|
Programs |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Final Report for the
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
1. Men with Men AIDS Prevention for Men who Have Sex with Men
Background This was a sub-project developed by ABIA (Associação Brasileira Interdisciplinar de AIDS) in Rio de Janeiro in association with Grupo Pela Vidda in São Paulo. For the first time in Brazil a large-scale program was developed for the population group that has suffered the greatest impact from the AIDS epidemic. According to the Epidemiology Bulletin of the National Program of Sexually Transmitted Diseases and AIDS (PN STI/AIDS), 40 percent of reported AIDS cases are related to sexual transmission among homosexual and bisexual men. This shows that despite the growing numbers of women affected by the epidemic in Brazil, men who have sex with men are still vulnerable to HIV infection. These figures illustrate and justify the necessity of a project specifically aimed at the prevention of HIV/AIDS within this population. The sub-project aimed to de-mystify the relation between homosexuality and HIV/AIDS, and encourage the development of an environment of social support to reduce high-risk behavior among homosexual and bisexual men. Objectives
Accomplishments Safer-sex promotion among the MWM community in Rio de Janeiro and São Paulo included site visits by peer educators with face-to-face interventions, safer-sex workshops and debates, production and distribution of BCC material including condoms, STI referrals and expressionist theater workshops.
Evaluation Two HIV seroprevalence studies among men who have sex with men carried out in São Paulo showed similar figures: 12.2 percent in 1988(1) and 13.9 percent in 1995-96(2). In a cohort study of 594 MWM, a 1.42 percent per year(2) incidence was found. In Rio de Janeiro, the results were not as consistent with a 25 percent seroprevalence rate found in 1987-89(3), 25 percent in 1995(4), and 8.9 percent in 1995-96(5). A cohort study among 600 men found an incidence per year of 3.4 percent, however half of the sample were male prostitutes or bisexual men (5). The knowledge of HIV prevention methods has risen and awareness was high in both cities in 1995. It is interesting to note that in Rio de Janeiro the most frequently cited preventive method is condom use, (91 percent) whereas in São Paulo the method most often cited (95 percent) was reducing the number of partners. The proportion of MWM who have zero or only one partner in both São Paulo (45.6 percent) and Rio (42 percent) has not changed much in the last 5 years. However, the use of condoms ("always use condoms") has shown an important increase: from 21.3 percent in 1989, 60 percent in 1992 88 percent in 1993, and 93 percent in 1995(6) . (1) Dias, M.B. (1988/89) Another important change in the perception to negotiate safe sex was the proportion of men who would not accept having unsafe sex, going from 40.4 percent in 1989 to 81.7 percent in 1994. In 1994, 84.3 percent reported they were at risk while only 18.7 percent said that in the passion of the moment they do not think of having safe sex. Data showed that a change occurred in the perception of the risk of HIV infection, complemented by an increase in awareness of prevention. In spite of these changes, there is still the occurrence of high-risk sexual behaviors because of low citizenship awareness, insufficient schooling, and other social problems. These statistics should be taken into account when designing other AIDS prevention programs. Qualitative data shows that prejudice against homosexuals is an important factor for high-risk behavior. The individuals who exposed themselves most to the risk of infection are the ones who suffer from the conflict of homoerotic desire versus the difficulty of coming out as homosexual. The study shows that effective prevention must address the struggle of intolerance for moral and physical reasons. Constraints A discrepancy between the implementation of the sub-project with the implementation of the STI project in Rio de Janeiro followed by delays on the procurement and shipment of STI drugs to the states. These generated important delays in the availability of STI treatments in the region. Social discrimination and physical violence against homosexuals is a problem in Brazil. The persistence of high-risk behavior among men who have sex with men is closely associated with the social isolation and internal conflicts caused by moral prejudice. The project had difficulties in reaching gay and bisexual youths, especially those belonging to low-income strata of society. Lessons Learned/Recommendations
Budget
Process Indicator Summary
HIV/AIDS Prevention for Men who Have Sex with Men
Background The project continued to promote public discussion about sexual practices and behavior between same-sex oriented men and the discrimination and stigma resulting from such practices and behavior. The project also helped increase the level of awareness regarding the necessity of group action and an atmosphere of solidarity in the movement towards collective change. The main goal of this sub-project was to reduce HIV infection among homosexual and bisexual men through the continuation of successful sub-project outreach activities. Objectives The primary objectives of the original project were to demystify the relationship between homosexuality and HIV/AIDS, to encourage the development of social services necessary to reduce the levels of high-risk behaviors of men who have sex with men, and to address specific issues that had been brought to light by the original project, such as adolescence and homosexuality, seropositivity and bisexuality. Accomplishments Sub-project activities included interventions at gay community sites, expressionist theater and cultural workshops. To support interventions, BCC materials were produced and distributed, including the ABIA Bulletin (a circulation of 20,000 copies) about STI; providing addresses of hospitals and health centers for STI treatment and HIV testing; distributing 22,856 educational materials (from both phases of the MWM project) and 15,000 postcards aimed specifically at gay adolescents, seropositive individuals and bisexuals. A total of 7,622 condoms were distributed in all activities and during specific events, such as Carnival festivities.
Besides intervention activities, this sub-project developed activities to invite the participation of other interested groups who could use this experience as a model for interventions. A database was developed to catalog all of the materials produced by the Project MWM, in both phases (93-95 and 97). This database, the documentation, and the widespread dissemination activities results can provide the basis for the creation of an action group focused on increasing the solidarity among populations affected by HIV/AIDS. It can also serve to stimulate the development of similar projects in other cities in Brazil and Latin America. Two books were produced during the life of the project, one about Homosexuality in Brazil (in press) and other containing the script of the play Cabaret Prevenção which was produced by the members of the Expressionist Theater workshop. In addition 5 articles and essays were produced and submitted for publication in scientific journals. Two manuals were produced (in press) documenting the experience and the methodology of the Expressionist Theater workshops and of the weekly Gay Cultural Sessions. To disseminate this sub-project ABIA participated in national and international seminars, conferences and congresses One important result of the Project MWM was the replication of the AIDSCAP/ABIA Prevention Model for MWM. Between 1993 and 1995, when ABIA started to work in collaboration with AIDSCAP for the implementation of intervention programs for MWM, few initiatives targeted this population in Brazil. Through dissemination of work at seminars, meetings and conferences, a series of projects following the ABIA model are being implemented in several capital cities such as Fortaleza, Belo Horizonte, Port Alegre, São Paulo, Londrina, and other cities in Brazil. The Project MWM became a resource for the development similar projects in the country at both the national and international level. The Project MWM participated in a meeting with the Ministry of Health to define the policies of the ministry in relation to the male homosexual population of the country. The work and the experience of the Project MWM also provided the initiative for the regional meeting organized by ONUSIDA in Colombia in June, 1997, whose objective is to establish a policy for the prevention of HIV/AIDS within the MWM population in Latin America. Constraints The interruption of the previous project in December 1995 due to budget cuts from AIDSCAP LAC/Regional Office to AIDSCAP/Brazil Program was a major constraint in this sub-project. Activities were interrupted and project-trained staff left ABIA. Because of the short time available for project development, some of the objectives were not fully met. The issues of bisexuality, seropositivity, and adolescent homosexuality proved to be more complex than anticipated and need to be addressed in the future. The topic of bisexuality was addressed by specific themes in the workshops. It was noted, however, that this is an extremely complex subject, due to the disassociation of bisexuals between their sexual practices and social identity. To work with adolescents proved to be very complex since adolescents are less likely to have known people who have HIV/AIDS, or to have seen people die from the consequences of AIDS. To adolescents, AIDS seems distant and unreal. They know that HIV/AIDS exists, but their life experience does not reflect that knowledge. Furthermore, this group behaves with the characteristic attitude of denial, thinking "This will not happen to me "1 . The implementation of the social marketing of condoms was biased on the uproar provoked by the media about the inferior quality of both domestic and foreign condoms sold in Brazil. There were some difficulties with the intervention work in the saunas frequented by MWM. The dynamic in the saunas is completely different than that in open places such as bars, clubs, and beaches. Due to the anonymity in the saunas, the peer educators are unable to explain their presence in any detail, thus giving them the appearance of not "belonging" in the saunas. 1 Castelo Branco et al. (1996) AIDS and Education: an invitation to prevention. Rio de Janeiro, ABIA. Lessons Learned/ Recommendations HIV/AIDS prevention should not be limited to information dissemination. Studies have shown that the level of knowledge about HIV/AIDS within the homosexual population is quite high. However there is a need for formal and informal networks to allow people to share their knowledge and experiences, as well as the social and psychological aspects surrounding the issues of AIDS and homosexuality. These topics need to be presented in positive light with respect to sexuality. Such an approach promises to facilitate behavioral change, and is more likely to take place within community networks. The issues of violence and discrimination play an important role in all aspects of the daily lives of men who have sex with men (in their personal lives, at home, in the workplace, and from police). This reinforces the vulnerability of this population, in relation to the HIV/AIDS epidemic and other STIs, and in relation to civil rights. The Project MWM/97 looked for ways to integrate the forces of this community through increasing their knowledge and working toward equity, and in creating opportunities for community mobilization and development. The project publications (brochures, manuals and books) clearly show the worth and the importance of the social and psychological support networks established through the workshops. Future HIV/AIDS work needs to more fully address the issues of bisexuality, seropositivity and adolescent homosexuality. Specific projects aimed at these populations need to be developed, to enable the idiosyncrasies of each population to be better observed, identified and addressed. In this way, interventions aimed at these groups are more likely to succeed. In relation to bisexuality, the construction of a positive social identity needs to be addressed, and interventions need to include strategies for dealing with blame, prejudice and discrimination. There are very few studies that have examined this group and their characteristics. Sound scientific studies and reliable data about bisexuality would be extremely helpful in the design of interventions for these men. Future discussion about bisexuality should include a dialogue with feminist groups including guidelines for discussions about reproductive health. This suggestion is based on the great number of women that are infected by HIV through sexual relations with bisexual men. It is essential that women's groups understand the importance of this issue and include it on their agenda and in their discussions. As regards to seropositivity and living with AIDS, it is important to reinforce life experiences and to increase access to information about therapies, treatments, and safer sex techniques, among other issues. Future projects should include ethnic issues of homosexuality, and there should be an increased dissemination of HIV/AIDS information among other marginalized and impoverished populations such as the Black-Brazilian community. It is the important to open and maintain social and psychological support networks, not only for MWM but also within the general population. It is through this network of support that issues such as citizenship, human rights, and legal rights, among others, can be fully developed. The stimulation of cultural events such as plays and street theater also play an important role in the prevention of HIV/AIDS. The issue of STI prevention should be included in HIV/AIDS prevention for men who have sex with men. There is a general lack of knowledge about STI transmission, particularly hepatitis B, herpes, and parasitism. This recommendation is especially helpful for people already infected with HIV who should be careful to avoid other infections that affect the immune system. Additional efforts to increase STI awareness diagnosis, treatment and prevention are important. Recent studies conducted in São Paulo during 1997 are showing a relapse in the adoption of safer sexual behavior among gay men. There is an important need to access the impact of the cocktail in the adoption of safer behaviors and an increase in the number of people who believe that the cocktail can be used as a "day after pill" to prevent infection. Budget
Process Indicator Summary
Education Intervention for CSWs in Fortaleza, Ceará and São Luis, Maranhão
Background The goal of this project was to promote safer sexual practices among CSWs and their clients and to prevent the spread of HIV infection in Fortaleza and São Luis. The Northeast region in Brazil is the poorest area of the country, and prostitution among the low-income population is a way of survival. During the AIDSTECH project, a group of leaders and community agents in Fortaleza and São Luis were trained for HIV prevention among CSWs and their clients and developed an outstanding program. The success of the program was extended to AIDSCAP in order to continue activities through IMPACT/InterAIDE (Implementing Agency for Cooperation and Training). The project used peer educators to reach CSWs and clients through the use of BCC materials and condom social marketing, aiming to encourage safer sexual behaviors and consistent condom use, and to improve access to STI diagnosis and treatment. Objectives
Accomplishments Activities planned were training of health agents recruited among target population; weekly supervision of peer health agents, and face-to-face interventions at commercial sex sites by peer educators providing counseling, information and referral for STI treatment. The activities included 3,297 visits to prostitution sites where educational activities were performed with condoms and BCC materials distribution. Other activities included formal and informal meetings at commercial sex sites. A total of 72 specialized campaigns were organized. An additional 19,310 persons not belonging to the target population were reached by the program during Carnival time and World AIDS day. Peer educators received recognition from their communities and were invited by schools to provide HIV/AIDS education. In addition, most of the women are no longer working as prostitutes. This project since its inception developed relationships with local and national organizations through collaboration in AIDS prevention activities. The shared experiences, from conferences to condom distribution, have forged an informal network in each city. Two associations were formed by the teams of multiplicadores, and have matured into local partners: APROCE in Fortaleza and Fundação InterAIDS in São Luis. Presently the MHO/World Bank and the European Community are funding project activities. Based upon this experience and lessons learned under AIDSTECH/AIDSCAP, the European Community is funding a large intervention project for CSWs in 9 Brazilian states using the same methodology.
Evaluation The quantitative KABP surveys conducted in 1992 and 1993 among 500 CSWs showed the following relevant results in reference to behavior change. In November 1992, 12 percent of CSWs reported always using a condom, in November 1993, 34 percent reported always using a condom. In 1993, 99 percent of CSWs interviewed had extensive knowledge of AIDS. In 1992, 42 percent reported not using condoms with boyfriends, however in 1993, only 33 percent reported not using condoms with their boyfriends. Constraints Lack of proper STI diagnosis and care by the public sector during project implementation. Lessons Learned
Budget
Process Indicator Summary
Education Intervention for CSWs and their Clients in Municipality of Santos
Background This sub-project aimed to reduce the spread of HIV/STI among CSWs and their clients in Santos. It was implemented by the Health Secretariat of the Municipality of Santos, São Paulo, Brazil and by OASIS (Organização de Apoio ao Portador do Virus da AIDS/Organization for the Support of HIV Positive People) a non-governmental organization which was responsible for the financial and administrative management of the project. It was originally designed as a three-year project and extended through May 30, 1997, in order to expand the Santos CSWs model to other Brazilian states (Ceará and Bahia). Santos, a coastal city of a half million people, had the highest incidence of AIDS cases in Brazil at the beginning of this sub-project. Santos is a major harbor in Latin America with a workforce of 20,000 harbor workers. The port receives approximately 1,800 ships annually and attracts numerous sailors and truck drivers. By 1989, the harbor area was stigmatized because of the high prevalence of AIDS cases and a large, visible prostitution area. A seroprevalence study conducted in 1991 among low-income commercial sex workers (CSWs) showed that 27 percent were HIV positive and 69 percent tested positive for syphilis. Santos is also part of the international drug route in Latin America, making drugs easily accessible in the city. Furthermore, it is a tourist destination that attracts more than three times its population size during holiday and summer months. Objectives The main objective of this project was to decrease the risk of HIV/STI transmission among CSWs and their clients in Santos through the promotion of safer sexual behaviors among these populations. Activities of the project included training of outreach workers, educational interventions with CSWs and their clients, distribution of BCC materials and condoms, and the improvement of STI treatments. Integration of activities with other USAID/AIDSCAP-funded projects in the city included the expansion of STI care, an intervention for harbor workers, a comprehensive condom social marketing program and technical assistance in the area of logistics management for condoms and STI drugs. Accomplishments A fieldwork team (comprised of 10 health professionals and community agents) was trained to conduct outreach work with CSWs and their clients in human sexuality, HIV/AIDS/STI, education and counseling techniques. The team mapped the geographic area for project implementation and identified the commercial sex trade sites which were visited over the life of the project. From August 1996 to May 1997 project activities were funded by the national STI/AIDS program of the MOH after concluding that the continuation of these interventions was crucial.
As part of the integrated approach to HIV/AIDS/STI prevention in Santos, CSWs were referred for STI treatment and care to the polyclinics trained in the syndromic management approach to STI treatment. Some CSWs were reluctant to seek STI care at the polyclinics due to the time spent in the waiting room and potential loss of earnings, so in 1995 a mobile clinic was purchased with funding from the MOH/World Bank loan to provide STI services in the neighborhoods. The one-year extension of the overall AIDSCAP contract provided the opportunity to expand the experience of this project to the northeastern states of Bahia and Ceará. Evaluation Despite the improved surveillance system, a decrease in the number of reported AIDS cases has been observed in Santos since 1994. At the beginning of this sub-project, Santos had the country's highest incidence of AIDS (287 per 100,000). In 1994, the incidence decreased to 99.49 per 100,000 inhabitants, and by 1996, it had decreased to 59.47 per 100,000. Although there are some discussions that this could be a deflection of the first wave of the epidemic and a second wave will start soon, the MOH argues that it is the efforts of the integrated interventions in Santos that have contributed to the decline in the number of reported AIDS cases. Partial results from the quantitative research study being conducted among CSWs by the MOH and the Health Secretariat of the Municipality of Santos show an increase in knowledge of HIV/AIDS and modes of transmission from over 80 percent to more than 90 percent. However, reported condom use with clients appears to have decreased (96 percent in 1990/91 to 84 percent in 1996), although this may be attributable to the migratory flow of the CSWs. As these data are partial with final results not available until May 1998, the data should not be definitively interpreted. However, the results appear to indicate the need for continued interventions with CSWs and their clients, with particular emphasis on condom use with regular partners. A focus group discussion conducted in July-August 1995 reinforced the study's finding that condom use with regular partners is low (18 percent). Constraints
Lessons Learned/ Recommendations
Budget (original)
Process Indicator Summary
1This number reflects the number of contacts with the CSWs and clients during educational interventions. CSWs and clients were systematically and repeatedly reached during the life of the project. AIDS Prevention with Commercial Sex Workers in the Metropolitan Areas of Rio de Janeiro
Background The AIDSCAP sub-project Commercial Sex Workers (CSWs) AIDS Prevention in the Metropolitan Area of Rio Janeiro aimed educational interventions to CSWs in Rio de Janeiro, focusing on the promotion of safe sex through peer education and outreach work. The city of Rio de Janeiro is located in the Southeast region of Brazil, the area most affected by the AIDS epidemic. The State of Rio de Janeiro has a population of about 13 million people, 44 percent of this population living in metropolitan Rio de Janeiro. Besides being a tourist destination famous for its beaches, the city also has a major harbor. This environment attracts an important migration flow of all social classes, especially the poor. Historically commercial sex has been an important activity in the city since Rio was the capital of the Portuguese Monarchy. It has been estimated that the city alone has about 5,000 CSWs. This sub-project was planned to assist 15 commercial sex areas in the metropolitan area of Rio de Janeiro, comprising an estimated population of 7,000 CSWs. Objectives
Accomplishments The project was developed by a team of five people working with 10 peer educators (called "health agents"). Six university students participated through Civiu, a theater group responsible for street interventions carried out during special events. Activities planned to support these efforts included training of health agents recruited among the target population; weekly supervision of peer health agent activities; and face-to-face interventions at commercial sex sites by peer educators providing counseling, information and referral for STI treatment for CSWs and clients. Other activities included formal and informal meetings at commercial sex sites and meetings with those responsible for the local health system, to ensure CSWs and their clients access to STI diagnosis and treatment. Contacts were also made with managers and clients of commercial sex establishments informing them about the main STI referral centers. In addition, special events were held with a total participation of 163,291 people. The sub-project also achieved the important role of supporting the political discussion about citizenship and conditions of CSWs. Meetings and seminars were conducted in which the legal situation of CSWs, STI/AIDS prevention, safer sex and specific women's health issues were discussed.
Evaluation Project evaluation included data analysis of a baseline study, the conduction of a KABP survey at the end of project, a qualitative data collection and analysis of CSW focus group discussions. The main finding of the project showed that there was an increase of condom use among CSWs from 75 percent in 1991 (baseline study) to 97 percent in 1997. There was also an increase of condom use with regular partners from 18 percent to 22 percent. This demonstrates the adoption of safer sex behavior. However, with their non-paying partners, CSWs still engage in unprotected sexual encounters. This points to the need of continuous interventions focusing on the fact that love and affection do not protect people from HIV infection. Another important finding is that the HIV transmission knowledge is unevenly distributed among the CSW population as there is a constant influx of newcomers to prostitution sites. Additionally, the high rate of legal and illegal drugs used by CSWs can influence condom use. The progress of the sub-project, with its multiple needs and demands, created the institutional need to establish a new and independent NGO. In January 1996 PIM (Integrated Program on Marginality) was created with the support of ISER and other NGOs resulting in an increase of target population participation in the project activities and a progressive growth of the peer educators as community leaders at local, regional and national levels. Organization of CSWs was increased and enhanced through their participation in events conducted to improve their political, social and individual awareness regarding HIV/AIDS transmission and other issues. As a result of PIM and AIDSCAP collaboration which created a model intervention, a partnership with the Ministry of Health/World Bank project was strengthened with ISER/PIM. In addition, the program conducted by the ASTRAL group, which focuses on transvestites, also received collaboration and support from the sub-project. Furthermore, the experience of PIM enables NGOs to expand the model to new projects, such as the project "Meninas da Calçada" (Sidewalk Girls) which aims to provide educational opportunities to adolescents engaged in prostitution. This project was approved and funded by the Solidarity Community and provides professional training and educational support to street teenagers, who, due to their family disruption, engage themselves in prostitution. Constraints
Lessons Learned/Recommendations
Budget
Process Indicator Summary
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
