HIV infection, achieve early and timely diagnosis, reduce AIDS cases and mortality, and increase adherence to treatment and access to prevention supplies. But which prevention approaches are used in these communication campaigns? How consistently are they used? What are the key messages? This study aims to identify and discuss the prevention approaches and technologies presented in the HIV and AIDS campaigns broadcast by the Ministry of Health of Brazil between 2012 and 2022.
It should be emphasised that the purpose of this analysis is to understand how the health interventions known as communication campaigns are being used to prevent HIV and AIDS in Brazil, from the perspective of Health Surveillance and Health Communication. This is an unprecedented study in the country, as it analyses a recent period in the history of the HIV and AIDS epidemic, as well as highlighting existing information gaps in communication strategies and providing a picture of the promotion of technologies and/or approaches adopted by national health management.
In this context, health and communication extend beyond conceptual or functional discussions, as they are fundamental rights, especially communication, as it cuts across cultures and plays a crucial role in the expression of ideas, desires and opinions, social participation and access to information, which are essential for HIV and AIDS prevention.


MATERIALS AND METHODS

A total of 66 posters, 24 videos and 20 audios that directly or indirectly mentioned HIV and AIDS in communication campaigns produced by the Brazilian Ministry of Health between 2012 and 2022 were analysed. Materials that were not included in the campaigns or that were described as giveaways, such as fans, T-shirts, caps, etc., were excluded. The pieces were located on the websites gov.br/aids and gov.br/saude and then described or transcribed, coded - taking into account the type and period in which they were broadcast - and organised in spreadsheets. In addition to the type and year of publication, the description included details of the messages, characters and references to websites and/or social networking sites.
This is a qualitative-quantitative study14, exploratory in nature, based on thematic content analysis15,16 and descriptive statistics17. Procedural techniques from documentary and bibliographic research were also used to collect and analyse the data18.
The closed categorisation model was chosen19. The research analysed the types of prevention technologies and approaches used in the campaigns and classified them according to levels of prevention. These in turn were transformed into thematic categories of analysis: primary, secondary, tertiary and quaternary7.
The first included content on condoms, pre- and post-exposure prophylaxis for HIV (PrEP and PEP). The second included information on testing, self-testing, antenatal care and treatment. The third section covered issues such as stigma, prejudice and respect. Finally, the fourth section included findings on combination prevention.
The results were analysed in the light of the literature on Health Surveillance and Health Communication, with an emphasis on prevention. The information presented in this article is the result of research on the evaluation of campaigns for a doctoral thesis covering a period of eleven years, from 2012 to 2022, as part of a national research project carried out between 2020 and 2023, funded by the National Council for Scientific and Technological Development (CNPq).


RESULTS AND DISCUSSION

A total of 109 pieces of communication campaigns on HIV and AIDS over 11 years were analysed, including 66 posters, 24 videos and 19 audios. During the period covered, an average of 9.9 pieces were produced per year. It was also found that the years with the highest frequency of production were 2015, with 12 posters, 3 videos and 3 audios, and 2017, with 11 posters, 3 videos and 3 audios. The years 2013, 2018 and 2019 stand out with 9 posters, 6 videos and 3 audios respectively.
According to the findings, over the past 11 years, the Ministry of Health\'s HIV and AIDS communication campaigns have mainly emphasised primary and secondary prevention strategies, with secondary prevention being 13 times more frequent than primary prevention, which was recorded in 90 pieces. This difference may be related to the fact that PEP and PrEP started to be offered in the SUS in 201520 and 201721 respectively. Thus, condoms were mentioned in 63 pieces and in all years (Figure 1). Nevertheless, several studies indicate that this barrier strategy has not been effective to the same extent as it has been recommended.
Some of the findings are worrying. For example, Dourado and colleagues point out that there is a lack of approaches to the role of pleasure and sex in interventions on condom use. According to them, there are few studies on factors associated with condom use among the groups in which the epidemic is concentrated22. Sex and pleasure are not even mentioned in the campaigns analysed, demonstrating that the social taboo surrounding these issues is perpetuated in scientific research and HIV prevention campaigns. This is a challenge for health managers and communicators, as sexuality is an important dimension of life, encompassing biological, psychological, social, cultural and historical aspects, and is directly linked to the human right to sexual and reproductive health23.
Figure 1

Another fact to highlight in relation to the primary category is the paucity of information about condoms. The sentences are almost always imperative to use them, but in the period analysed, only in two video pieces - the 2016 and 2022 World AIDS Day campaigns - is there information about condoms, stating that it is ‘the simplest form of prevention’ and that there are ‘male or female’ condoms. The posters say that condoms are free and that it is everyone\'s responsibility to use them (Figures 2 and 3). However, there is no information about safety, materials, available sizes, the importance of combining them with lubricant, etc.
The results give an indication of why there is a lack of knowledge about condom use among young people, as has been found in other studies24,25. This target group would like to broaden their range of information on sexuality and prevention, but they stress that there is a shortage of information and that the media is not a source of information that can satisfy their curiosity and doubts, as it does not go into depth, contextualise or approach the subject in a complete way. In addition, the messages are not very didactic or informative, with a language that is difficult to understand and that assumes prior knowledge of prevention24-26.
Figure 2

This becomes clear when we look at the occurrences of PEP and PrEP in the pieces, as they literally appear as if by magic. Regarding PEP, it is called post-exposure medication in the audio, poster and video from the 2016 World AIDS Day campaign, where the only information about it is given as follows: ‘PEP? Yes. Post-exposure medication. You have to take it within 72 hours of having sex to prevent HIV infection, right? It\'s already a kind of treatment’. As far as PrEP is concerned, it has been included on campaign posters alongside PEP since 2016. However, it only appears four times, and the only instance of advice is found in the 2018 World AIDS Day video: \'Ask your doctor about PEP and PrEP\'.
As for the secondary category, most communications focused on testing, which was mentioned in over 60% of products analysed in this category. Treatment comes in second place with 34% of communications, and prenatal care comes last with only 6%. The urgency and superficiality of the information on these topics are the same as in the primary prevention category. The emphasis of the information in the messages about the test is that it is ‘free, quick, safe and confidential’ and that you should go to a health centre. In 2013, the campaign emphasised the importance of testing for early detection. Self-testing was only mentioned in the 2022 campaign.
Figure 3

Testing is directly linked to Treatment as Prevention (TasP), because by starting ART immediately after a positive test and achieving viral suppression, people with HIV infection stop transmitting it to their sexual partners27-29. However, this information is not explicitly communicated in campaigns. In addition, research shows that in people\'s perceptions of their use of the test, this motivation was rarely considered to characterise testing as a prevention and care routine30. This is one of the challenges for health managers and communicators, as there is a prevailing overlap between prevention and care, suggesting that biomedical knowledge and practices are given greater weight. This perspective runs counter to the social determinants of HIV and AIDS - particularly stigma and discrimination - and ignores the participation of activists and people living with HIV or AIDS who know and practice prevention29.
Another barrier is treatment adherence and retention. This issue was addressed in the 2015 World AIDS Day communication campaign with statements that treatment is not easy, but necessary to maintain health and quality of life. Once again, the issue was presented in a superficial, uninformative way and without addressing the social determinants31. Although treatment is provided free of charge by the SUS, for it to work people need to have access to it and follow a healthy diet. However, many people living with HIV or AIDS are unable to access antiretroviral drugs from health services because they do not have the money to pay for transport, for example, or if they do access them, they find it difficult to use them because they do not have food32. Later on, we will look at issues related to viral suppression and non-transmissibility, which are also not addressed in the campaigns.
The rarity of pieces on HIV prevention in antenatal care is surprising. Of all the items analysed, only 6% addressed this issue. The elimination of vertical transmission of the virus has been a goal of the World Health Organisation since 2011. This topic is fully in line with the concepts and practices of secondary prevention, but it is still poorly disseminated in Ministry of Health campaigns and among pregnant women and health professionals. In the case of pregnant women and health professionals, this restriction is linked to fear of diagnosis, stigma, drug use and lack of professional qualifications34,35. Finally, it is during antenatal care that testing, monitoring - in the case of pregnant women living with HIV - and the necessary preventive or therapeutic care take place, preventing vertical transmission and ensuring the quality of life of pregnant women and children36. Once again, there is a possible link between the lack of approach and information in the campaigns and the behaviour of the population.
Looking at the third category, there was a large gap with regard to tertiary prevention, as it only appeared in 8% of the pieces and only in the 2015 and 2018 campaigns. When analysing this category, it was assumed that messages aimed at avoiding stigma and prejudice and promoting respect fall under the concept of tertiary prevention, because without these barriers and with respect for the rights of people living with HIV or AIDS, it is possible to treat and control the HIV infection so that they can achieve viral suppression and non-transmissibility27,28. This can guarantee an improvement in their quality of life, allowing them to work, play sports, have sexual relations, start a family, among other human experiences.
In 2015, the issue of respect for diversity was mentioned in an audio for a campaign aimed at the Gay Parade in São Paulo. In 2018, the intervention addressed the 30-year history of the HIV and AIDS epidemic and included the phrase ‘Fight stigma and prejudice with correct information and positive attitudes’ on 5 posters. These were the only times that these issues were addressed in the pieces. It should be noted that audios and posters are the second and third products of communication campaigns, as the main piece is usually the video, as it includes visual, graphic and auditory elements and is considered more complete in terms of communication.
The literature on this subject is as nascent as the approach to it in HIV and AIDS campaigns in Brazil37. However, stigma and discrimination are so strong in society that 81% of people living with HIV or AIDS interviewed in a national survey said that in the 21st century it was still very difficult to reveal that they had HIV infection. These people also reported that they had been victims of discriminatory comments and gossip (46.3%), lost income or jobs (19.6%) and even been excluded from family activities because they had HIV (17.3%)38. Discrimination against this population in the workplace is still a reality in Brazil, with both visible effects - loss of financial independence, informality and inability to participate in public tenders - and invisible effects - difficulties in reintegrating into the labour market, social isolation and the development of mental health problems39.
Stigma and discrimination, as well as disregard for the rights of people living with HIV or AIDS, are reflected in other forms of violence against them, particularly structural40,41 or symbolic42,43 violence, which also occurs in health care settings. Given the organisational logic of the SUS and the expanded role of this level of care in the care of people living with HIV, particular attention should be paid to primary health care. Various issues can compromise or improve care practices, such as inequalities in access to diagnosis and treatment due to urban violence and gender relations in a context of intersecting vulnerabilities and strong stigma44. Nevertheless, there are sufficient public policies for comprehensive health care and the protection of people\'s rights. To this end, it is necessary to expand access to education, including vocational training, which will lead to greater protection and care for people, thus avoiding an increase in vulnerability45. In this context, communication campaigns have immense potential and are necessary for tertiary prevention and the promotion of human rights.
With regard to the quaternary category, a total of 34% of the pieces analysed dealt with combination prevention or \'all forms of prevention\' of HIV and AIDS. According to the Brazilian Ministry of Health, this prevention strategy makes simultaneous use of biomedical, behavioural and structural prevention approaches applied at different levels - individual, relational, community, etc. - in order to respond to the specific needs of certain population groups and certain modes of HIV transmission9,46. Combination prevention is therefore part of quaternary prevention, especially in terms of providing alternatives to condoms48. However, this is not mentioned in the campaigns. Again, there is no information - either for the general population or for health professionals - about what it is, how to do it and what it means.
Combination prevention has enabled the expansion of biomedical technologies for prevention, but the availability of these technologies alone is not enough, because access encompasses much more than that. As Ferraz47 pointed out, we need to return to the pillars of comprehensive health care, the defence and promotion of human rights and social mobilisation. The pieces analysed make extensive use of the catchphrase \'Shall we combine?’, but always in the individual sphere and linked to biomedical interventions. This is in line with the findings of Lucas, Böschemeier and Souza. They note that the conditions that increase people\'s vulnerability to HIV, the one-off policies and programmes, inequalities in access to health services and social support, the global financial crisis and the persistence of HIV-related stigma and discrimination have not been sufficiently overcome to promote greater involvement of people living with HIV and key populations in social and health policies48.
As in the previous categories, there are many information gaps in the communication campaigns on combination prevention. In 2016, the strategy was covered for the first time in the materials analysed. A 1-minute 30-second video from the 2016 World AIDS Day campaign - very rare in campaigns, as they use the commercially established standard length of 30 seconds - showed a dialogue between two young people about different ways to prevent HIV. Once again, we see different biomedical interventions isolated from each other, which are described as other levels of prevention, but which differ from the concept presented by the Brazilian Ministry of Health itself. Structural and behavioural interventions - directly linked to social determinants - are completely absent49.


 
CONCLUDING CONSIDERATIONS

The categorisation of HIV prevention approaches and technologies by levels - primary, secondary, tertiary and quaternary - can provide the population with greater understanding to choose how to prevent HIV and AIDS in different contexts. However, the results of this analysis show that the Brazilian Ministry of Health mainly promotes primary and secondary prevention strategies, with a view to encouraging the use of barrier methods, mass testing and treatment as prevention. However, it still shows difficulties in promoting campaigns on tertiary and quaternary methods, mainly because they involve interventions that go beyond the biomedical and are related to the social determinants of health.
Another fact that stands out in all the pieces analysed is the superficiality of the information, which even contradicts studies - especially those on knowledge, attitudes and practices - that state that communication campaigns play an important role in acquiring knowledge about forms of prevention. Campaigns - as a health communication strategy adopted with the aim of providing information for HIV and AIDS prevention - need to be evaluated so that they can be improved, especially for the prevention of HIV and AIDS among key and priority populations for infection and disease.
A possible limitation of this analysis is the time frame of eleven years, as it only analyses part of the campaigns that were broadcast during the HIV and AIDS epidemic in the country. In addition to a study evaluating HIV and AIDS campaigns, it is extremely important to conduct comparative studies with countries that have a similar health care system, including social and environmental determinants of health.


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