Paulo Henrique Longo is helping male homosexual prostitutes, major transmitters of AIDS in Brazil, deal with the psychological factors involved in their life-styles and in unsafe sex practices. Since there can never be enough psychologists to undertake this task one patient at a time, Paulo is pioneering community self-help psychological care.
The New Idea
Male homosexual prostitutes are one of the highest risk groups in Brazil, but they have been largely ignored by studies done on AIDS transmission in Brazil. The one study that has focused on this group found that forty-three percent were HIV positive.In his work with AIDS in general, and with male prostitutes in particular, Paulo suggests some reasons why this high risk group might be resistant to practicing safe sex -- the only real hope now for controlling the spread of AIDS. Typically, this form of prostitution involves contact with multiple high-risk partners daily. And, Paulo adds, clients are often willing to pay higher prices if the sex they buy is not "hampered" by condom use. As most male homosexual prostitutes have turned to the practice of selling sex out of economic necessity, this financial incentive is sometimes all too tempting.Paulo is undertaking the difficult task of trying to get male prostitutes to practice safe sex through an individualized counseling program that builds the self-esteem of these young men. Paulo's counselors are not psychologists or medical professionals, but peer "educators" mostly from the community who nightly "hit the streets," talking to prostitutes where they work, giving them condoms and informing them about health care availability. The established members of this community counsel new arrivals, and those who succeed in changing their life pattern encourage others to do so. The noncoercive and nonjudgmental nature of Paulo's approach reinforces his central theme that these people must take charge of their own psyches and lives. His technique for organizing community self-help psychological care is itself a major innovation, whose implications extend well beyond this one community.
Brazil is one of the world's fastest growing AIDS hotspots. While the number of Brazilians who are currently HIV positive is estimated at 700,000, estimates for the year 2000 suggest that up to 5.7 million people will be infected, with as many as 260,000 already fully manifesting HIV-related illnesses.The demographic patterns of the disease in Brazil are quite different from what has been seen in the United States over the last decade. While the incidence of American women contracting the disease through sexual relations increased only four percent between 1988 and 1990, in the same period in Brazil AIDS transmitted through sexual intercourse increased ten percent among women.This disparity is due in large part to the fact that bisexuality is more common in Brazil than in the United States. In Brazil, as elsewhere, male bisexuals represent one of the most important target groups for AIDS prevention and education campaigns, as they are often the "transmission bridge" to women. Male prostitutes, for example, often have girlfriends or wives, but engage in male prostitution for lack of other options.Another problem has been the government's AIDS information campaign, which has largely been based around the theme "AIDS kills," and relies on scare tactics to promote safe behavior. Paulo suggests that this moralistic approach has been ineffective among prostitutes because of the other risks they face daily from the police and from their clientele.
While some programs for female prostitutes exist, Paulo's "Pegacao" initiative is the first that has been designed for their male counterparts. Paulo attributes this to the fact that male prostitution, though widespread, is more hidden than the female sex trade.While most programs stress large-scale information campaigns, Project Pegacao works on an individualized basis, using a counseling model. Changes in behavior will not occur until the individual is convinced that he must help himself to save himself. Accordingly, Paulo is not only interested in how to provide information on safe sex, but also in working with clients to build self-esteem so that they themselves opt for condom use and, ultimately, survival. He is convinced of the need to develop new approaches to encouraging safe sex practices, especially as studies continually reveal that most people are adequately informed about preventing transmission of the AIDS virus yet still engage in unsafe sex.Paulo's educators are peers, or they at least take care to approach the prostitutes as such, often offering them a drink or sandwich or simply a chance to talk. The information they provide is neither moralistic nor judgmental but merely educational and practical. They are told what services Project Pegacao offers, such as condom distribution or medical care, and receive reliable information that should encourage the youths to protect themselves. Self- concern leads to self-esteem. This truth is reinforced by the educators, who have personal contact with the prostitutes, often as friends, on a regular, daily basis. It is hoped that this very individualized counseling program will, in the long term, lead the prostitutes to find an alternative lifestyle.Paulo hopes that his work will serve to engender a large-scale discussion in Brazilian society about male homosexual prostitution, which has heretofore been ignored. He seeks to widen the discussion and diversify the approaches Brazil takes toward its AIDS crisis through his active participation in the policy debate, as well as by talking with other AIDS service organizations, public health authorities, and groups working with poor youth (often the source population for male prostitution). Paulo also hosts regular call-in radio and television programs, during which he answers questions about sexuality, AIDS, and other sexually transmitted diseases.
As a psychologist and health care professional, Paulo Henrique Longo has always made an effort to understand health issues in their wider social context in order to avoid the narrow clinical perspective that so often dominates health care thinking.The second person in his family to suffer diabetes, Paulo grew up sensitive to health issues. While a student at the University of Bahia, he became involved in community health projects that incorporated alternative methods for reaching poor populations, such as teaching hygiene through popular theater.Upon relocating to Rio de Janeiro, Paulo became involved in AIDS work through an internship at the Gaffre and Guinle Hospital, where he was in charge of providing psychological counseling to AIDS patients. His involvement grew when he began volunteering with the AIDS service organization, GAPA (Support Group for People with AIDS), for which he has given talks at schools, businesses, and community centers.Paulo's work, be it in hospitals, poor communities, or AIDS support groups, has always been characterized by a search for understanding personal health as something inextricably tied to the patient's whole personality, life experience, and interaction with society. He is a rare embodiment of the belief that in order to introduce lasting changes in public health, one must show the importance of working in-depth, and in a caring manner, with the individuals at risk.