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Final Report for the
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3. STI Patients Training on Sexually Transmitted Diseases Management in São Paulo
Background This sub-project aimed to increase the correct management of STI in three urban areas in the State of São Paulo: the metropolitan region, Santos and Campinas; and was implemented by the BUASTI (Brazilian Union Against STI/ União Brasileira Contra As DST). BUASTI is connected to the STI service of the Public Health School of the University of São Paulo. Although São Paulo is the most developed and industrialized state in Brazil, it still has many problems related to poverty. STIs remains a non-tackled problem with large numbers of people seeking treatment through shop assistants in pharmacies and self-medication. As a result, there is an increasing percentage of STI agents resistant to traditional medication. Objectives The goal of this project was to reduce the rates of STI in three selected areas in the state of São Paulo, by expanding the quality of STI prevention, diagnosis and treatment. In addition, the project sought to train Health Care Providers (HCP) in appropriate STI management, strengthen laboratory services for improved diagnosis and detection of drug resistance, increase condom distribution, and produce informative newsletters for HCP for increased dissemination of information. Accomplishments A total of 1,539 STI patients were assisted by the program through the STI clinic of the School of Public Health, University of São Paulo and at the STI clinic in Guarulhos. The STI clinic of the School of Public Health is a traditional STI service for homosexual men in São Paulo city. Approximately 70 percent of the service users are MWM. A further 1,356 medical consultations with counseling and education were performed in the Guarulhos STI clinic. A total of 1,045 VDRL and 192 FTABs were tested, as well as 301 bacterioscopies using the Gram technique. A total of 1,293 other lab tests such as cultures and direct bacterioscopies were also performed. The sub-project distributed a total of 6,500,000 condoms during the life of the project. In 1993, 3,000,000 condoms were distributed to STI/AIDS clinics in target areas. Among theses 1,800,000 were distributed by the Regional Health Offices and approximately 1,200,000 by the Women's Comprehensive Health Program. Since the use of condoms as a contraceptive method is very low, (about 4 percent) it is assumed that majority of condoms were distributed among female STI patients and their partners. In 1994, 3,500,000 condoms were donated by USAID to the Logistic Unit of São Paulo State Health Department and were distributed according to a specific plan. A total of 98 HCPs were trained in STI management in three long-term training courses. This project produced a total of 4 issues of the newsletter "Boletim de la Union Latino Americana Contra las Enfermidades de Transmission Sexual". A total of 128,000 newsletters with updated articles on STIs were distributed to HCPs. Two sentinel surveillance studies were conducted during the life of the project with all STI cases assisted by the sub-project. All patients were tested for HIV-1 through two Elisa and one Western Blot test. In 1993, 9.8 percent of the STI patients were positive for HIV-1 and in 1994, 11.2 percent were positive for HIV-1. Constraints
Lessons Learned/Recommendations
Budget
Process Indicator Summary
Project for the Control and Prevention of HIV/STIs in Santos Municipality
Background The goal of the project was to reduce the rate of HIV/AIDS/STI in the city of Santos through improved diagnosis, treatment and prevention of STI and expanded access to STI services in Santos. This sub-project was implemented by the Health Secretariat of the Municipality of Santos, and OASIS (Organização de Apoio ao Portador do Virus da AIDS/Organization for the Support of HIV Positive People), the non-governmental organization which was responsible for the administrative and financial management of the project. It was originally designed as a three-year project, however received a one year extension to expand the Santos STI model to other Brazilian States. In 1993, Santos, a coastal city of a half million people, had the highest incidence of AIDS cases in Brazil. Although the municipality of Santos has one of the most organized public health systems in the country with 22 polyclinics serving its population, in 1993 only one polyclinic was providing care for STIs. Approximately 10 patients with STI-related complaints were reported per day, and the total number of STI cases reported to the municipality during the one-year period was 519. The syndromic approach for the diagnosis and treatment of STIs was rarely used by HCPs. The only STIs that are required by law to be reported to the MOH are AIDS cases and congenital syphilis. Additionally, an inefficient and passive STI surveillance system was in place when the project began. Objectives
Accomplishments All polyclinics received training on the syndromic management of STIs to provide diagnosis and treatment of STIs. A total of 838 HCPs were trained throughout the life of the project, including physicians, nurses, social workers, psychologists, receptionists, nurses' aides, pharmacists, health educators, dentists, public health personnel and laboratory personnel. A special training was conducted for gynecologists to treat congenital syphilis, and public and private sector pharmacists were trained in STIs. Trained HCPs and polyclinics received copies of technical materials, among them the National Guidelines for the Syndromic Management of STI from the MOH and AIDSCAP/Family Health International's STI handbook, Control of Sexually Transmitted Diseases: A Handbook for the Design and Management of Programs (Portuguese version). Supervisory visits and staff meetings were conducted to discuss STI case management, including diagnosis, treatment, counseling, reporting, condom promotion and distribution of BCC materials; and to determine needs for STI drugs and condom supplies. In addition, technical and BCC materials were produced and distributed at the polyclinics, including manuals, posters, folders, and pocket folders. Part of these materials were produced by the sub-project and part by other institutions, such as the MOH/NACP, the State Secretary of Health in São Paulo and the Health Secretariat of the Municipality of Santos. Condoms were distributed free to all STI patients. Technical assistance in logistics management was provided by John Snow, Inc. for the control of free distribution of condoms and STI drugs in the polyclinics. In addition, DKT do Brasil promoted condom use in Santos through promotional TV campaigns during Carnival, World AIDS Day and other special events, and implemented an aggressive CSM project in pharmacies, supermarkets and alternative outlets. It was estimated that 20,000 STI patients and their partners would be assisted by the project, however a total of 74,988 STI patients and their partners (66,905 female and 8,083 male) were diagnosed and treated, surpassing the original target by over 300 percent. From 1993 to 1995, the Health Secretariat of the Municipality of Santos provided STI drugs as part of its counterpart contribution. In October of 1995, the Health Secretariat of the Municipality of Santos received the first donation of STI drugs from the Ministry of Health/NACP. A STI surveillance system was established in the 22 polyclinics in Santos to record STI data to be subsequently aggregated by the Municipality Center for Disease Control (MCDC). Based on this model, the MOH is presently developing a national surveillance system for STI. Laboratory equipment was donated by USAID/AIDSCAP for the establishment of an STI laboratory in Santos. The laboratory was later expanded by the municipality to perform other tests and syphilis screening for pregnant women. An unforeseen accomplishment of this project was the expansion of STI care and management to include a local women's prison in Santos, whereby in a one-year period 140 female inmates received STI care, counseling and condoms. By the end of this project, the Health Secretariat of the Municipality of Santos had significantly improved skills in report writing, preparing and negotiating agreements, and planning and conducting training programs. Capacity building also resulted in improvements in financial management, budgeting and accounting through adoption of the financial accounting system developed by AIDSCAP/Brazil. The staff gained considerable technical skills in the areas of FGD and KABP survey methods, data collection and analysis, condom programming, and logistics management. Evaluation A pilot study was conducted in 1996 to assess the WHO indicators PI6 and PI7 in the municipality of Santos and the state of Rio de Janeiro. The results indicated that the syndromic approach was utilized in 50 percent of the male cases and 2.6 percent of the female patients. Ninety percent of the male patients reported receiving preventive messages regarding partner treatment, while just 34 percent of the female patients reported receiving these messages. Similarly, 80 percent of the men and 28.2 percent of the women reported receiving counseling on condom use. While the use of the syndromic approach to diagnose and treat STI has increased to 50 percent for males and 2.6 percent for females since the beginning of the project, it is important to note that the increase was not substantially higher due to the resistance of the HCPs to accept the syndromic approach as a valid method to diagnose and treat STI, particularly in the case of women. These data reflect the struggle by HCPs, professors at the University of São Paulo and other opinion leaders to accept the syndromic approach and demonstrate the remaining problems in STI case management, particularly in the diagnosis and treatment of women. The MOH has reported a decline in reported AIDS cases in Santos in the last four years. In 1994, 416 new AIDS cases were reported, while in 1995 there were 374 new cases, and by October of 1996, only 249 cases had been reported. This decrease has occurred despite the improved surveillance system, and although further research is needed to determine the contributing factors, it does appear to be the result of Santos' integrated approach to combat the epidemic. Constraints
Lessons Learned/Recommendations The frequent and systematic supervisory visits to support the trained HCPs and polyclinics were a key factor in ensuring the quality and quantity of STI case management. The visits allowed for further discussion and instruction on the implementation of the syndromic approach and proved useful in the sensitization of gynecologists to STI, since most did not consider some cases of vaginal discharge as STI and did not report these cases. In addition, the supervisory visits motivated the HCPs to expand STI care beyond the clinic walls, with one of the unexpected results being the provision of STI care to female inmates in a local prison. The provision of STI drugs by the Health Secretariat of the Municipality of Santos as part of its counterpart contribution was an essential component of the program. It allowed the project to diagnose and treat the target populations of the other USAID/AIDSCAP-funded projects, such as low-income CSWs, harbor workers and truck drivers, who otherwise may have had difficulties affording the treatment. While significant improvements in surveillance, data collection, and STI diagnosis and treatment have been made during the life of this project, further improvements can be made in these areas as well as in the quality of STI care and in the partner referral system. Interventions to address the practice of males seeking STI treatment at pharmacies need to be considered. Training of pharmacists on STI is one approach, but strategies should also be developed to improve male attendance at STI polyclinics. AIDSCAP/Brazil also recommends the implementation of a pilot study, similar to the Mstop project in Cameroon, whereby STI kits based on the syndromic approach are distributed to men seeking treatment in pharmacies. Studies are also needed to better identify and understand the factors involved in the decline of reported AIDS cases in Santos. AIDSCAP/FHI's STI handbook should be translated into more languages for further worldwide distribution, based on the overwhelming response the Portuguese version received by the HCPs and polyclinics. Budget
Process Indicator Summary
Prevention and Control of STD in Rio de Janeiro
Background The Prevention and Control of STIs in Rio de Janeiro project aimed to expand and improve the quality of diagnosis and treatment of STIs within the state of Rio de Janeiro by developing training activities for health care providers (HCPs) and by adopting the syndromic approach model. These activities took place in 24 primary health care facilities, located in 16 municipalities in the state of Rio de Janeiro, covering 8 administrative regions. The sub-project was implemented by the State Health Department of Rio de Janeiro and the Institute of Religious Studies (ISER). This sub-project was developed within the context of the action plan proposed by the MOH and the state program. In 1992, the MOH received financial support by the World Bank for a National Project of STI and HIV/AIDS Prevention and Control. This AIDSCAP sub-project was integrated into the World Bank project, adding activities complementary to the MOH program. The activities developed under the AIDSCAP sub-project were expanded to another 67 municipalities through the MOH project, which began one year later. Objectives
Accomplishments During the life of project a total of 12 training courses on STI syndromic management were attended by 119 HCPs. Six training courses were replicated at regional and local levels training an additional 516 HCPs working in 90 health clinics. Moreover, 311 HCPs received STI syndromic approach training through the 119 HCPs trained at the central level. Another 177 people were trained in other areas, such as logistics and HIS, in order to support the sub-project. Thus a total of 1,123 HCPs were trained over the life of the project. A Health Information System (HIS) was implemented and STI surveillance was improved significantly. As a result of the HIS, 12 municipalities sent notification forms regularly during 1995. In 1996 and 1997 all of the project municipalities sent STI case reports. There was a marked improvement in STI notification and reporting during the life of the project due to the HIS implementation. In 1994, only five STI cases were reported; 10,469 STI cases were reported in 1995; and 17,113 STI cases were reported in 1996. In 1997 (January to June) a total of 7,354 STI cases were reported. Similar results were observed with the case reporting of congenital syphilis (from 1994-1997). In 1994 only 16 cases of congenital syphilis were reported in the state, compared to 311 cases reported in 1997 (January-June). Constraints Most of the constraints faced by this sub-project were related to the status of public health care provision in Brazil, such as insufficient supplies, high turnover of personnel, political changes and lack of infrastructures. For the success of STI case management, it is essential to have available drugs for the treatment of patients. However, this sub-project depended on the MOH for STI drugs which arrived 10 months after the sub-project had started. Another major problem was the high turnover of HCPs and their lack motivation to participate in the project. This was particularly true in the case of physicians, since the sub-project involved a one-week training far from their municipalities. Due to low salaries versus the high cost of living in Brazil, it is common for doctors to have more than one job, and many cannot afford to stop working for an entire week. Lack of transportation for supervisory visits to the municipalities was also an important constraint during project implementation. This was resolved in September 1995, when a van was bought with MOH/World Bank funds. Although STI data reporting has increased significantly during the life of the project, this was an important constraint faced by project staff, since the only STIs required by law to be reported to the MOH are AIDS cases and congenital syphilis. There was also some resistance from the HCPs to integrate the STI program into the other existing primary health programs. Thus, one of the goals of the supervisory visits and team meetings was to show the disadvantages of a vertical program. Evaluation A pilot study was conducted in 1996 to assess the WHO indicators PI6 and PI7 in the municipality of Santos and the state of Rio de Janeiro. The study utilizing exit interviews with STI patients was conducted by trained interviewers in 12 primary health care centers in Santos (São Paulo) and in 13 health centers in Rio de Janeiro, using a structured, pre-tested questionnaire. A total of 162 patients were interviewed, 20 men and 142 women. Approximately 50 percent of the drugs prescribed were recommended by the MOH, and the syndromic approach treatment was prescribed in 50 percent of the men and in 2.6 percent of the women. Preventive messages concerning partner treatment were reported by the patient in 90 percent of the men, and in 34 percent of the women. Condom promotion was reported by the patient in 80 percent of the male patients, and in 28.2 percent of the female patients. These data reflect the struggle by the HCPs and other opinion leaders to accept the syndromic approach and demonstrate the remaining problems in STI case management, particularly in the diagnosis and treatment of women. Lessons Learned/Recommendations The main objective of the prevention program activities was to prevent HIV infection. Preventing STIs effectively prevents HIV. Simple etiological diagnosis and treatment does not offer much in the way of a prevention program, especially given the current structure of the public health system in Brazil. The syndromic approach to STI management has shown itself to be both viable and pragmatic. The procurement and distribution of STI drugs is costly, but the cost benefit is high. STI management strategies which consider only clinical diagnosis have shown themselves to be ineffective from the public health perspective. The syndromic approach to STI case management, which is based on the detection of clinical symptoms and signs also has its limitations, and should be complemented by methods of identification and treatment of asymptomatic individuals. The MOH met with a group of STI experts to determine the exact medications to be used for HIV treatment in Brazil, and recommended that medication and condoms should be available in all treatment centers. A new medical supply system capable of supporting the state health network is being implemented. The new system demonstrates how stock problems resulting from insufficient training can be avoided. Due to training, 100 percent of the municipalities send their stock re-supply requests to the central supply center, which in turn uses these requests to plan the allocation and distribution of medication to health centers. This system allows stock to be distributed as needed, and avoids the problem of depleted stock, allowing medications and condoms to be supplied to clients on a regular basis. Regular supervision of health centers by trained teams is essential. Continuous direct contact is necessary for supervisors to identify and understand any problems encountered during the admission, diagnosis, explanation of treatment, and counseling of clients. Early detection and correction of difficulties in the system could prevent repeat infections among clients and their partners. The recognition of system limitations allows supervisors to develop solutions and to follow the program guidelines and procedures. STI prevention activities have been integrated with those provided by the Programa de Assistencia Integral à Saúde da Mulher, Criança e Adolescente (Integrated Health Program for Women, Children and Adolescents). These services were linked due to the fact that 70 percent of STI clients are women who attend gynecology and pre-natal clinics, and because the most serious health-related consequences tend to occur among women and newborn children. The current stage of development of the MOH STI program requires the consolidation of monitoring and evaluation mechanisms. The methodology being used within the health centers presupposes the utilization of data via standardized monthly forms (notification of the number of STI cases and management of medications and condoms). Activity reports and reports of meetings with municipal program managers are one way of assessing difficulties occurring at the local level, especially if supervisory visits can only be made on an annual basis. The evaluation study carried out by AIDSCAP in 1996 showed that adapting the methodology in this way can be useful to assess a number of indicators; for example, the client's perception of the quality of care provided, risk assessment and changes in attitude and behavior in relation to relative risk of STI/HIV. In the health clinics where the sub-project was implemented, STI syndromic management proved to be effective. Regular supervision of the health centers by trained teams is essential. Continuous direct contact is necessary for supervisors to identify and understand any problems that may occur during the admission, diagnosis, explanation of treatment, and counseling of clients. Despite the improvement in STI case reporting, efforts in STI case management should continue in Rio de Janeiro as there are still many steps to be taken in order to expand these actions. The STI programs in Brazil were implemented due to the relevant counterpart contributions from local government that committed resources for the procurement of STI drugs. In the recent review conducted by the World Bank of the national STI/AIDS Program they decided not to provide resources in the second loan to Brazil for STI drugs. This decision is due to the fact that STI drugs were used to treat other health pathologies at local levels. It is highly recommended that the MOH/World Bank review this position, as addressing STIs are key for HIV/AIDS prevention. In order to meet World Bank requirements, a logistics system should be established. The examples of the AIDSCAP projects implemented for STIs in Santos and Rio de Janeiro should be taken into consideration. Budget
Process Indicator Summary
** 12 seminars were developed centrally and at least 6 locally by the multiplier. The process of multiplication is still continuing. Cohort Study of High-Risk Populations for HIV Infection in Brazil
Background The goal of this sub-project was to decrease the transmission of STI and AIDS among the harbor workers in Santos. The Center for AIDS Prevention Studies (CAPS) of the University of San Francisco California developed the project in collaboration with the Health Secretariat of the Municipality of Santos, and a local NGO, Santos Association for Research and Intervention (ASSPE). The intervention was designed for the harbor workers in Santos following the cohort study design and implemented by CAPS for this population. Santos is the major port in Latin America and receives hundreds of ships from all over the world and thousands of trucks daily. The port is very large and has approximately 20,000 port workers. Since AIDSCAP was already focusing interventions on CSWs and STI patients in the city, it was important to develop an intervention for harbor workers using the established structure for behavioral research, providing BCC materials, condom access and other HIV/AIDS prevention activities. Objectives
Accomplishments The project was developed by a team of six trained health agents who visited the harbor daily working in pairs. Activities consisted of face-to-face contacts, safer sex "demonstrations", workshops, video debates, counseling and referrals for STI treatments, and distribution of condoms and BCC materials. Other activities planned included selection, recruitment and training of health professionals and weekly supervision of health agents. Contacts were made with the local health system to ensure that harbor workers had access to STI diagnosis and treatment. Four training courses were conducted for peer educators and a total of 56 harbor workers were trained in a 12-hour training. These peer educators had no special assignment in the project but to gave institutional support to the project activities. Evaluation A Cohort Study among Harbor Workers was conducted by CAPS/UCSF and ASSPE (FCO# 44045) from January 1994 to August 1996. A total of 601 male harbor workers aged between 25 and 55 were randomly selected and invited to participate in the study. Interviews and blood samples were collected for 395 men in the first wave and 394 in the second wave. The study population was randomly selected from the Santos Port Authority harbor workers. These men are relatively stable harbor workers; most of them are married and have families. In the baseline of 1994, 1.1 percent were found to be positive for HIV, 2.2 percent were positive for syphilis and 38 percent reported a history of STIs. After one year no one became HIV positive, however six men (1.5 percent) became positive for syphilis. The knowledge about HIV transmission was high (HIV can be transmitted by needle sharing - 98 percent, sex intercourse without condom - 97 percent, and only homosexuals are in risk of AIDS - 93 percent). Ninety-one percent reported that condoms were never used with their regular partner. Twenty-six percent reported having had more than one sexual partner in the past year, and only 42 percent of those reported consistent condom use during vaginal sexual intercourse, and 7 percent during anal intercourse. After one year, the proportion of men with more than 1 partner remained the same (26 percent). However the proportion of men who never use condoms with regular partners was reduced to 55 percent and qualitative studies suggest that these workers have a low-risk perception. Due to their work environment, they believe themselves to be very powerful and not vulnerable to diseases, including AIDS. Constraints
Lessons Learned/Recommendations
This was the first large intervention project developed for harbor workers in Brazil and the lessons learned as well as intervention techniques created an important model for the country. Considering the increase of AIDS among women, it is crucial to foster intervention programs for married men. Budget
Process Indicator Summary
AIDS Prevention and (STI treatment) among Street Children and Low-Income Youth in Rio de Janeiro
Background Rio de Janeiro State is the second most affected by the AIDS epidemic in Brazil with a total number of 15,092 cases in 1996, and the city of Rio Janeiro has 64 percent of the AIDS cases in the state. Analysis of the epidemiological data shows that the most affected age group is between 25 to 44 years old. Considering the long incubation period of HIV infection, it is probable that many were infected during adolescence. This sub-project was designed by Childhope-New York, a US based PVO, in collaboration with Childhope-Brazil. Childhope-Brazil worked in close collaboration with the Adolescent Health Clinic (UCA) which is now called NESA, and is a nucleus of study of the State University of Rio de Janeiro (UERJ). Objectives The goal of the project was to stabilize or reduce HIV/STI prevalence among low-income youth in Rio de Janeiro. Its purpose was to decrease high-risk sexual behavior among youth in favela and street youth in target areas of Rio de Janeiro by providing AIDS education, STI information, diagnosis and treatment and general health services. Accomplishments This sub-project focused on activities among poor adolescents living in slums, shelters and streets in the city of Rio de Janeiro, where violence and drug trafficking are daily threats. In conjunction with the target population, project coordinators decided to call this sub-project Projeto Papos, which roughly translates as the "Chat project". During the life of the project, a total of 108,971 adolescents were reached by project teams, street educators or teachers trained through a series of educational activities such as group discussion, face-to-face interventions, safer sex workshops, video presentations, theater presentations, lectures, context participation, brochures, pamphlets, newsletters and other materials. In addition, adolescents were diagnosed, treated and counseled on STI, a condom distribution program was developed and special events were promoted. Educational interventions for adolescents were developed following a holistic approach in which human sexuality, reproductive health and rights, exercise of citizenship, self-esteem, and human rights were discussed. All these subjects were very important to be addressed because of life conditions of adolescents living in slum areas, streets and shelters of Rio de Janeiro. A broad understanding of the environment was essential for the project team to understand and design proper intervention activities. The project developed participatory and dynamic activities which are very much appreciated and interesting for young people and therefore more enjoyable and effective. Evaluation A total of two quantitative studies and one qualitative were conducted during the life of the project. Data showed that the perception of the existence of AIDS increased from 93.4 percent to 99.0 percent (p<0.01). Condom use was the preventive means more frequently cited to prevent HIV transmission (94.6 percent among females and 96.2 percent among males). Among the sexually active adolescents there was an insignificant increase in risk perception of getting infected among the males (57.1 percent to 70.6 percent). Sexually active females no change was found in risk perception between the two studies (64.5 to 66.7 percent). The proportion of adolescents who reported consistent condom use increased from 25 percent (20/80) to 40.4 percent (23/57) among girls and 40.4 percent (23/57) to 76.5 percent (52/68) among boys (p<0.0001 for both genders). The use of condoms in the last sexual intercourse increased from 30.4 to 38.7 percent among females and 50.0 to 57.6 percent among males. There was a decrease in STI occurrence in both sexes: 12.5 (10/80) to 4.5 percent (3/67) among female and 13.8 percent (5/58) to 5.9 percent (4/68) among male adolescents (p<0.05 for both genders). Data on children recruited through the residential shelter showed that 80 percent of adolescents identified at least two prevention strategies and there was 100 percent increase in reported condom use during last intercourse. Constraints Administrative Changes -- Changes in the administrative staff delayed project start which shortened the life of the project affecting its results. Condom distribution -- There were different positions among the school heads regarding condom distribution. Many were resistant to have condoms distributed arguing about the legality of this procedure and concerned about parents' complaints. Strikes -- During the life of the project there were several strikes affecting school classes and project planning and schedule. Violence -- Situation of violence related to the drug traffic wars interrupted project activities many times. The situation of vulnerability the adolescents faced due to drug traffic also affected their participation in the project activities. Non-Approval of the COAS -- The unexpected non-approval of the Anonymous HIV Testing Center (COAS) has affected project results since some goals could not be reached. Lessons Learned/Recommendations The development of a partnership with governmental organizations produced important results. It facilitated the accomplishment of tasks through institutional support and sensitized heads of programs to the needs of the target population. Working with teachers and community leaders is an important strategy to reach young people. Training must emphasize life conditions of low-income youth and their needs. In addition, the use of peer educators to reach target populations is also an important strategy to reach young people. Since young people are still learning about their sexuality they want further information and orientation on the subject and not only about STI/AIDS prevention. The challenge seems to include such messages within educational activities meeting the needs and interests of the youth. Although youth have a high level of knowledge about HIV/AIDS, believe that HIV/AIDS exists, that condoms are effective and have a high-risk perception, the increase of condom use was found relatively low but significant. This suggests that there are influences of social forces especially sexual scripts. In fact, gender inequality concerning condom use and sex negotiation is a major finding of the qualitative study. This showed that there is clear and conservative sex double standards among teenagers. In addition, the notion of sex as uncontrollable and the image of the passionate short-term encounter are pervasive among young people. This idea fits into both gender scripts, which certainly influence the attitudes and behavior related to STI/AIDS prevention. Sexual activity was found as irregular and associated with specific social events -- such as parties and rap dance -- where drug and alcohol are used to encourage loss of control. There is a need to discuss drug use, sexual abuse and sexual coercion. Sexual coercion may also complicate the ability to negotiate sexual relationships, to communicate to partners and to feel one has control over his/her body. Given that traditional classroom-based AIDS education -- which tends to be information-based instead of values or feeling-based -- seems to have no impact either to level of knowledge about AIDS or condom use, alternative methodologies should be considered. The lack of clear and specific laws regarding condom use by adolescents hinders the discussion of HIV/AIDS prevention, especially in schools. Budget
Process Indicator Summary
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