Gender, Sexuality, and AIDS in Brazil: Transformative Approaches to HIV Prevention

Gender, Sexuality, and AIDS in Brazil: Transformative Approaches to HIV Prevention

Daisy Deomampo
Department of Anthropology, The Graduate Center,
City University of New York

To accurately discern regional patterns of HIV/AIDS transmission one must exceed the fields of knowledge circumscribed by biomedicine; it is imperative that the social, political and economic aspects of the epidemic be taken into consideration. As researchers began to investigate the importance of cultural systems in shaping sexual practices relevant to HIV, emphasis on the structural factors shaping vulnerability to HIV infection emerged. In Brazil, the AIDS epidemic offers “an especially vivid example of how powerfully sexual culture can shape even the most apparently biological dimensions of sexual life, while, at the same time, how fundamentally historical the patterns of culture in fact are” (Parker 1991:167). By examining gender, sexuality, power and inequality in Brazil anthropologists have made important contributions to a growing body of literature that elucidates the complexities of sexual negotiations between men and women (see Barbosa and Parker 1999; Dore 1997; Goldstein 2003; Gregg 2003; Parker 1991, 2001; Parker and Barbosa 1996; Parker and Gagnon 1995).

This paper aims to build on current public health and anthropological approaches that call attention to the interconnected set of concerns that have become prevalent in the field of HIV research (e.g., Farmer 1992; Susser and Stein 2000). Following an analysis of HIV/AIDS and the interaction of gender, sexuality, inequality and power in Brazil, I will examine how gender stereotypes advanced by HIV interventions and the media run counter to local realities, often resulting in inadequate and ineffective programming. I argue that effective responses to HIV/AIDS must be both culturally specific and transformative. Following Leith Mullings (1996), I assert that effective HIV prevention programming must entail a transformative or revolutionary approach that aims to reform class, race and gender inequities.
HIV/AIDS in Brazil

A comprehensive understanding of AIDS in Brazil must take into consideration the nation’s social and economic history; in the last three decades Brazil experienced intense political and economic upheaval, growing inequality, and rapid urbanization. AIDS surfaced in Brazil in the early 1980s alongside the fall of the military dictatorship, and the disease’s spread coincided with the country’s democratization in the midst of a devastated economic and social welfare system. Brazil remains one of the most unequal societies existing today: the poorest one-fifth of Brazil’s 182 million people earn less than three percent of the national income, and the country is second only to South Africa in a world ranking of income inequality (World Bank 2006). Between 1970 and 2000 the share of urban dwellers living in the coastal cities of the Southeast and Northeast increased from 58 to 80 percent (Da Mata et al. 2005) and initial reports showed that AIDS was most prevalent in urban centers among men who had sex with men, including transgendered prostitutes (Biehl 2004; Kulick 1998). Within this context of rapid urbanization and impoverishment in Brazil, and rising rates of HIV infections around the world, the Brazilian government prepared to mount a nationwide campaign to curb the spread of HIV/AIDS.

In 1992, the World Bank predicted that by the year 2000 there would be 1.2 million Brazilians infected with HIV. That same year, the World Bank approved a significant loan of US$250 million for the creation of a new national program that was supposed to control what many health experts were calling “the Africanization of AIDS in Brazil”1 (Biehl 2001; Levinson et al. 2004). The National AIDS Program (NAP), together with AIDS activists, politicians, economists, and scientists, organized an impressive governmental and non-governmental response that is believed to have contained the epidemic’s growth through community-mediated prevention projects that focused on condom distribution, HIV testing, and behavioral change among so-called high-risk groups. Here, grassroots and regional state interventions were not antithetical to each other and shared a progressive political commitment (see also Galvão 2000 for an examination of the Brazilian response to AIDS from 1981-1996). In 1997, the Brazilian government began to provide free antiretroviral drugs to all of the country’s registered AIDS cases (Biehl 2004). Since then, a relative stabilization of AIDS incidence has occurred and Brazil entered the 21st century with an estimated 620 thousand people living with HIV/AIDS (UNAIDS 2006). The Brazilian response to AIDS was widely touted as a model for challenging the perception that it is impossible to stem the pandemic’s course in low- or lower-middle-income countries.

Yet many researchers questioned the utility of a ‘model’ that can be uncritically applied in other contexts. Indeed, an important lesson from the Brazilian experience is that there is no homogenous HIV/AIDS epidemic nor a universal approach to addressing it (Berkman et al. 2005). As well, although the quality of life of people in Brazil living with HIV/AIDS has been improved by free and widespread distribution of antiretroviral treatment, many are highly critical of the National AIDS Program. Such criticisms recall Bourdieu’s concepts of habitus and practice. Despite ideals of governmental and non-governmental organizations for the Brazilian population in general, the realities of practice reveal the constraints of culture and an individual’s social history, where structural inequalities incorporated into an individual’s habitus do not always result in AIDS “success stories” as commonly as is assumed.

Gerson Winkler, coordinator of the AIDS program in Porto Alegre in 1995, challenged the perceived successes of Brazil’s AIDS management (in which he was also involved):
It’s a big lie. What is really at stake is the making of a clear division between the ones who have access to the financial and medical provisions of the AIDS world and the ones who don’t. Poor people are lost in the fight for access. The machine does not absorb the demand. It is a fictional government. [Biehl 2001:131]

Winkler led João Biehl, an anthropologist studying the impact of AIDS strategies among the poorest in urban centers, to Vita, an insecure rehabilitation center for drug addicts and alcoholics that soon became a haven for the homeless, mentally ill, and dying persons to await their eventual deaths: “You must go there. It’s the deposit of life’s leftovers. You will see what being human in this land is becoming, what men do to men” (Biehl 2001:131-132). Despite the evident successes of Brazil’s HIV/AIDS prevention and treatment projects, Biehl reveals how the poorest remain socially abandoned:
The abandonados in Vita are the carriers and witnesses of the ways in which social destinies of the poorest and the sickest are ordered. The experience of these who live in such a dead space/language is traversed by the country’s structural readjustment, unemployment, malfunctioning public health system, and infamously unequal distribution of wealth and technology. Brazil’s welfare system has been historically structured in such a way that the state’s intervention varies according to the population segment claiming social protection. Citizenship has been conceived as universal for the minority rich, regulated according to market inception for the working class and middle class, and denied to the majority of poor and marginal populations. [Biehl 2001:136]

The reach of Brazil’s HIV/AIDS projects, then, did not always extend to those most affected by poverty and marginality, and increasingly, anthropologists such as Biehl have sought to reveal and address such disparities.
The role of gender and sexuality

These emerging criticisms took shape at a moment when the epidemic began to display vast gender differences, with HIV/AIDS spreading six times faster among teenage girls than boys. At the start of the epidemic, AIDS was most prevalent in cities among men who had sex with men, yet this epidemiological profile would quickly shift. In 1983 there were 40 men for every woman with AIDS; in 1990, the ratio was six to one; in 1996, the ratio was three to one; today, it is almost one to one (Biehl 2004). AIDS has been the leading cause of death in women aged 25–34 in São Paulo municipality since 1993, and accounted for 20 percent of deaths in women of this age group in 1994. In the same year, AIDS became the third leading cause of death in women aged 25–34 in Rio de Janeiro municipality (Giffin and Lowndes 1999).2 Despite the significant number of AIDS cases averted by free distribution of antiretroviral treatment, the increasing rate of HIV infection among girls and young women demands a more socially nuanced examination of the cultural context of sexual relationships and local perceptions of risk.

A number of factors contributed to the rapid transformation of the male/female ratio, including the cultural construction of sexuality in Brazil. Here, sexuality is defined in symbolic terms of sexual activity and passivity rather than on homosexual identity (see Parker 1991 for more information on the cultural construction of male sexuality). This self-definition enables self-described heterosexual men to engage in homoerotic sexual activity without explicitly identifying themselves as homosexual or publicly acknowledging these activities. At the same time, despite Brazilians’ celebration of sexuality in general, there exists a well-developed homophobia and aversion toward homosexual men. The combination of this culturally inscribed definition and homophobia has created a situation where in reality, a considerable proportion of men are sexually active with both men and women yet define themselves publicly (and to their female partners) as exclusively heterosexual (e.g., Barker 2000). With regard to hegemonic Brazilian masculinities, this construction of sexuality also characterizes the “activity” of men and the “passivity” of women, and the predominance of the sexual agency of men over the sexual agency of women (Parker 1991:41).

By framing these issues within the public discourse on AIDS and sexuality, Donna M. Goldstein (1994) shows how the actual private discourse of low-income urban women in Brazil remained relatively untouched: contradictions in public AIDS discourse protected male sexual freedom in the name of sexual freedom for all, while women’s sexuality, sheltered in the private sphere, remained unchanged and locked into Brazilian cultural norms. In the struggle to protect citizen’s rights to privacy and sexual freedom, Brazilian female citizens lose the discursive right to question a pervasive set of double-standards surrounding sexuality (Goldstein 1994). This holds enormous implications for AIDS prevention and education programs, demanding a re-examination of conventional programs originally designed for and addressed to homosexual men and drug users. This, too, raises questions surrounding popular conceptions concerning who is at risk, revealing the difficulties of teaching prevention strategies to heterosexual women who are naïve about their risk because they are unaware of or unable to openly acknowledge their male partners’ sexual practices.

While there are numerous and complex reasons for the increase in heterosexual transmission and cases of AIDS among women in Brazil, the popular notion that vulnerability to HIV must be linked to female promiscuity is inaccurate. One study among HIV-positive women in São Paulo, for instance, found that HIV entered the lives of most women through only one sexual scenario: 77 percent were infected by their steady partners, either current or past. Of all the women who participated in the study, 37 percent of women reported male partners who were intravenous drug users, 21 percent reported male partners with multiple female partners, 6 percent reported male partners who were bisexual, and 2 percent reported male partners who had other partners (sex unknown). Only 6 percent of the women reported multiple male partners, and 6 percent reported their own injection drug use as the source of infection. Almost all of the sexually active women were monogamous: 92 percent had one steady partner at the time of the interviews (Santos et al. 1998). Other studies completed in São Paulo and Rio de Janeiro confirm similar trends, again revealing the inadequacy of prevention programs that recommend decreasing the number of sexual partners and use of the condom (Giffin and Lowndes 1999; Paiva et al. 1998). These studies demonstrate that many women simply cannot diminish the number of their sexual partners because they are already monogamous, and, due to gender norms surrounding condom use, they cannot insist on condom use without risk of conflict, suspicion of unfaithfulness, or violence (Paiva 1993).

These issues are of particular salience to young men and women. A recent study on the gender dynamics of condom use among high school teenagers in Salvador, Brazil, explored cultural and psychological issues involved in condom use (Levinson et al. 2004). In all the girls’ focus groups, the discussion revealed difficulties and fears related to obtaining, discussing, and carrying condoms. The majority of the girls could not imagine talking with their parents about anything related to sex and they strongly agreed that they would never tell the truth about carrying condoms because of boys’ negative reactions. Unfortunately, these perceptions were confirmed by what the boys confessed they do think when they realize that a girl carries condoms; one boy noted that, “[t]he deal is this: if she asks that we use one, we will do it, but if she has it in her pocketbook, it makes her into a slut” (Levinson et al. 2004:217).

These trends were complicated further by the culture of contraceptive use that developed in Brazil largely due to certain family planning programs geared toward women. These programs traditionally sought to circumvent barrier methods perceived to interfere with the sexual act or to demand negotiation between men and women, opting instead for oral contraceptives that would largely avoid any necessity of communication between sexual partners. This existing contraceptive culture has presented particular problems when promoting condom use as an effective means to HIV/AIDS prevention, while maintaining structures of gender power relations that render women without the capability and skills to negotiate effectively with their male partners. In effect, when a husband knows that his partner uses oral contraceptives, her possibilities for suggesting condom use are all the more restricted.

Thus, emphasis on the interaction of gender, sexuality, inequality and power imparts a profound understanding of how to develop more effective program interventions that take into account the context of an individual’s reality in bringing about behavior change. Indeed, over the past decade social science research increasingly has come to identify the role of gender in determining individual risk and vulnerability in the HIV/AIDS pandemic. Many scholars and activists have documented that sociocultural norms about masculinity and femininity, and the unequal balance of power between men and women that arise from these norms, restrict women’s access to productive resources such as income, education, and credit. In turn, such norms increase men’s sexual freedom, and therefore combine with biological and physiological factors to compound individuals’ risk of infection (Rao Gupta 2002).

In her ethnography Virtually Virgins, Jessica L. Gregg (2003) describes the sexual strategies used by Brazilian women in attempts to reinterpret the hegemonic cultural model of female gender and sexuality, which constructs Brazilian women as hyper-sensual, a dangerous condition that renders them in need of male control, particularly given the value attached to virginity and female fidelity. This model delineates the various social expectations for women that Gregg suggests are “two sides of the same coin” (2003:33). She argues that, “[w]hile one dominant system of logic in the Brazilian sexual universe stresses and idealizes the extreme sexuality and sensuality of the female population, another focuses on sex as shame and virginity as virtue” (Gregg 2003:32). Thus, because all Brazilian women are expected to be more sensual than women of other cultures, male control of female sexuality is necessary. The following section will elucidate the ways in which media and health interventions address these conceptions and powerfully influence their effectiveness in improving health outcomes.
Contradictions in HIV/AIDS discourse

As social scientists set out to address gender hierarchies in HIV/AIDS research, increasingly crucial is an examination of the role of language and the way that words serve to enact and reinforce deeply entrenched, pervasive, and often conservative cultural constructions about gender in HIV/AIDS discourse. The pandemic is inextricably bound up with political, economic, social and cultural factors that influence rates of transmission, and it is crucial that we take into account the nature of language and its enormous power to generate meanings outside of our control. In popular media narratives as well as in prevention programs, what is said and what is left unsaid shape how the HIV/AIDS epidemic is imagined, experienced, and contested.

The impact of such meanings generated by HIV/AIDS discourse is evident in AIDS awareness campaigns launched in the late 1980s and early 1990s by both Brazilian and non-Brazilian organizations, which are now considered to have been largely ineffective because they did not place enough emphasis on the sociocultural context in which heterosexual relations take place. These programs were directed toward the general population, and often proved to be problematic. For instance, the public AIDS messages presented during this period by the Brazilian Ministry of Health was based on slogans such as, “If you’re not careful enough AIDS will catch you” or, “Just looking at a face, you cannot see AIDS” (Ramos 1988:6), providing no helpful tools or strategies with which to avoid infection. In fact, such messages often served to create or reinforce fatalistic attitudes: as one boy put it, “After all, if I’m going to catch it, I’ll catch it anyway, there’s nothing I can really do about it” (Paiva 1993:109).

Sometime after 1992, subsequent prevention programs allowed medical professionals, the political elite, and other powerful groups to impose their own culturally constructed judgments of risk on the general public. These programs were developed partially in response to the shifting priorities of international funders and partially with the objective of ‘controlling’ HIV through provision of information, education, and communication to ‘at risk’ groups, which in Brazil comprised homosexual men, commercial sex workers, and intravenous drug users. HIV seropositives thus became ‘victims’ of their own ‘risky’ behavior. This model of AIDS education, however, functions only where men assume homosexual identities and acknowledge their risk behavior, or where women have power to negotiate safe-sex practices. What does the gay-identified and male ‘First World’ model, focusing exclusively on condom literacy and safe sex, offer to low-income Brazilian women who face the task of demanding that their husbands or partners use a condom? Again, the ongoing increase in infection of women due to heterosexual contact and the gender-hierarchical nature of sexual interactions reveal the need to examine the cultural context of sexual relationships.

Acknowledgment of such contextual factors did not enter the discourse until recent years. As the seemingly neutral epidemiological term ‘risk group’ gained increasing importance in public discourse in the 1980s, most interventions were directed entirely toward one single behavioral act: that of putting on a condom. In her analysis of the representation of sexuality and HIV/AIDS in three Brazilian women’s magazines, Cristina Cavalcanti (1995) shows how in their various approaches to safer sex, each magazine put the burden of HIV prevention entirely on women’s shoulders. Disregarding the potential perceptions of women who attempt to introduce condoms into a relationship as unfaithful, not trusting of their partner’s fidelity, or even HIV-infected, these approaches neglected to account for risk of conflict, violence, and loss of economic support that women face. Despite the fact that many researchers recognize women’s subordination as directly contributing to their vulnerability to HIV, the press failed to point to this as a factor to be taken into consideration in public health policy.

The Brazilian edition of the French magazine Marie Claire, for instance, projects a “liberated,” autonomous woman who is well-educated, independent, and fully capable of imposing on their partners the values of safer sex. With this construction of the ‘ideal’ woman, it is not surprising that there is no mention that negotiating safer sex can be difficult and that women face their own lack of power in a relationship when they attempt to do this. On the other hand, Claudia—a women’s magazine inspired by Good Housekeeping—centers women’s identity around the roles of spouse, housewife, and mother. Through this lens of domesticity, AIDS is viewed from a distance and kept far from the perceived security of one’s marriage and home: “You may be thinking to yourself: ‘This does not concern me.’ And it doesn’t. But it could be a problem for one of your friends, who is newly divorced” (Cavalcanti 1995:48). As Cavalcanti points out, such representations reveal one of the most difficult challenges of HIV/AIDS prevention campaigns, that is, how to present this subject to married and monogamous women (see also Bond et al. 1997 for further discussion of these challenges in Africa and the Caribbean). Cavalcanti asks, “How can the idea of safer sex be introduced into a relationship that is, in itself, synonymous with security? How is it possible to express a lack of trust within a marriage or stable relationship without destroying the very trust on which the relationship is supposed to be based?” (1995:48). Unfortunately, Claudia neither considers these questions and nor offers strategies for the negotiation of safer sex.

In contrast, media representations more recently have shifted to portray these women as unlucky victims, ill-informed and disempowered. Veja, a popular Brazilian weekly news magazine, published a special report in 1998 in which various photos of women appeared alongside the headline, “Sleeping with the Enemy,” together with their quotes in large letters: “I got AIDS from my husband,” and below, “Dramatic stories of women who were infected by men they trusted blindly” (Bessa 2002:337, emphasis added). These stories aimed to horrify and shock their primarily female readers. At issue here is the way in which such dramatizations tended to essentialize women’s identities as unwitting and passive victims, failing to provide nuanced examinations of the textured realities of women’s lives and perpetuating fixed portrayals of women.

Such inaccurate and static representations of Brazilians’ sexual realities reflect the urgent need in Brazil to develop AIDS narratives that address the social construction and dynamics of sexual relationships between men and women, incorporating local perceptions of these relationships (see also Klein 1996 for a discussion of Brazilian mass media narratives related to HIV/AIDS). The following section will elucidate the ways these narratives may then reveal and threaten the underlying gender and sexual power relations that structure everyday life, thus changing the course of AIDS.
Transformative approaches

Gradually, public health practitioners found that many prevention programs and media representations were not significantly changing sexual conduct because individual behavior was greatly influenced by the specific contexts within which they took place. Thus, research efforts were redirected to examine the gender-related economic and socio-cultural factors that contribute to women’s and girls’ vulnerability to HIV. The objective was to gain deeper insight into the dynamics of sexual interactions and sexual experiences; that is, what motivated these interactions and who controlled the outcomes. Specifically, how and why do women acquire information about prevention and how do they act upon the information? (Giffin and Lowndes 1999).

It is important to acknowledge that hierarchies of power affect not only women’s freedom to make decisions, but also men’s risk of infection. As anthropologists began to listen to boys and men who have sex with men discuss the pressures to be heterosexual, to have multiple partners, to be sexually adventurous and assertive, to be knowledgeable about sex, and to be self-reliant and never ask for help, it became apparent that gender norms and structures negatively affect both men and women and increase the vulnerability of both. Incorporating a gender analysis into HIV/AIDS discourse, then, means dissecting the ways in which women and men relate to each other, how both women and men reinforce traditional gendered structures and enforce sanctions against ‘noncompliant’ individuals, and how men and women submit to gender norms of sexual behavior – which are harmful to all in the context of increasing HIV infections (Rao Gupta 2002).

In his study of more “gender equitable” young men in a low-income setting in Rio de Janeiro, Gary Barker (2000) considers the implications for working with boys to promote gender equity, including increased attention to sexual health. While a number of initiatives emphasize the empowerment of women, many women’s rights advocates increasingly acknowledge that improving the health and well-being of women generally requires engaging men. Barker poses several vital questions for improving the health and well-being of women and men:
How can some of the harmful aspects of certain traditional versions of masculinity be changed? How can we promote more gender equitable attitudes among young men? How can young men be encouraged to assume greater responsibility for reproductive and sexual health issues, to be more involved with the children they father, and to show greater respect in their relationships with women? [2000:264]

In the context of the AIDS epidemic, these questions have particular salience where there is increasing consensus that men’s participation is crucial in HIV interventions that challenge the gender status quo.

After mapping the various versions of masculinity present in his study, Barker suggests that no single variable enabled any young man to become more gender equitable. Rather, a combination of interacting variables (including those personal and family-related, and social environmental factors) and an individual’s subjective meaning given to life experiences created a path to a more gender equitable identity. Regarding the implications for prevention and education programs perhaps most significant is the fact that these young men assist in overcoming widely held myths about the “nature” of men as callous and predatory (Barker 2000:279). Indeed, they indicate the great potential of approaches that aim to transform underlying structures of gender hierarchies.

Vera Paiva (2000) outlines a prevention program that engages with both young men and women that considers the social and cultural norms surrounding condom use, sexuality and gender. In her ongoing work with young people in São Paulo, Paiva found that social vulnerability consistently compromised the efficacy of AIDS prevention programs. These realities led her to ask the following questions: “How should an AIDS prevention program address social and cultural factors that shape and regulate ‘risky’ sex? How can AIDS prevention programs go beyond a focus on behavioral change and individual responsibility?” (Paiva 2000:217).

These questions guided the development of a theoretical framework for the AIDS prevention programs developed with teenage students at public elementary night schools in São Paulo. Based on the tradition of Latin American liberation theology, the framework seeks to promote citizenship while encouraging sexual agency. Four concepts are key: (1) the sexual subject (from the Portuguese term sujeito); (2) consciousness-raising or “conscientization” (from the Portuguese conscientização); (3) gendered scripts and bodies (i.e., the way social context shapes gender systems); and (4) the sexual scene (i.e., the social and cultural contexts in which sex occurs).

The main objective of the prevention program was to promote the sujeito sexual (“sexual subject”), the “agent who regulates his/her own sexual life, coping with the complexity of factors competing in his/her life that can result in either ‘riskier sex’ or ‘safer sex’[...]The sujeito is one who takes action, one who enacts” (Paiva 2000:218). One way of promoting sexual subjects draws on the Freirean tradition and compels the group to deconstruct their own sexual scenarios through “consciousness-raising” and “coding and de-coding.” The concept of conscientização in the Brazilian liberation education tradition situates the “self” within a social group; therefore consciousness becomes more than simply “awareness” but also about citizenship. This provides an important way to respond to the powerlessness and fatalism often felt by the students, whose disproportionate social vulnerability tended to ruin their awareness achieved during the workshops, as indicated by student comments: “I can’t have a choice, destiny will choose for me, I see what I can do with it afterwards” and “AIDS is just another burden, why bother? To survive in this crazy and difficult world, and have some fun with sex is the only right I have” (Paiva 2000:219).

One response to this sense of powerlessness and fatalism is to help participants deconstruct how social cues regulate their sexual lives, and to highlight how social factors can discourage attempts to practice safer sex and control their own sexual lives. Concurrently, collaborative group activities help participants to work through the confusing obstacles in various sexual scenes, while contributing to a sense of responsibility. For example, in one group activity students modeled erotic and reproductive body parts from dough, decoding the gendered sex education traditionally received at home and at school:
Through this group activity, they learned about HIV transmission and about reproduction, and by talking about sex through highly concrete body parts rather than through complicated science classes enacted on blackboards, they deconstructed sexist education and gender culture, and explored the pluralism of pleasures and morals. In discussion about communication with partners, and about other obstacles to enacting their risk-reduction intentions, they also created “sexual scenes” through which they decoded gender relations and sexual scenarios, passive/active relations, and the socio-economic contexts where sex occurs. [Paiva 2000:220]

This process built on the transformative approach outlined by Paulo Freire (1993) in the tradition of Latin American liberation pedagogy. Here, access to education and literacy is key to “breaking the silence of the poor” but can only be achieved through valuing popular language and relevant themes. Literacy programs that used popular language as codes proved a successful way to give access to reading and writing. In the context of reproductive rights and AIDS movements, liberation pedagogy takes new forms with workshops and small groups used within health education programs to discuss desire, intimacy, and gendered bodies, to de-construct and re-construct identities, and to fight violence and discrimination. Through coding and decoding “sexual scenes” individuals can address how different sexual scripts are enacted in different scenes, taking into consideration that these scripts are learned quite differently depending on whether one is a girl or a boy. Too frequently, ‘gendered scripts’ limit the power and agency of the sexual subject. The transformative approach of coding and decoding each context provides opportunities to challenge these scripts. AIDS, sexual meaning, power hierarchies, and gendered scripts must be codified and decodified in order to highlight the internal contradictions in each sexual culture. These contradictions in turn create opportunities for agency, for individual and group cultural innovation, and transformation (Paiva 2000). This model of a successful, interactive AIDS education program resulted in attitude changes showing more flexible values concerning sex and traditional gender roles, more confidence in the reliability of condoms, and broadening of risk perception. Rather than depending on depoliticized models of behavioral change, Paiva notes that real AIDS prevention demands a new pedagogy and activist wisdom.
Concluding thoughts

The logic of HIV distribution is entangled within broader systems of inequality. Therefore, messages about AIDS prevention and international campaigns on AIDS and stigma are valuable only in so far as they challenge the prevailing power structures. Just as the AIDS epidemic in Brazil is shaped by systems of sexual meaning and inequality discussed in this paper, it has itself profoundly influenced changes presently taking place. Questions related to sexuality have never been raised as vividly as in the discussions surrounding AIDS. As the research discussed in this paper suggests, there are already signs that issues raised by HIV are reshaping conceptions of sexuality in contemporary Brazilian life. AIDS has provided a focus for social activism, which has demanded greater social justice and more effective medical and social services. The positive impact of these progressive social forces draws attention to the fact that gender inequality and sexual oppression are not unchangeable facts of nature, but “artifacts of history” (Parker and Easton 1998:14). The Brazilian response to HIV/AIDS illustrates that structures of inequality, which so often organize the sexual field like other forms of injustice, can be transformed through international action and enlightened policy initiatives.

1 In 1991, “pauperization” and “Africanization” became buzzwords used by the media to describe HIV/AIDS in Brazil. The concept of Africanization of AIDS in Brazil was based on the patterns of transmission defined by the World Health Organization. When some women started to become sick, the media declared that the epidemic had changed from pattern I to pattern II, which was linked with stereotypes associated with poverty, poor hygiene, and promiscuity, rather than with transmission associated with particular “risk groups” (e.g., homosexuals, injecting drug users), then dominant all over the world except in Africa. The expression gave in to derogatory racial connotations and is now widely dismissed by researchers on the basis of ideology and biology (Bastos 1999).

2 See also the Brazilian Ministry of Health’s website:

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