Maíra Menezes (IOC/Fiocruz)
The first thesis developed under the system of international co-supervision research at the Graduate Program in Tropical Medicine of the Oswaldo Cruz Institute (IOC/Fiocruz) shed light on an important public health problem: The spread of HIV at the border between Brazil and French Guiana. Through data collection and interviews, the study highlighted factors that contribute to the virus infections and AIDS cases.
Flávia gave a lecture to residents of Oiapoque, at an event promoted by the Health Department. Research identified the population's difficulty in accessing information about the disease (Photo: Personal collection)
The research was carried out by biologist Flávia Divino, who took her doctorate at the IOC and at the University of Guiana, in French Guiana. The thesis was supervised by researchers Paulo Peiter, from the Institute's Laboratory of Parasitic Diseases, and Mathieu Nacher, from the French-Guyanese university. For the thesis defense, Flávia received two doctoral degrees: One in Tropical Medicine, from the IOC, and one in Diversities, Health and Development in the Amazon, from the University of Guyana.
An important initiative for the internationalization of education at Fiocruz, the co-supervision allows for the double degree of students who develop their graduate studies at the Foundation and in foreign institutions, through cooperation agreements. “The co-supervision is different from a sandwich or an internship because you are a student at both institutions. In the research, co-supervision opened doors for both sides of the border. At the same time, it has made it possible to learn a new language, take courses at the University of Guyana, and to live with doctoral students over there. I had many opportunities”, celebrated Flavia, who also received a residence permit from the French government after finishing her thesis, with authorization to work in the country until 2026.
With experience in the study of health at the borders, Paulo Peiter points out that the results achieved in the thesis became more robust with the co-supervision system. “The great difficulty in studying health at the borders is obtaining data from both sides. Cooperation between institutions, through co-supervision, was key to access information and carry out fieldwork in French Guiana. Carrying out the same study in both countries allowed us to understand the dynamics of HIV/Aids in that region”, points out the researcher, who is part of the project ‘Cross-border Observatories for the Environment, Climate, and Vector-Borne Diseases – International Mixed Laboratory’ (LMI Sentinel), maintained in a partnership by Fiocruz, University of Brasília (UnB), and the Research Institute for Development (IRD), from France.
The research was carried out in the cities of Oiapoque, in Amapá, and Saint Georges de l'Oyapock, in French Guiana, located on opposite sides of the border and separated by the Oiapoque River. To carry out the study, Flávia lived for six months in the Brazilian city and two months in the French commune. The research included a survey of HIV and AIDS records, mapping of health services, analysis of medical records, observations of activities in the services and the daily life in the cities, and interviews with health professionals and the population.
The fieldwork also included the region of Vila Brasil, a village located 6 hours by boat from Oiapoque, which concentrates the circulation of people and commerce related to mining. The activity, which is mostly illegal, usually attracts Brazilians to the neighboring country's territory.
According to Flávia, the study pointed out dynamics of HIV dissemination that are related to problems in the organization and supply of health services and social contexts of vulnerability. “Brazil is a pioneer in the fight against HIV, provides free medication, and our control program is recognized worldwide, but it is necessary to look more carefully at the territories. Oiapoque has flaws in the access to health and in the range of care recommended by the Ministry of Health, as there are unique characteristics in that environment”, comments the newly-doctor.
The border demarcated by the Oiapoque River divides two territories with great inequality. On one side, Amapá, one of the poorest states in Brazil. On the other side, French Guiana, a French overseas domain and the only European territory in the Americas. In Amapá, one of the data that characterize the HIV epidemic is the annual increase in AIDS cases, in contrast to the scenario of stabilization or decrease in most of Brazil. Marked by low immunity, which leads to the development of complications, Aids occurs when there is no adequate treatment of HIV infection.
French Guiana has almost no AIDS cases. Among Latin American countries, the territory reached the highest proportion of infected people undergoing treatment and with an undetectable viral load. However, annually, new cases of people with HIV are registered in the territory. The border condition is a determinant in the configuration of the HIV/AIDS epidemic in the region. Oiapoque and Saint Georges are twin cities, which depend on each other in economic and social issues, but they have a very large asymmetry, with differences at all levels”, emphasizes Flávia.
HIV/AIDS and its social determinants
Among the social determinants for the dissemination of HIV and the advance of the disease, which thus leads to the development of AIDS, the research points out to the intense mobility of the population in the region, associated mainly with the mining. “Mobility is characteristic of the border, which is a place to pass through. In Oiapoque, there is major population fluctuation. The cities in that region were created by mining and the population fluctuates with the exchange rate, with the price of gold, with situations such as the drama of the Yanomami, which causes the miners who were there to migrate to other regions, and with police operations that occur on both sides of the border, since most of the mining is illegal”, says Paulo.
The analysis of medical records revealed that, among 39 people with HIV undergoing treatment in Saint George, 33 were Brazilian, and 29 were residents of Oiapoque undergoing therapy in the neighboring city. Regarding the places of origin, most had been born in Amapá, Pará and Maranhão.
On the Brazilian side of the border, among the 62 people with HIV being followed up at health services in Oiapoque, 40% had previously been treated in French Guiana. All patients lived in Oiapoque, but came from 28 different municipalities, most in Amapá, Pará and Maranhão, in addition to some in Ceará, Goiás and São Paulo.
Among the men, mining was the most commonly cited occupation, although many patients seemed to have reservations about stating their profession. Even among those who indicated other occupations, displacements to mining areas were observed, which led to interruptions or abandonment of therapy. This also occurred among women, although work in mining was rarely stated.
“Miners are in various places, in the North of Brazil, in French Guiana, Suriname, Guyana, Venezuela. They stay in Oiapoque for a while and when they have the opportunity to go to the mines, they leave everything behind and go”, points out Flávia, adding that there are other migration flows that occur. “In the interviews, we saw that many people in Oiapoque are from Pará and Maranhão. These people sometimes return to their places of origin and others arrive in the region”, she clarifies.
Contexts of vulnerability
On both sides of the border, there are more men than women with HIV and the most frequent stated transmission category is the heterosexual. Social contexts of vulnerability and lack of access to information about the disease were other determinants identified in the research.
“There is a lack of information about HIV and AIDS at the border and the population has little education, so it is necessary to provide adequate information. There are also many factors that put the population in vulnerability. The miner, who lives and travels in this region, experiences situations of illegality, violence, overexposure to diseases. Sex workers are another vulnerable population”, said Flávia.
Problems in the care cascade, ranging from diagnosis to continued treatment, were observed during the research. Among them is the absence of infectology specialists in Oiapoque, which forces the referral of patients to Macapá. There is also a lack of confirmatory tests, lack of psychologists and training of health professionals, difficulty in listening to patients and promoting autonomy, as well as interruptions in patient follow-up. “On the other hand, in Saint Georges, the same problems do not occur, which makes many Brazilians seek assistance in French Guiana”, says Flávia.
The work identified major problems in the recording of HIV and AIDS data, with mismatched information between local, state, and national levels. “For example, the Sinan [national system for case reporting] is not the same as what is in the Health Department, which is not the same as what is accessed in basic health units. What is recorded in French Guiana is also different from Brazil. This makes it difficult to plan health actions in the region”, evaluates the newly-doctor.
In addition to contributing to public policy, the study has advanced answers to questions raised in previous studies on the spread of HIV in the region. In his doctorate thesis, which received the Capes Thesis Award in 2006, Paulo observed a distinctive pattern of the HIV epidemic in the extreme north of Brazil, in the border regions, with a high incidence of AIDS cases, in a pattern similar to that of the Caribbean.
Carried out in the field of geography, the study caught Flávia's attention during the development of her master's degree in the Graduate Program in Computational Biology and Systems at the IOC. Under the guidance of researcher Gonzalo Bello Betancor, from IOC's Laboratory of AIDS and Molecular Immunology, the student analyzed the HIV virus genomes in Brazil and identified the circulation of the Caribbean HIV-1 B subtype in states of Northern Brazil and in Maranhão.
“When I defended my master's degree, I didn't want to stop at computational biology. I sought Paulo to work at the border and investigate how this dissemination dynamics occurred in the place. In the thesis, we didn't conduct molecular analysis of the viruses, but we saw the circulation of people, which can explain the presence of Caribbean HIV not only in the border area, but in states like Maranhão and Pará”, said Flávia.
“We already had partnerships with Amapá and French Guiana in laboratory research, in addition to participating in the international mixed laboratory with France. When the opportunity arose to co-supervise Flavia's study, everything came together. It was a very interesting partnership, which resulted in the identification of these social determinants of the HIV epidemic at the border”, comments Paulo.