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Final Report for the
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This section summarizes the major accomplishments obtained through the six components of AIDSCAP's technical strategy of the overall project in Brazil. These are the reduction of STIs, BCC, condom programming, policy development, behavioral research and evaluation. In terms of project implementation, the AIDSCAP project in Brazil was able to fulfill all the strategic planned actions, activities and accomplishments although implementing a project in huge geographic areas such as Rio de Janeiro and São Paulo states (292,718 km2) was not a smooth or easy process. It is important to note that those geographic areas are in population and extension bigger than many countries -- such as France, Spain or any other country in Latin America and the Caribbean. Although in terms of area, the states of São Paulo and Rio de Janeiro represent only 3.42 percent of Brazil, they have almost 30 percent of the Brazilian population (47,000,000). Several constraints had to be recognized in order to bring forth results. The process of implementation and the evolution of the project during its life was rich and complex, responding to the AIDS epidemic in its multiples forms. This diversity was not only due to the differences of target populations but also to the different cultural settings in which AIDSCAP was developed in Brazil. Certainly the diversity of responses to the AIDS epidemic is related to the great variance of partners who developed these responses in cooperation and collaboration (the private sector, the media, the NGOs, women's groups, etc.). The partnerships that developed were crucial for the AIDSCAP implementation and success. 2. Accomplishments and Constraints a. Behavior Change Communication BCC was a very strong component of the AIDSCAP Brazil program. A wide range of BCC techniques were produced and tested under the auspices of AIDSCAP. BCC lessons learned from previous interventions indicate that behavior does not change in isolation, and that there is a need to focus on several levels of education simultaneously. Interventions to impact and affect social norms must assume that information-based campaigns do not independently cause individuals to become proactive. Audiences should be segmented and situational factors such as lifestyles and professions need to be considered in terms of multiple reinforcing messages and multiple channels for reaching AIDSCAP target groups (MWM, CSWs, MAFH, and people with STI and their partners). Once a specific group has been identified, combined BCC initiatives may include mass media that targets specific audiences reinforced by small media (such as brochures), and peer education/counseling to engender support from friends, family and community. BCC can be effectively utilized by all approaches, and serves to link behavior and prevention together. Traditional BCC techniques such as face-to-face counseling or production of IEC material were enhanced during the life of the project in Brazil. A total of 1,331,614 people were educated and a total of 7,744,458 BCC material were distributed during . Among the activities carried out with the target populations were safer-sex workshops, group discussions, face-to-face interventions, individual counseling sessions, condom use demonstrations, video debates, street theater, role plays, and sociodrama techniques. BCC activities were conducted by trained health or community agents, health care providers or by trained peer-educators. A relevant accomplishment was obtained after the production of a brochure based on the intervention for Adolescents in São Paulo Night students cohort study, named "Speak boy, speak girl." This IEC material was reproduced for the whole São Paulo State under the State Department of Education and 300,000 copies were issued. The MOH/World Bank sponsored the graphic production of this brochure. This material was also requested by the MOH for reproduction and national distribution. Other innovative new techniques such as the "Maze Installation" were produced and tested under the RRF program. Radio programs, video production, newsletters, brochures, pamphlets and posters were produced during the life of the project. In association with the private sector, W/Brazil, Graficos Burti and others, a glossy glitter brochure for CSWs was produced by the country office using 50,000 US dollars. The Levi Strauss Foundation sponsored the production of 5,000 copies (price of 15,000 US dollars). Two editions, totaling 10,000 issues were published in 1993 and 1995. In 1994, the Brazilian Association of Graphic Material recognized this material as the best didactic material of the year with an award. After the MOH-World Bank loan, a large and diverse amount of IEC material was produced by Brazilian NGOs and by the MOH itself. AIDSCAP sub-projects also used and/or reproduced good IEC materials produced by other NGOs or GOs. Through the MOH/World Bank loan several materials produced by AIDSCAP were also requested and reproduced by MOH, such the "Fala Preta" brochure, "Women and AIDS: pleasure without fear", and "Speak boy, speak girl." In 1996, in association with the private sector, the Levi Strauss Foundation and the British, the country office produced a display of the female and male body in natural size (8,000 issues). These IEC materials were distributed during the reproductive health and HIV prevention/integration training conducted for 104 health care providers from four Brazilian States. A database bank designed to rate IEC material on its quality was developed in 1995. For example, for the adolescent population alone more than 300 IEC materials were processed, analyzed and rated. However, due to budget constraints the BCC officer position was canceled and this initiative was ended in 1995. AIDSCAP/Brazil considers this procedure to be a responsibility of the National Program on STI/AIDS from MOH. Unfortunately, up to now, there has not been any database analysis of IEC material produced in Brazil, and due to the size of the country it is common to have replications of efforts and IEC materials. The main constraint in the BCC component of AIDSCAP project in Brazil was the limited resources to pay for mass media messages on TV and radio, which are expensive in Brazil. However, considering the size of the country, mass media messages are very much needed. To overcome these obstacles some strategies were developed in association with the private sector with ABRIL Editors through Claudia Magazine, Capricho, the fashion industry in the campaign Wear for a Cure, and the media in general. Analysis of free media published in local newspapers and magazines with the participation of AIDSCAP/Brazil was calculated on 6.8 million US dollars by a private company. Due to the size of the country, another major constraint was the quantities of materials necessary for national distribution versus needs and demands for AIDSCAP-produced materials limited to the AIDSCAP-targeted geographic areas and programs. For instance, several requests of IEC material were made at the country office but could not be satisfied because they did not fit the implementation plan. Because Brazilian culture is considered open and explicit, many BCC materials produced and used by IA to target geographic areas were produced by other donors or by the private sector. AIDSCAP/Brazil did not permit IA to produce very explicit IEC materials that could cause controversies outside Brazil. One leaflet produced in Santos without the permission or revision of AIDSCAP/Brazil was not distributed to the target population. b. Sexually Transmitted Infections The STI strategy focused on improving the utilization and expansion of services to existing private and public clinics offering medical services for STI care to the target populations (persons with STI, CSWs, MWFH, MWM). Interventions included:
During AIDSCAP program a series of accomplishments were achieved regarding the STI component. The AIDSCAP sub-projects targeting STI patients became models for the MOH project. For instance, in the city of Rio de Janeiro, the STI project which started with AIDSCAP for 24 clinics was expanded all over the State of Rio de Janeiro. By the multiplication effect, the original goal of 24 clinics became 114 health care facilities trained for syndromic approach on STI. Health Information Systems on case reporting has remarkably improved under AIDSCAP Project. In 1994, only 5 STI cases were reported, in 1996 this number had increased to 17,113 STI cases. In Santos, the STI program became a national referral center for MOH -- which has, in addition to AIDSCAP, enhanced the facilities of the local laboratory originally established by AIDSCAP. A total of 106,558 STI patients were diagnosed, counseled and treated during the life of the project. A major accomplishment was the translation of the book Control of Sexually Transmitted Diseases: a Handbook for the Design and Management of Programs, edited by Dallabeta, G., Laga, M. and Lamptey, P. AIDSCAP/ FHI, into Portuguese. This addressed the resistance in the academic area in Brazil to the syndromic approach to management of STI, and was a strategy to disseminate the approach to health professionals. This book was translated and launched during a satellite seminar carried out at the 8th Pan American and 10th Brazilian Infectious Diseases Meeting in Salvador, May 1997. AIDSCAP Brazil, in association with MOH, conducted this seminar. The proper implementation of a comprehensive approach to STI in Brazil is an unmet, relevant public health need. Successful programs in the future will be highly dependent on the availability of STI drugs and condoms. Most clinics had condoms during the life of the project because USAID donated 15 million condoms to be used for the AIDSCAP Project. However, a major impediment was the delivery of STI drugs which took about 10 months to arrive at the clinics after the project had started. The STI procurement and distribution were the responsibility of the MOH and suffered because of a long, bureaucratic process which hampered the States' receipt of STI drugs at the clinic level. In Santos, this obstacle was overcome by the Municipality's contribution to the project: the Health Secretariat of Santos Municipality bought all STI drugs needed for the project implementation. In Rio de Janeiro, where no funds were committed for STI drugs, it was difficult to keep health providers motivated without these supplies. Another constraint was the crisis of the health system and the low salaries paid for health professionals, especially in the state of Rio de Janeiro. Gynecologists are still very resistant to the syndromic approach in Brazil and their involvement will be is very important in future programs. Despite all efforts from the government and NGOs, men continue to rely on drugstores for the treatment of STIs. Innovative approaches, such as Mstop, are an important need for future programs. Use of the STI Handbook as a tool for sensitization, mobilization and for the training of University representatives is an important strategy to be used in the next HIV/STI program funded in Brazil. c. Condoms At the beginning of the AIDSCAP Project in 1992, the supply of condoms in the health system and NGOs was sporadic, and mostly dependent on donors. A field investigation revealed widespread complaints about the lack of condoms and the short supply of STI pharmaceuticals. There was an increase of condoms sold commercially during the life of the project, showing an increase of awareness and some behavior changes regarding condom use. In 1992, 50 million condom units were sold in Brazil. In 1996, this number increased four-fold: 200 million condoms were sold. This is a great achievement considering the national production of condoms is insufficient to meet the needs of the country, which means that condoms were imported which is a time-consuming and inefficient process. During the life of the project all 86,700,030 condom units were dispensed by AIDSCAP. Among those, 14,791,489 condoms were donated from USAID for free distribution to the target geographic area and target populations in Rio de Janeiro and São Paulo. Most sub-projects relied on condom donations for free distribution during their activities. An additional 71,908,541 condoms were sold through the CSM project by DKT do Brasil from July 1993 to March 1997. CSM was developed in conjunction with 63 NGOs all over Brazil but focused on the AIDSCAP target geographic areas where 41 of these NGOs were located. Logistics AIDSCAP helped design a comprehensive logistics system to alleviate difficult conditions while giving initial attention to the project areas, to the essential commodities management information system (ECMIS), and to an allied distribution system. The State Health Departments of Rio de Janeiro and São Paulo created a Logistics Officer position and the personnel hired for this position were trained by AIDSCAP through John Snow Incorporated (JSI). The proposed logistic system was favorably received by the Federal Government of Brazil and the National Program on STI/AIDS. Two professionals from the MOH were sent to the United States for training. Unfortunately, the MOH has never created a Logistic Officer position due to high turnover of personnel. The logistics system created at state level in Rio de Janeiro and São Paulo sent essential HIV/AIDS commodities to targeted outlets, and traced their flow. Logistics needs were identified, such as expanded warehouse efficiencies, training of trainers (TOT) for logistics management, and improved inventory control. These efforts were successful to implement logistics in the system. The main constraint in the logistics project was the ECMIS technology which was not appropriately transferred by JSI. Constant problems with the software made AIDSCAP opt for another software created at the country office. This latter can be easily supervised and technical assistance can be given in-country. d. Policy Policy development had three initial objectives for Brazil: 1) to create an awareness among policy-makers of the potential socio-economic and political impact of HIV/AIDS; 2) to encourage the revision of selected policies that present obstacles to AIDS prevention initiatives and/or suggest policy options that may enhance initiatives; and 3) to encourage greater investment by Brazilians in AIDS prevention initiatives. From a policy development standpoint, the primary issue in Brazil was the tariff on condoms. There was compelling need to convince policy-makers that benefits are greater for Brazil and Brazilians if they would authorize a considerable reduction or elimination of the import duties and local taxes on condoms. From 1994 until 1995, AIDSCAP in conjunction with the MOH was able to reduce the taxes on condoms in the category of industrialized products (IPI-Industrialized Product Tax). Nevertheless, the federal government changed after the initial reduction and taxes were reinstalled and climbed as high as 40 percent. Lobbying, documentation and petitions were sent to policy makers in order to convince them of the benefits of tax reduction. In 1996, a reduction from 18 to 7 percent was obtained at the São Paulo State level for the "Circulating merchandise tax" called ICMS. At the national level all taxes continued to be charged. During the year of 1996 and 1997 the campaign for tax reduction led by the Associação Saúde da Família (ASF -- the organization which implemented the AIDSCAP/Brazil project and acted as the AIDSCAP country office in Brazil) collected 5,309 signatures from newly elected politicians (64 percent), senators, all Brazilian NGOs working with HIV/AIDS, and civil society. Copies of certified petitions were sent on February 1997 to the President of Brazil, the President of the Senate, the House of Representatives and to the Governor of São Paulo. On October 15, 1997 the São Paulo State governor launched a decree reducing to zero any taxes on condoms at the state level. On the same day, ASF with a group of NGOs representatives, Union leaders, artists and representatives of the society handed the petitions to the Minister of Health. On October 20, 1997 the Minister published a decree reducing all condom taxes at the national level. This was a major accomplishment. A second important policy objective is to utilize known human and financial resources controlled by the private sector. AIDSCAP/Brazil developed activities in partnership and cooperation with the private sector, especially with media, marketing and publicity companies. These partnerships had goals to promote fundraising and sustain the attention of the media. (These experiences are explained in detail in section V. Non-Sub-Project Highlights.) A third policy issue is to facilitate analysis and discussion among policy-makers about the existing regional approach. Increasing the awareness of the socioeconomic impact of HIV/AIDS -- such as in the areas of national health care and lost productivity of workers -- is one way to move beyond this regional approach. Special evaluation needs in Brazil indicate that recurrent analyses of costs and cost effectiveness are needed for the STI and condom distribution programs. Analysis should be conducted to determine if investment in AIDS prevention can have significant health and economic benefits in the future. Financial analyses can be used to create policy options on cost recovery and the sustainability of these interventions. With these objectives a socioeconomic study was planned to be conducted in Brazil. AIDSCAP/Brazil negotiated with the MOH that was willing to develop the study. However, when a concept paper was sent by AIDSCAP/Brazil to MOH for comments and suggestions, the MOH decided not to carry out the study since they were going to conduct a larger study with resources from the MOH/World Bank. Up to now no study has been implemented to evaluate the socioeconomic impact of HIV/AIDS in Brazil. An important accomplishment in the area of policy was the production of the HIV/AIDS Policy Book coordinated by Prof. Richard Parker from Centro de Estudo e Pesquisa em Saude Coletiva/Universidade Estadual do Rio de Janeiro (CEPESC/UERJ). The book has seven chapters discussing major issues of the HIV/AIDS Policy in Brazil, starting from an introduction in which the organizer analyzes the evolution of the AIDS epidemic in Brazil and the political response from the government and society. The first chapter by Euclides Castilho and Pedro Chequer, the current Coordinator of the NACP/MOH, analyzes the epidemiological situation of the epidemic in Brazil. The second chapter by Paulo Roberto Teixeira approaches the public policies and programs that were carried out in the country in the last 15 years of the epidemic. Jane Galvão is the author of the third chapter, which analyses the actions of Non-Governmental AIDS Services Organizations as well as the Religious Organizations in chapter five. Chapter six, by Veriano Terto, Jr., describes and analyzes the response of the private sector, and chapter seven approaches the impact of HIV/AIDS on women in Brazil by Regina Barbosa. This book is under revision for publication and will contribute to a more comprehensive and up-to-date view of the AIDS epidemic in the country. AIDSCAP/Brazil participated in commissions and committees to prepare documents, guidelines and policies that define the strategies for HIV/AIDS/STI prevention and control in the country over the life of the project. The main committees that AIDSCAP participated in are as follows: Member in meetings held by the National Committee for Integral Prevention (CONEPI/SEPESC/MEC) providing technical assistance to the Minister of Education in the development of AIDS Prevention Strategies for Brazilian schools, 1993-1995. Dr. Maria Eugênia Lemos Fernandes; Member of the scientific commission for AIDS/STI in the State of São Paulo to discuss and produce documents and recommendation on several policies regarding the prevention, treatment and care of HIV/AIDS and STI in São Paulo, 1992-1994. Dr. Maria Eugênia Lemos Fernandes; Member of Technical Advisory Committee Organized by INMETRO to discuss the control of Quality of Male Condoms for the Mercosul, from 1995-1997. Dr. Maria Eugênia Lemos Fernandes and Dr. Elisabeth Meloni Vieira; and Member of the Certification Committee Organized by Institute Falcon Bauer to certificate Quality of Male Condoms, 1996-1997. Dr. Maria Eugênia Lemos Fernandes and Dr. Elisabeth Meloni Vieira. In August 1997 Associação Saúde da Família was elected by the Forum of NGOs to be part of the commission on HIV/AIDS vaccine trials in Brazil. e. Behavior Research São Paulo night school students youth cohort study This controlled intervention trial targeted poor young adults (ages 18-25) completing their primary and secondary education in night schools. Three waves of HIV/AIDS-related questionnaires were given at 6-month intervals to 100 students at each of four schools. Between wave one and two, the students at two of the schools received a four-session intervention while those at the two other schools served as a wait -list control group. After wave two, students at the remaining two schools participated in the intervention. Of the total of 394 students enrolled in the study, 304 (77 percent) completed the study. Baseline data showed that 87 percent of the students were sexually active and 76 percent reported having had sex in the last 6 months. Among the sexually active, 67 percent reported regular partners only, 12 percent casual partners only, and 21 percent both casual and regular partners. A minority of students reported consistent condom use in vaginal sex (15 percent). Two cases of syphilis (0.7 percent) and 2 cases of gonorrhea (0.7 percent) in the last 6 months were reported by students. Nineteen percent of youth reported vaginal discharge or itching and 5.3 percent reported genital sores. Fourteen percent reported having taken an HIV test and two were positive. The intervention was based on a series of four 3-hour workshops. Males and females were separated in different groups. The workshops involved subjects such as HIV/STI transmission, reproductive health, sexuality, gender norms, condom use, and homosexuality. The effectiveness of the intervention was measured by a self-administered questionnaire before and after the intervention program in both groups. This questionnaire included a series of scales on the AIDS risk reduction model and asked additional questions regarding gender norms. ANCOVA was used to compare changes between intervention and control groups. Two major changes were observed over the course of the study:
The study could not detect significant changes among men and regular partners. Causes for not using condoms included that the youth do not plan when they will have sex, and therefore do not have condoms with them. Some students complained that condoms were too expensive. The average condom price is R$0.5, equivalent to 0.4 percent of minimum wage. The topics of poverty, violence, lack of opportunities and access to quality and free reproductive health care and counseling consistently came up during workshop discussions showing several other important problems competing with AIDS. Additionally, other qualitative data from the intervention showed that AIDS is seen as less important than other problems, such as undesirable pregnancy. In order to improve intervention effectiveness, the socioeconomic aspects listed above should receive more emphasis for future programs. The low effectiveness of the intervention observed among male adolescents is still challenging educators and is a question that should be investigated by appropriate study design. The intervention was well accepted by the students and teachers. As a result of this study, the school based AIDS prevention program will be "scaled up" in 2,800 schools in the State of São Paulo. A total of 300,000 manuals based on the curriculum of this project are being distributed to schools throughout São Paulo and other states. Santos harbor workers cohort study A randomly selected cohort of 226 male harbor workers aged between 25 to 55 years old were followed for 3 years. Interviews and blood samples were collected in the first and second waves. Intervention was carried out between waves two and three. The majority of men were married (81 percent) and an additional 11 percent had a steady partner. At baseline, HIV seroprevalence was found to be 1.1 percent, and syphilis was found to be 2.2 percent. Thirty-eight percent of harbor workers reported a history of a STI. No intervention took place between wave one and two, because the two waves were planned to establish baseline levels and detect major trends prior to the intervention. Since no significant changes were found between wave one and two, it was assumed that there were no important and significant behavior change trends. In the third wave, after the educational intervention, important changes were detected, such as a reduction in the number of secondary sexual partners in last 12 months, and an increase in condom usage, especially with casual partners. Only 10 men reported unprotected vaginal sex with casual partners compared to 28 in wave two (representing a 64 percent reduction, p<00.1). The main results are presented in the table below:
Though not a specific measure of the interventions effects, subjects were tested again for HIV and syphilis in wave three. One HIV seroconversion was identified giving a 0.2 percent incidence/year, and 21 men (9.3 percent) were FTA-positive for syphilis. Truck drivers: Prevalence of HIV and other sexually transmitted diseases and risk behavior A cross-sectional study involving face-to-face interviews and blood drawings was conducted among 300 male truck drivers in the port of Santos made up of a consecutive sample of drivers who were waiting in long lines at the port to load and unload cargo. Measures of HIV and syphilis serology (using two tests: VDRL and FTA-Abs), demographic characteristics, work history, sexual behavior and drug use behaviors, sex with different partners and history of STI were collected. Results: Of 300 subjects, 4 (1.3 percent) were positive for HIV, 25 (8.3 percent) were VDRL-positive and 38 (13 percent) FTA/ABS-positive. Ninety-three percent lived outside of Santos and 56 percent were away from home for over a week. Forty-seven percent reported ever having had any STI (38 percent gonorrhea and 5 percent syphilis). Seventy-one percent were married and 40 percent referred having more than one sex partner; 21 percent had sex with CSWs, 14 percent with girls they met on the road, 22 percent with friends and 16 percent with other men's wives. Three percent reported sex with other men in the last 12 months. A great proportion of them (43 percent) use Rebite, an oral stimulant. The use of this drug was statistically associated with FTA-ABS (p=0.04). Having sex with friends was associated with becoming HIV-positive and having sex with steady sex partners and other men's wives was associated with being VDRL-positive. It is important to highlight that all these sexual partners are considered "safe sex " by the truck drivers. This was the first study to determine the HIV and syphilis seroprevalence among truck drivers in South America. Findings confirm that this group has a high potential risk for HIV and STI infection and the potential to spread infection to other areas of the country. It is clear that this is also an important epidemiological group to be included in intervention programs. f. Summary of Process Indicators for Aggregate Country Program Major AIDSCAP programs
*Included STI counseled during visit to the Health Service for STI treatment. AIDSCAP rapid response fund process data
ASF process data
*Number of spots in the magazines/newspaper and. X=the average number of issues of that magazine/newspaper. Total AIDSCAP/Brazil process data
Note: Major projects were systematically reviewed on TV; however, the PIF form did not allow registration of this data. Thus, media spots of major projects are not reflected in the table above. Biological Data Biological data can provide important information about the status and trends of the epidemic. It is not adequate as an evaluation of prevention programs because cultural behavioral changes take time, and even more time will be needed to reduce HIV seroprevalence. Incidence-rate studies would be more appropriate than prevalence studies in detecting behavior changes, but they are prohibitively expensive and logistically challenging. Due to the cost, AIDSCAP did not fund large-scale HIV seroprevalence studies in Brazil. Data is available in a range of populations targeted by AIDSCAP interventions and in studies funded by other sources. Data from research in Rio and São Paulo among MWM, CSWs, and STI clinic patients show an inconsistent and conflicting picture of the epidemic. Due to differences in sampling, high rates of migration into and out of target populations, and the unknown effects of AIDS-related mortality, it is difficult to identify specific trends in HIV incidence. Nonetheless, biological studies leave the clear impression that a devastating epidemic is established in high-risk populations in Brazil, and making significant advances into the general population. Based on several studies, the Brazilian Ministry of Health is estimating an HIV seroprevalence of 1.0 to 1.2 percent among men and 0.8 to 1.0 in women from 15 to 49 years-old in the states of Rio de Janeiro and São Paulo. The biological studies available among AIDSCAP target populations are presented below: Two HIV seroprevalence studies among MWM carried out in São Paulo showed similar figures: 12.2 percent in 1988 and 9.1 percent in 1997. The latter seroprevalence data was taken from 695 MWM candidates participating in an HIV seronegative cohort study. A total of 594 volunteers were included and followed in the cohort. The HIV incidence rate was 1.42 percent per year (8 seroconversion for 562.9 persons followed by one year) and has been stable. This cohort sampling is composed mostly by exclusively homosexual subjects. In Rio de Janeiro the results of seroprevalence studies among MWM were not very consistent. A 25 percent HIV seroprevalence was found in 1987-89, while in 1995 two other studies had different results: one reported a seroprevalence of 25 percent and another reported 8.9 percent (1995-96). A cohort study with over 600 HIV seronegative MWM showed an incidence of 3.4 percent per year. Over 50 percent of the subjects were male CSWs and bisexuals, a much higher risk population than the São Paulo cohort study, therefore both incidences are not comparable. CSW seroprevalence data has varied substantially in Santos. In 1991 Lurie and cols. found a seroprevalence of 27 percent (n=100) among lower income and 1 percent (n=100) among higher income CSWs. Another study conducted by the MOH in 1995-97 attempting to include all Santos CSWs, found an 8.6 percent ( n=625) HIV seroprevalence. This data should be examined with caution as it is difficult to compare both data because of their selection methodological differences Additionally, the last study has not was not been analyzed yet by income. In Rio, a CSW seroprevalence study was carried out in a poor area of Rio and showed a prevalence of 11.6 percent in 1991 and 11.2 in 1992-3. No other recent data are available among CSWs in Rio. An HIV seroprevalence study in STI sentinel clinics showed a 23 percent (n=343) in Rio de Janeiro in 1994 and 15 percent (n=164) in São Paulo in 1993. A recent study involving 23,000 male recruits at least 18 years old carried out in 1996-97 showed a 0.5 percent syphilis seroprevalence. HIV data is not available yet. Behavior Outcomes In 1996, for the first time, National DHS included questions regarding AIDS/STI and sexual attitudes and practices. This survey interviewed 12,559 women and 2,921 men from a representative sample of the Brazilian population (see notes on the evaluation studies at the end of this chapter). AIDSCAP had a leading role in the questionnaire design and gave economical support to the data analyses and results dissemination. The DHS findings showed that the majority of population knows that AIDS is a sexually transmitted disease and that condoms can prevent its transmission. The large majority of the population considers itself at no or a very low risk of getting infected. Condom use is still very low among the general population. The findings suggest that women, less-educated people, older people and adolescents (less than 20 years old) are more vulnerable than other groups. Unfortunately, there is no previous similar study available to provide comparative behavior trends among the general population. Among the AIDSCAP target populations, the data from several studies conducted by the AIDSCAP and IA (see notes on the evaluation studies at the end of this chapter) suggested that a significant improvement in knowledge and risk perception was achieved among the CSWs, MWM, Harbor workers and adolescents at intervention areas. Additionally, improvements in self-esteem, self-confidence and group organization were achieved by the MWM and CSWs. These are conditions considered necessary in order for safer sexual behavior changes to occur. A significant reduction in the percentage of harbor workers reported casual partners after intervention. The use of condoms has increased in all four target population, especially among CSWs and MWM. Adolescents in the intervention area have higher condom use rates than the average Brazilian population their age. Despite the successes of interventions, there is a proportion of people who still engage in high-risk practices. i. Knowledge General population -- DHS data showed that among the surveyed population, condom usage was the most preferred HIV prevention method (80 percent for female and male). The other methods -- such as the use of dischargeable syringes (27.5 percent for both sex) or having only one partner (8.6 percent female and 1.9 percent of male) -- were not cited by the majority of parties interviewed. Knowledge of HIV prevention was highly associated with level of education. Condom usage was cited by 92 percent of men and women with 12 or more years of schooling and only 49 percent (50 percent of female and 48 percent of male) with no education. Additionally, the proportion of people who did not know how to avoid HIV transmission (10 percent of female 8 percent male) varied from zero among men and women with more than 12 years of education to 37 percent among females and 26.4 percent of males with no school education. A much smaller difference in knowledge about HIV transmission was found between age groups. The oldest age group (40-49) interviewed had the lowest knowledge for both sexes about HIV transmission and prevention. In this age group, 12 percent of women and 15 percent of men did not know what to do to avoid HIV transmission whereas only 7 percent among the 25-29 age group did not know how to avoid infection. A high proportion of people gave incorrect answers about HIV prevention (20 percent of men and 17 percent of women) such as avoid contact with a HIV-infected person, not using public bathrooms, going to see doctors, etc. Knowledge about other STIs was much lower than AIDS. A great difference was also observed between genders, in that 68 percent of men knew or have heard about gonorrhea and 36 percent about syphilis, while only 35 percent and 29 percent of women knew about gonorrhea or syphilis respectively. Target population -- A significant increase in knowledge of HIV transmission and prevention was observed in all AIDSCAP target populations with almost universal understanding among the adult and adolescents populations. CSWs -- The baseline studies revealed a great variation in knowledge of HIV transmission and ways of preventing transmission among lower-income CSWs in Rio and Santos. Improvements were observed in both places and in all variables. Correct answers about HIV transmission (via vaginal intercourse) has increased and is almost universal among the CSWs surveyed, increasing from 79 percent in 1993 to 95 percent in 1997 in Rio, and 90 percent in 1991 to 98 percent in 1996 in Santos. Over 97 percent of CSWs in both towns recognize condoms as a means to prevent AIDS. Additionally, 99 percent in Santos and 95 percent in Rio agree that sharing syringes and needles can transmit HIV, and 95 percent in Santos and 92 percent in Rio recognize that a pregnant woman might transmit HIV to her baby. Despite this progress there is still a proportion of CSWs who thinks HIV can be transmitted by social contact: kissing (5 percent), and drinking from the same glass (16 percent). MWM -- Among the MWM population, knowledge of means of HIV transmission and prevention have risen substantially in the period 1993-95, and is now very high in both Rio and São Paulo. Condoms as a method to prevent HIV transmission increased from 71 percent to 93 percent in Rio, and to 95 percent in SP. Over 96 percent of MWM know HIV is transmitted by semen or blood. Changing perception of risk can be demonstrated by the increase in proportion of men who would not accept having unsafe sex, from 40.4 percent in 1989 to 81.7 percent in Rio in 1995, and 81.3 percent in São Paulo the same year; and by the reduction of the proportion of MWM who incorrectly cited that HIV is contracted by chance (from 70 to 10 percent in Rio). MWM as a group's understanding of what "safe sex" means has changed with time. In 1989, 50 percent of those interviewed associated it with condoms use and 52 percent with "selecting your sexual contacts" and 75 percent associated it with "avoiding sperm in mouth." In 1995, 100 percent would associate "safe sex" with constant condom use and only 8 percent with the other practices. This trend may reflect the position of the MWM implementing agencies which emphasize the use of condoms as the most important and efficient strategy to avoid transmission. BCC messages emphasize this message rather than partner reduction and partner selection, which are not viewed as effective strategies to prevent HIV/STI. Adolescents -- Adolescents' perception of the existence of AIDS was high and increased in both sexes from 98 percent to 100 percent among females, and 93 percent to 99 percent among males (p<0.01) Citing condoms as a method of HIV prevention increased from 80 to 89 percent (p<0.05), and a larger increase was observed among women (from 78 percent to 89 percent). Adolescents were increasingly able to contradict false statements about HIV/AIDS, such as: "only homosexuals and IVDU have AIDS" (correct answers increased from 91.8 to 95.8 percent, p<0.01). The correct answer about the perception that someone might have the AIDS virus despite appearing healthy also increased from 76 to 90 percent for both sexes. Additionally, sexual transmission (97.7 percent), blood transfusion (95.5 percent), and shared use of syringes (93.7 percent) were the most common means of HIV transmission identified, while condom use was the preventive method most frequently identified through checklist questions (over 95 percent) for both sexes. The differences in the answers between two questions about condoms as a method of HIV prevention described above (citing condoms as methods and identifying condoms by checklist) may reflect some insecurity by a small portion of adolescents about the subject. A significant reduction (p<0.05) in the proportion of incorrect HIV transmission means was observed: the perception of transmission by mosquito bites (30 percent to 18 percent) and public bathrooms (39 percent to 18 percent) declined. Regarding knowledge of other STIs, an increase was observed in the proportion of adolescents citing STI besides AIDS (increasing from 87 percent to 95 percent among female and 92 percent to 96 percent among male adolescents p=0.003). The most cited STIs were gonorrhea, syphilis and herpes. Despite these improvements the proportion that correctly answered questions regarding existence of non symptomatic syphilis and gonorrhea in women has remained stable (26 to 27 percent among females and 32 to 23 percent among males adolescent). This suggests that more emphasis on other STIs should be given in interventions with adolescents. ii. Sexual partner and behavior change - sex negotiation General population -- The great majority of the population consider themselves at no- or low-risk of HIV infection (ranging from 77.3 percent in northeast to 85.5 percent south of Brazil). Conversely, the proportion that perceived themselves as high-risk ranged from 3.9 percent in São Paulo to 9.8 in the Center-west of Brazil. Although there is not much difference in risk perception between genders, men tended to initiate more behavior changes than woman (over two times higher) in all age groups.
It should be highlighted that, despite perceiving themselves at a high risk, 69.4 percent of women did not initiate any changes to protect themselves. The low rates of behavior changes among women in comparison with men reflects the male-dominant cultural values of Brazilian society in which women are powerless to make choices, especially regarding sexuality. Several studies have confirmed this male-dominant cultural aspect of society. Trust, love and economic dependence were considered by several studies to be more important than risk perception in determining behavior changes. This matter should be considered during the program design of interventions. As expected, behavior changes were associated with higher levels of education. Seventy percent of men and 92 percent of women with no schooling did not report any behavior changes. Among men (48 percent) and women (78 percent) who have had 12 or more years of education, lack of behavior changes was lower. Target population -- Reduction of the number of sexual partners was not emphasized in the interventions with CSWs, MWM and adolescents for different reasons. The interventions emphasized consistent condom use and also stimulated the CSWs and MWM group organization and self-esteem in order to improve their self-confidence. The improvements in self-perception empowered them to negotiate safer sex and to care their own health through healthy behaviors. In the case of harbor workers, the reduction of number of partners was used as a strategy. A reduction of 30 percent in the proportion of males having sex with casual partners, and the 23 percent of the mean number of non-primary partners over the last 12 months was observed. CSWs -- The CSWs KABP survey showed that the majority of women have increased confidence in negotiating condoms use. Over 87 percent reported that they would not accept sex without a condom and 96 percent had condoms with them in the interview. However, there is a minority (13 percent) stating they would have sex without a condom if they needed money. In the focus group discussion (FGD) in Rio and Santos, it was mentioned by sex workers that techniques learned with peer educators to overcome men's resistance to condom use have been helpful. The influence of alcohol and drugs were cited as important barriers to the use of condoms. A total of 65 percent in Santos and 78 percent in Rio of sex workers reported a gynecological visit within the past year. Although these figures are far from ideal, they are much higher than the general population of Brazilian women, with only 37 percent reporting prior-year gynecological visits. MWM -- The majority (87 percent) of MWM reported some changes in their sexual behavior because of what they know about AIDS and 50 percent cited great changes. The most frequent change was the use of condoms with casual (60 percent) and regular (50 percent) partners. Other safer practices, such increasing masturbation (35 percent), reduction of penetrative sexual relations with casual (36 percent) and regular (25 percent) partners were reported. The proportion of the MWM population reporting zero or one sexual partner in the past 12 months is similar, in São Paulo at 45.6 percent and in Rio at 42 percent. In Rio this figure remained stable from 1993 to 1995. Changing from a passive to more active attitude to avoid transmission is demonstrated by the proportion of men in Rio who disagreed with the statement "in the passion of the moment I cannot do safe sex" from 40 percent in 1989 to 74 percent in 1995 and 81 percent in São Paulo in same year. Agreement with, "I cannot change my fate" went from 30 percent to 87 percent. This suggests more empowerment by this population, which might lead to safer sex practices. Qualitative studies among MWM in Rio and São Paulo have shown that societal prejudices against homosexuality and risk factors for high-risk behavior are strongly associated. Individuals reporting the highest levels of risky behaviors were often at conflict with their homoerotic feelings. Because of this, important aspects of intervention were improved self-esteem and group support. The qualitative evaluation with participants and non-participants of interventions in São Paulo and Rio suggested that the focus of enhancement of self-confidence and self-esteem encouraged safer sexual behavior. Many of these results can be attributed to the MWM prevention intervention. Despite the general improvement there are smaller groups still resistant to changes. The KABP survey in São Paulo and Rio (1995) identified a pocket of MWM in a higher risk bracket for infection with HIV. These people are from the lower socio-economic and educational levels, people who identify as bisexual, and people from the youngest age group (14- 21 years old). Condom use among 14 to 21 years old was 68 percent whereas it was 84 percent among 22 to 31 age groups. These youth tend to have higher rates of unsafe sex, less confidence to negotiate safe sex, less access to information and less contact with gay organizations. Intervention programs have more difficulties reaching these groups; therefore, intervention programs should be designed to specifically target this population. Harbor workers -- Among the harbor workers, the proportion of men having sex with casual partners decreased 30 percent (from 20 percent to 14 percent, p<0.03) and the mean number of non-primary partners was reduced 23 percent (from 0.61 to 0.47, p< 0.015). Adolescents -- In Rio during the first wave in 1994, 30 percent of females and 62 percent of males were sexually active. No important changes were detected in the second wave in 1996 (32 percent of females and 65 percent of males). Among the sexually active adolescents in Rio, the reported ability to talk about condoms use with partners increased among female adolescents (73 to 84 percent) and remained stable among males (69 to 72 percent). Similar findings were observed in the behavior study of youth in São Paulo (see behavior studies session). Only female adolescents showed behavior changes (increase in the ability of discuss safe sex with male partner and reduction of unprotected sex with casual partner) as result of the intervention. No significant changes were observed among males. In both interventions in São Paulo and Rio, the best results of interventions targeting safe sex behavior changes through sexual self-confidence were achieved by females. This is an important outcome because in Brazil women tend to have less power in their relationships with men. Additionally, several qualitative studies in Brazil have shown that youth are most likely to act out the traditional male and female sexual roles. This presents a significant obstacle to safer-sex negotiation for women. As it was shown in the National DHS in 1996, women report making fewer behavior changes than men, even when they consider themselves at high risk of HIV transmission. The intervention in both sites successfully empowered female adolescents to insist on safer sexual practices. Male adolescents seemed to be more resistant to talking about STI/AIDS and using of condoms, especially in São Paulo. This subject should be investigated through specifically designed studies. The baseline qualitative research showed that sexual relations are irregular among adolescents and it is rare for them to have regular partners. Therefore, it was not considered feasible to expect reductions in the number of partners in this population. iii. Condom Use General population -- Although the health benefits of condom use is known by over 97 percent of general population, it is not commonly used. Only 33 percent of women and 60 percent of men reported ever having used a condom. The reported use of condoms during the last sexual contact (no matter the type of partnership) varied among women from 7.5 percent in the northeast to 14.4 percent in São Paulo, and among from men 29.6 percent in the south to 35.4 percent in north. Important educational level differences in condom use can be observed among both sexes (see table below).
These findings reinforce previous data presented on knowledge about HIV prevention and behavior change between sex. The findings showed that people with lower educational (and therefore, socioeconomic) levels and women in all strata seem to be at higher risk of getting infected. The epidemiological surveillance data on AIDS showed an important increase of AIDS cases among women and in the inner parts of the towns. Target population -- It is important to highlight that condoms are still not frequently and regularly used either for STI prevention or family planning by the general population in Brazil. The 1996 National DHS reported that only 4.3 percent of woman use condoms regularly and about 10 percent use condoms for STI protection. Additionally, two-thirds of women and 40 percent of men have never used condoms before. Increases in the use of condoms during all sexual contact has been achieved among CSWs, MWM, harbor workers and adolescents. Condom use for MWM and CSWs (in sexual contact with clients) is now an internalized value and the norm rather than the exception. CSWs -- CSWs in Santos are a highly mobile population. Over 50 percent of them reported a primary address outside of the city of Santos. This implies that interventions need to be intense and continuous because of the high turnover of this population. Despite this, the use of condoms by CSWs with clients has shown an ongoing increase. The consistent use of condoms with clients (use of condoms in the last five sexual intercourses) increased from 57 percent 1991 to 74 percent in 1993 and 93 percent in 1997. In Rio, condom use in the last sexual intercourse increased from 87 percent in 1993 to 97 percent in 1997. In the city of Santos, a large study conducted in 1996 showed 86 percent of CSWs used condoms in the last sexual intercourse and almost everyone in the study (96 percent) had condoms with them during the interview. A minority of CSWs in Santos (13 percent) stated that they would sometimes accept sex without condoms if they needed money. The first KABP in Santos was conducted in 1991 and showed that 97 percent of the CSWs with both high and low incomes reported the use of condoms. Trend comparisons between both studies are hampered because each one had a different sampling, the questions were asked differently, and the second study has not been analyzed by income yet. Quantitative and qualitative research with CSWs in Rio has detected an important and positive trend among hotels to give or sell condoms as part of a CSW-targeted program's package. This is particularly important because it was a barrier a few years ago as many hotels did not want to sell or give condoms because they feared problems with police. Qualitative studies identified barriers to condom use such as lack of use with long-time clients (regular and faithful clients), and using condoms can be perceived as disrespectful to clients. The use of alcohol by CSWs, which is greatly encouraged in brothels and by escort services, was also identified as a barrier to the use of condoms. CSWs reported that they often forget to use condoms when drunk and/or clients would take them off without the CSW's awareness. Condom use with regular partners, despite the significant increase from 12 percent in 1993 to 22 percent in 1997, is still very low. Trust and love ("I don't use condoms with someone I love") were identified as major barriers to condom use. CSWs stated that regular partners often refused to use condoms in order to appear "macho." But for the most part, condom use with clients is reported to be high and well-accepted practice, and considered a norm by CSWs. This is important to ensure ongoing use. It is easier to keep CSWs using condoms when it is already an internalized value. On the other hand, the use with regular partner is rare because relations with the regular partners are considered an "exception." Because of this, CSW-targeted interventions should also focus on supporting use with the regular partner. MWM -- Qualitative and quantitative studies found that condom use was accepted as a norm and an internalized value among the gay community. This is an important achievement for the sustainability of the high rates of condom use. The frequency of condom use ("always use condoms") has shown an important increase -- from 21 percent in 1989, 60 percent in 1993 and 89 percent in 1995 in Rio and to 82 percent in São Paulo in 1995. The rates for the reported use of condoms in last sexual intercourse were somewhat smaller at 83 percent in Rio and 77 percent in São Paulo. Among MWM in São Paulo whose last sexual contact was with a casual partner, 87 percent used condoms, demonstrating higher rates of infection are perceived when a higher risk sexual contact is made. Harbor workers -- Condom use with casual partners among harbor workers increased substantially. The proportion who reported unprotected sex decreased from 12 percent in 1994 to 4 percent after the intervention in 1996, representing a 67 percent reduction (p<0.001). Adolescents -- The proportion of adolescents in Rio who reported always using condoms increased from 25 percent (20/80) to 40 percent (23/57) in girls and 40 percent (23/57) to 77 percent (52/68) in boys (p<0.0001 for both genders). Reported condom use in the last sexual intercourse increased from 30 percent to 39 percent among females and from 50 percent to 58 percent among males. This change, however, was not statistically significant because of the small sample size of sexually active adolescents. The differences between the two variables ("always use condoms" and "use condoms in the last sexual contact") might reflect differences in the frequency of condom use. It is not clear whether the use of condoms in last sexual intercourse reflects the more regular use and whether the variable "always use condoms" represents use with partners adolescents think are of higher risk. The rate of condom usage among the female adolescents in the intervention areas is much higher than the average of Brazilian female adolescents in the same age range. The 1996 National DHS study showed that in the general population only 20 percent of the sexually active female adolescents aged 15-19 use condoms.
Note: It is difficult to make comparisons between the two studies among CSWs in Santos because of different methodologies of sampling. The first study selected 100 high- and 100 low-income CSWs. The second tried to select all CSWs in the city, and collected 650 women. Additionally, CSWs in this city have a high rate of turnover. At any one time, it appears 50 percent of CSWs do not live in Santos -- they come for period of time to work and leave, only to be replaced by more incoming CSWs.
iv. STI General population -- The DHS showed that in the last 12 months, 24.1 percent of women reported STIs or symptoms related to STIs (i.e., vaginal discharge or itching, open sores, ulcers or warts in vulva). Candidiasis was the most common infection (13.2 percent). Other STIs reported were trichomoniasis (3.4 percent), genital herpes (1.1 percent), syphilis, and gonorrhea/genital warts (0.5 percent). The majority of women interviewed who had any symptoms sought treatment through health services (70.3 percent), a little more than half sought publicly provided health care (37.8 percent), and 14.9 percent sought care from the private health sector. Two percent sought pharmacological care only. Among symptomatic women, 42.9 percent took precautions to protect their partner, 32.2 percent practiced sexual abstinence, and 5.3 percent used condoms. Despite the universalization of public health services in Brazil over the last decade, only a small proportion of the female population has routine/preventive gynecological visits and pap smear exams. Among all women interviewed, 60 percent had at least one visit in their lifetime to a gynecologist (excluding antenatal care), and 37 percent reported a visit within the last year. Only 45 percent of all women reported pap smear tests (although it should be taken into consideration 19 percent of the sample were between 15-19 years old and gynecological visits and pap smear exams are not commonly expected at this age). The health services still cover only part of the population and preventive visits are still not routine for most of women. Target population -- Reliable data on the prevalence of STI is very difficult to assess. There is no simple, reliable and cheap test to detect STIs. Additionally, self-reporting of STIs underestimates cases because people frequently do not recognize STI symptoms. Nevertheless, self reported cases might track STI trends if appropriate methodology is used to conduct such a study. In these two KABP surveys with adolescents and CSWs and in both waves, identical methodologies and instruments were used. CSWs -- The percentage of CSW reporting STI dropped from 27 percent in 1993 to 16 percent in 1997. Eighty percent of the latter group was treated in health services. Adolescents -- The proportion of adolescents in the intervention areas of Rio who reported one or more episodes of STI decreased in both sexes from 1994 to 1996. Among girls, this figure decreased from 13 percent (10/80) to 4.5 percent (3/67). A similar decrease was noted among male adolescents, from 14 percent (5/58) to 6 percent (4/68) (p<0.05 for both sex). STIs were treated by a medical doctor in 83 percent (15/18) of male and 71 percent (5/7) of female adolescents. STI Control Program -- AIDSCAP's STI Control Program achieved accessibility of STI treatment. In Santos, STI treatment was decentralized from 1 to 22 health centers covering 100 percent of services. In the State of Rio by the end of the project, 114 health services were trained directly or indirectly by AIDSCAP to apply the syndromic approach. All services were trained to use a syndromic approach and counseling in the handling of STI cases. By the end of the project, treatment for STIs was available in every health unit of the city of Santos and in every town of the State of Rio de Janeiro. During the project a STI health information system (HIS) was implemented in both sites by the health departments as part of the STI control program. The importance of the HIS for the health departments of Santos and Rio de Janeiro can be demonstrated by the number of cases reported in both places. Additionally, congenital syphilis reported in Rio de Janeiro by the HIS had a steep increase of almost 30-fold, from 16 cases in 1994 to 477 in 1996. The larger proportion of women than men in the sampling culled from STI clinics reflect that men tend to treat STIs through pharmacies because it is the easiest treatment. This conclusion is supported by other Brazilian studies, and taken together they reinforce the importance of accessibility to health services. The quality of treatment assessed by the WHO Prevention Indicators 6 and 7 (PI6&7) showed a low compliance to the syndromic approach by the doctors -- especially regarding female treatment. Among 162 patients (20 male and 146 female) in the cities of Santos and Rio, syndromic treatment was used in 50 percent of male but only 3 percent of female patients. Eighty percent of male and 28 percent of female patients were counseled to use condoms and 80 percent of male and 46 percent female patients were educated on their partners treatment. Qualitative studies show doctors have difficulties discussing sexuality with patients, especially in the typical case of a male doctor attending a female patient. Additionally, the syndromic approach is not accepted by gynecologists, medical associations, or universities because doctors tend to follow treatment guidelines with which they are most familiar. The Brazilian universities and medical leaders argue that the US Centers for Disease Control (CDC) itself does not follow the syndromic approach. Changing doctors' behaviors will probably take longer than two years and it is necessary to open discussion with Universities and medical associations to increase support to the syndromic approach. In this context AIDSCAP's translation of the book STD Control and Prevention was a important technical support in the introduction and dissemination of a comprehensive approach among the medical community. Notes about the evaluation studies methodology The evaluation analysis was based on the following studies:
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