During AIDSCAP Project in Brazil several originally non-planned activities took place in order to respond to the evolution of the HIV/AIDS epidemic within the country. Among those activities was the inclusion of reproductive aged women as part of the target population. In the early nineties the heterosexual transmission of HIV was noticed due to the increase of cases among females. The male/female ratio that was 28:1 in 1985 become 3:1 in 1994. Also, during the project's evolution it was also noted that there was some resistance to the STI syndromic approach at academic institutions. An important goal to achieve during the life of the project became appropriating technical material which disseminated the syndromic approach and making it accessible for HCPs.
A national stamp campaign to raise HIV prevention awareness promoting the use of condoms was launched during 1997, in association with the Federal Post Office. An assessment of the private sector response to the AIDS epidemic was carried out in 1996.
In 1992, AIDSCAP was implemented in Brazil through a legally established Brazilian NGO named Associação Saúde da Família (ASF). From 1995, USAID gave permission to ASF to search for funding. This allowed ASF to begin a major fund-raising campaign with the fashion industry in Brazil.
The major non-planned activities developed during AIDSCAP Project were:
- Prioritizing through RRF actions to women
- Training on the Integration of HIV/AIDS Prevention and Reproductive Health for health professionals
- Female Condom Research
- The translation and publication of the book on STI
- National stamp campaign
- Assessment of the private sector response
- Fund raising and sustainability which included:
- "Wear for a Cure" Campaign
- Other donors
- Media collaboration
- In-kind fund raising
1) Training on the Integration of HIV/AIDS Prevention and Reproductive Health
Background
The Women's Health Comprehensive Program was established in 1983 by the MOH. This program offered comprehensive care to women's health during all phases of life and women's needs, including antenatal care, contraception, gynecological assistance, etc. However, due to the problems faced by the health system, it was assessed that only approximately 40 to 50 percent of the population has access to these services (Costa, 1992). In addition, with the spread of the AIDS epidemic, a strong social movement was able to demand actions from the state and national STI/AIDS program. As a result, the two vertical programs were developed, isolated and even in competition at the service level.
The number of cumulative cases among women for the period from 1980 to 1996 has reached 1/5 of all notified cases. AIDS, since 1992, has been the first cause of death for women aged 15-49 in São Paulo State. The MOH estimated that the number of all Brazilian women infected by HIV in 1996 is between 133,369 and 204,001. Most AIDS cases among women have been reported as due to sexual transmission (50 percent), with only half as many due to IDU (26 percent), and an even smaller proportion (12 percent) due to partnering bisexual men (MOH, 1996).
The increase in cases of congenital syphilis reported by the MOH reflects the improvement on data-recording but points to problems in antenatal care and the lack of proper management of STIs in medical services. There has also been a recent increase in the number of births in 10-14 year old women and among all births delivered in Brazil, 24.5 percent are among women less than 20 years old. The situation of female vulnerability to HIV is complicated by the fact that 40 percent of women in their reproductive years (15-44) are surgically sterilized and therefore protected from unwanted pregnancy but not from HIV, and sterilization was an obstacle for condom use.
A training model taking this situation into account was tested among 104 health professionals from São Paulo, Santos, Fortaleza and Salvador. The training was conducted in October 1996 and December 1996. In São Paulo the training was developed with the State Health Department, in Salvador with the Institute of Collective Health from the Federal University of Bahia, and in Fortaleza with State Health Department of Ceará and Maternidade Assis Chateaubriand from the Federal University of Ceará.
Objectives
The training course aimed to:
- provide information and support so that HCPs could implement educational prevention of HIV/AIDS into women's health programs;
- build the capacity of the HCPs to embrace new methodological approaches to develop prevention activities;
- update knowledge in reproductive health and HIV transmission and prevention among HCPs.
The training model
The 32-hour training course was comprised of lectures, seminars, group discussions and workshops conducted by local teachers specifically selected for the workshops. The subjects were: The Integration of HIV into Reproductive Health; IEC as a Form of STI/HIV Prevention, Anatomy And Physiology Of Reproduction; Sexual Response; The Epidemiology Of STI and AIDS in Brazil; Gender, Sexuality And Reproductive Health; STI/AIDS Among Women; STI/AIDS and Contraception; The Benefits Of HIV Testing, And Pre-And Post-Test Counseling; and STI Management. A participatory methodology was used to discuss subjects such as the body, sexuality and gender, contraception, AIDS prevention and the planning of educational activities. The goal was to increase HCPs abilities to establish and improve communication with clients in order to meet their needs. Health professionals were trained to use male and female body displays during workshops. A total of 200 samples of female and male body displays were distributed to each of the local services during this training.
Accomplishments
- 104 health professionals were trained to develop educational activities of HIV prevention in health clinics assisting women at reproductive age;
- 600 displays of the human body were distributed to serve as support material for educational activities;
- Training evaluation revealed an increase of awareness regarding HIV and gender issues among health professionals and managers;
- The training stimulated new routines in the health services and partnerships among local institutions; and
- The health program guidelines were strengthened after the training.
Evaluation
An evaluation questionnaire was administered immediately after the training and another evaluation was carried out in another 3 to 5 months. In the initial evaluation, most of the participants (91 percent) highly rated the training, 42 percent found it enriching and informative, 23 percent said it was very good, and 26 said that it was good. Some participants suggested allotting the program more time and including other topics. The later evaluation was comprised of site visits, in-depth interviews, questionnaires and following up on project proposals developed during training. This second evaluation showed that there were important results for the institutions involved as well as to participants of the training. There was a strengthening of the relationships among institutions.. There was sensitization of health professionals to AIDS/HIV prevention for women. The evaluation also showed that there was an effect of improving and changing the service delivered to target populations with the creation of new activities and group discussions for women at the clinics. There were also changes in the methodological approach in terms of carrying out activities already developed by the clinics, and in Salvador a commission to follow up the integration of activities was created after the training.
Changes regarding condom use and prevention attitudes from health professionals were also reported. Reported results were a more assertive attitude in recommending condom use, a greater understanding of the negotiation issues between partners and reinforcing knowledge of the correct use of condoms. The training had different results depending on the level of integration of each local health system. The training produced a sensitization effect in Fortaleza promoting change at the service delivery level, while in Salvador this effect was observed and broadened with the addition of having stimulated a seminar with several institutions and the creation of the commission. In Santos, the training produced new activities in the service delivery level and it reinforced the programs already being carried out in the region.
Lessons Learned/Recommendations
- This model of training should be improved and used to sensitize health professionals working at all health system decision-making levels including the executive, planning and management levels. The results of the training showed that it works to bring gender issues forward during discussions and to include HIV prevention in the agenda of health care institutions.
- Specific courses with more detailed information and a longer period of training should be developed, and feedback gathered after the training. The follow-up should include support, supervision and refreshment courses for the trainees.
- Facilities should refine the training according to specific local strategies and target populations most effected by the HIV epidemic.
- Assessing the results of the training is crucial to improve capacity-building of health professionals and their attitudes regarding gender issues.
2) Female Condom Research: Acceptability of the Female Condom among Clinic Users in São Paulo, Brazil
Background
A study of 101 women aged between 18 and 45 was conducted between September 1996 and January 1997 in a Women's Health referral clinic in São Paulo City.. Eligible women were randomly selected on weekly basis to attend a 30-minute meeting in which the female condom was presented. After the meeting they were given a questionnaire and were offered the female condom for personal use.
The objectives of this study were to:
- determine the proportion of women who would accept the device;
- discover the socio-economic and health characteristics of those women;
- assess the level of information and awareness about HIV/AIDS associated with the use of the female condom; and
- raise awareness about the device.
The questionnaire was structured to gather information about the female condom participants in five areas: 1) demographic and socio-economic data; 2) medical and obstetrics data; 3) sexual practices; 4) knowledge and risk perception for HIV/STI; and 5) data on use of the female condom. Eligible women did not have health problems, were sexually active and were willing to not get pregnant. The selection occurred once a week among the users of the clinic. Between 8 and 12 women participated in each weekly meeting. The women who accepted the female condom were given a box with 6 devices and had an interview scheduled two months after the initial interview. No dissemination or publicity was performed during the research conduction.
Results
Seventy-eight women out of 101 agreed to use the female condom and less than 25 percent (23 women) would not agree to try the device.
Thirty-four women returned for the second interview and used the female condom and two returned for the second interview, however did not use the female condom.
The initial interview showed that 63 percent of these women were married, 34 percent were single and the remaining 3 percent were divorced or separated. Ninety-five percent had an active sexual life, 97 percent had some education (knew how to write and read), and only 6 percent had attended university. As expected, none of them belonged to class A, the highest socio-economic group in Brazil. Eleven percent belonged to class B, most of them (66 percent) belonged to social class C or D, and 23 percent fell in social class E.
The average number of living children was 2.4, and 25 percent had had at least one abortion or miscarriage. The most used contraceptive was the pill at 38 percent, followed by the male condom at 28 percent. Other health-related questions revealed that only 3 women had used drugs and few had experienced STIs (3 hepatitis, 2 condiloma accuminatus, and 1 syphilis).
Many women (35 percent) reported worries about HIV/AIDS and among those the group of single women was significant. Still, only four percent reported they felt they had a great chance of getting AIDS. Only 16 percent reported they had ever had an HIV test.
Of the 78 women who accepted the device, 60 percent reported that it was because of dual protection, 21 percent reported it as a sole contraceptive and 19 percent used it primarily as protection against AIDS.
When the group of women who accepted the method was compared to the group which did not, the significant differences were that the former group had previously asked their partner to use a condom and had talked with the partner about the concern of getting AIDS. These women in general had greater concerns than the second group in relation to AIDS. This difference was statistically significant, showing that women with a higher risk perception are willing to try new protection measures.
Thirty-six women were interviewed after using the female condom when they returned to the health clinic. The remaining 42 did not come to the clinic although they had an interview scheduled with the doctor. Among the 36 women who received the condom and reported back for an interview, 34 used the device and two had not. One of these two women said that her partner did not want to use it and the other said that she had an IUD.
Most of women who used the device and reported back to the clinic were married (68 percent), 29 percent were single and 3 percent were divorced. Most women (25, 73 percent) used 3 or more female condoms during the two months observed. Only nine women used two or less. The average number of female condoms used was 3.76. Twenty-five women reported that they liked the experience (among those 6 women said that although they liked the condom, their partner did not), one said that the partner liked it but she did not, and 7 women along with their partners did not like it. Almost 60 percent of the partners (19 out of 32) liked the device. Most of women (66.6 percent) said that the main advantage of the female condom was the dual protection, 20.5 percent said that it was easy to put in and did not interfere in the intercourse, 5 percent said that sex was better with it and 5 percent said they liked it for other reasons.
The main disadvantage cited by 10 women was that it was difficult to insert and interfered with sexual intercourse, 7 women reported that it had too much lubricant, 5 women reported discomfort during sex, and 3 simply found it difficult to insert. Most women (66 percent) reported they would like to continue receiving the condoms, with most of them (26/34) willing to buy female condoms. Ninety-one percent said they would recommend it to their friends. Although with a limited sample size and short follow-up, this study shows that the female condom can be accepted as a part of a dual-protection method.
3) 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 in association with Te-Corá Editora coordinated the translation of this book into Portuguese. Brazil is cosmopolitan but the English language is not widely spoken. As a strategy to disseminate the Syndromic Management Approach of STI to Brazilian 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.
The book has 15 chapters and a preface from Dr. P. Piot, Director of the UNAIDS Program. It was officially launched in English during the 10th Conference on AIDS in Vancouver, 1996. The chapters are split into three sections. In the first section the management of STI programs is approached through 7 chapters which comprise a general overview of global challenges for STI control, guidelines for the management, issues surrounding the integration of STI treatment into health care systems, the communication approach, utilizing condoms, training and drugs. In Section II case management of STI is approached through case management, STI and pregnancy, behavior changes, partner management and STI laboratories. The Portuguese translation was complete and revised by AIDSCAP/Brazil and a group of Brazilian experts in several areas such as Infectious Diseases, Public Health, Behavior Change Communication and Condoms. This revision gives the book an endorsement from the academic institutions because most of the reviewers belong to important Brazilian Universities.
The book has been distributed to scientific forums, libraries, and medical schools -- especially to the departments of Dermatology, Infectious Diseases, Gynecology and to specialists working with HIV/AIDS. A hundred and seventy copies were donated to the MOH. NGOs working with HIV/AIDS prevention and care also received copies. The book has been used in the State Health Departments for training and to facilitate discussions with health professionals implementing STI programs with an emphasis on the USAID geographic target areas.
4) National Stamp Campaign
In association with the Brazilian Government Mailing Service a national stamp was launched in April 1997 by the Minister of Health. The proposal was presented by ASF to the Brazilian Post Office Company and approved through a competitive process after peer review. The stamp shows the red ribbon dressed in a condom with the ASF initials and the words: "Put on this cause." In an expressive and simple way the stamp to draws attention to the HIV/AIDS epidemic in Brazil. The artist used the red ribbon, a strong symbol of AIDS awareness and the World Campaign Against AIDS, and synthesized it with the symbol of prevention, the condom, drawn free-hand in gauche and brush. The stamp says, "Put on this cause and wear the condom". This is the first time a condom has been used in a national stamp. The background colors with the colors of the Brazilian flag reinforced the fact that HIV/AIDS is a Brazilian problem and major concern. Each stamp was sold for 0.23 cents totaling 690,000 USD. Further, a post card was produced as a part of the collaborative campaign. The stamp was launched on April 7, 1997 at the Pan-American Health Organization office during the Health International Day by the Minister of Health himself. The event had the participation of several authorities, ambassadors, donors and the media. Three million stamps were issued accompanied by a post card. The main objective of the stamp is to raise AIDS prevention awareness and to promote condom use. As it is stated in the promotional leaflet, the purpose of the stamp is "to remember that this is also a problem and a concern in Brazil."
5) Assessment of the Private Sector Response
Background
A study on the private sector was conducted in Brazil in 1997. The rationale for the study was to review experiences of "leveraging" private sector resources for HIV/AIDS prevention. Leveraging is "an intentional effort to involve businesses to invest" in HIV/AIDS prevention.
Methodology
In March 1997, a set of interviews was held in Brazil with representatives of twenty-one mostly private companies but included several significant government-owned companies. In addition, representatives of four major trade union confederations, ten NGOs, three business-financed agencies, and several state and federal government agencies were interviewed.
A representative sample of larger businesses was sought. Some of the elements in company selection included the diversity of industrial sectors, e.g., manufacturing, agriculture, food processing, retail, banking, insurance, transport, hotels and resorts; both long established companies and others that are relatively new; companies that operate in a single industry and some that are conglomerates; some companies known to have or have had HIV/AIDS prevention programs.
Most of the interviews were in companies that are large (at least four being among top twenty companies in Brazil) and who employed medical personnel. In several cases, efforts to set up interviews were met with little interest by company executives. It should be noted that the review of leveraging experiences explicitly was not to assess the prevention activities within the companies. This was made clear to those interviewed.
Over the course of less then 15 years, the HIV/AIDS epidemic in Brazil has emerged as one of the most serious public health problems facing the country. Economic conditions in the 1980s and early 1990s contributed to situations in which sexual activity carried higher risks. High unemployment (15-18 percent) and inflation made it more difficult for people, especially women, to secure adequate incomes. There has been a sharp decline in industrial employment every year for the past seven years -- companies "down sizing" is very much part of neo-liberal Brazil -- even though the past couple years have yielded relatively good economic returns.
The deterioration of the public health system, like other social welfare services in Brazil, took place during the authoritarian period from 1964 to 1984, and continued to worsen during the extended economic recession that accompanied the return to civilian rule. This limited the country's capacity to address its many existing health problems, and conditioned ways in which it might respond to the emergence of a new socially, culturally, and epidemiologically explosive infectious disease.
Findings
HIV/AIDS is not currently a priority concern for most Brazilian companies.
During 1990 the first known cases of HIV infection began to appear in many companies. Many interviewees recalled that "at first" no one knew what to do -- what the policy response should be, what benefits should be available to the person, how to address workplace problems resulting from the phobias of fellow workers, and so forth.
Most of the companies set up committees or other mechanisms, often with help of the health authorities and in some cases a NGO, to establish policies regarding HIV/AIDS. Fortunately, beyond laying the foundation for prevention, the policies tended to emphasize the rights of employees and which benefits the company would or would not provide relative to HIV/AIDS. Today, these companies are proud of their policies.
The companies now feel that the "AIDS problem" is under control. They believe they now have:
- enlightened (and legally correct) internal policies regarding HIV/AIDS;
- liberal benefits for those with HIV/AIDS; and, due to prevention education efforts both internally and in the public, an educated workforce;
- a workplace environment in which persons with HIV will be accepted and not regarded as "disruptive;" and
- confidence that the number of "cases" will stay low enough for the associated costs to the company to be manageable.
The chief of the health department at a government-owned utility company in the process of being privatized, stated that AIDS is far from the biggest problem for the company. In support of this assessment, he noted that the number of days of employee hospitalization for HIV/AIDS was 2.5 percent of the total hospitalization days for the 7,200 employees.
Currently, most of the companies pay for all or part of the costs of HIV/AIDS treatment including the anti-retroviral multi-drug "cocktail." The company also pays for diagnoses and other procedures not covered by the government. These companies appear to feel they can manage the current costs. However, several companies feel that they pay "doubly" for health: first through the taxes for health and then through the costs of their own health services and/or group health plans.
It is clear that the perception of those interviewed is that HIV/AIDS no longer represents a significant problem or, if it is a problem, is at least now manageable for business operations. The reported incidence of HIV/AIDS in the companies interviewed is quite low, ranging from 0 percent to one-half of one percent of the total workforce. Several of those interviewed acknowledged possible underreporting but thought that HIV/AIDS was not a significant problem for the company. Others commented that it appears that health authorities had exaggerated the extent of the epidemic.
The number of cases of AIDS reported in Brazil on a per capita basis is relatively low. Perhaps even more significant are the changes in the social and demographic profile of the epidemic. The recent data suggest that the epidemic has become increasingly focused in the poorest and most marginalized sectors of society. These are not the people likely to be working for the larger companies, even in the HIV/AIDS "epicenters" of São Paulo and Rio de Janeiro. To any extent likely to make a difference to the companies, even as customers, these social sectors have little impact.
Companies have devoted little attention and resources to HIV/AIDS prevention.
Most of the companies interviewed developed a response to the epidemic, but only after the first incidence(s) within the company appeared. Their focus was less on implementing HIV/AIDS prevention strategies than on understanding the rights of workers who became infected or ill; on the personnel and benefits policies relating to care and treatment; and on responding to discrimination and phobias on the part of co-workers.
The approach to prevention has been similar in every company interviewed. Usually it has been the health professionals on staff who have sought to provide employees with informational materials (often reproduced materials from government health authorities) including videos (in some cases produced by the company), and give formal and informal lectures. In some cases, short training sessions were provided for certain employees who then were to be "multipliers" (i.e., peer educators) of the prevention education they had received in the sessions. In many companies this approach was eventually extended to the dependents of employees. In certain communities with companies that are dominant, this approach was often extended to all residents of the community. The presentations have taken place on company time to ensure attendance. Peer educators usually received time off their regular schedule if they worked on weekends.
A 1988 decree by the Ministry of Labor required all companies to carry out internal AIDS prevention education as part of the annual Week for Prevention of Work-Related Accidents (SIPAT). The companies interviewed regard a talk, a play or a video during that week, or a pamphlet about AIDS, as both fulfilling the legal obligation and being a sufficient effort at prevention. No mechanism was set up for monitoring or evaluating the extent to which this decree has been implemented, especially outside publicly-owned companies and the larger (often multinational) companies. An official from the Prevention and Training Unit of the Department of Health of the State of São Paulo expressed his opinion that only a "small minority" of companies, outside the large ones, even have such activities. He noted that even though the decree carried a significant fine for non-compliance, he does not know of a single instance in which a fine has been levied.
In only a very few companies have costs, either in money or staff time, been considered significant enough to track. One exceptional past case is that of Goodyear do Brasil. In 1988 the company dedicated an edition of its in-house magazine on HIV/AIDS "in order to clarify a lot of misleading notions about AIDS in the media." They did this in consultation with the AIDS center at the Department of Health. At the request of the Department Goodyear do Brasil did several printings, producing a total of 750,000 copies, above and beyond the original plan to produce only enough for the 7,000 employees and their families. The cost, even without the factor of labor, was well over $2 million. Since 1988 the company at least twice a year tries to put an article about AIDS in its in-house magazine that appears every other month. Only a few other companies have developed pamphlets on HIV/AIDS and produced extra copies for public distribution.
Another case among the companies interviewed of devoting more than the minimum resources to prevention awareness is the Brazilian firm Industrias Villares. Within the company, six teams of AIDS educators have been developed and give HIV/AIDS prevention trainings in towns in the State of São Paulo. In 1996, 250 teachers in two towns received training. The company covers the staff time involved and the costs of reproducing materials from the Health Department of the State of São Paulo. Villares, along with the Health Department, is playing a leadership role in attempting to interest other companies in developing internal HIV/AIDS policies and programs.
Staff at publicly-owned companies felt that their employers involved more personnel and spent more money on internal HIV/AIDS prevention education than privately owned companies. A contrasting experience was offered at one of the publicly-owned utility companies in São Paulo. It carried out internal prevention education, including the making of a video, in 1988 with the collaboration of the Department of Health. Since then, however, there have only been mentions of HIV/AIDS in the annual posting regarding the prevention of accidents. Efforts by two social workers on staff raise further awareness have been opposed by their superiors and the top administration. The staff social workers interviewed commented that this may be because the company is under pressure to be more profitable in preparation for a likely sale to private interests.
As noted above, many companies feel they are contributing to HIV/AIDS prevention through their taxes. Materials have been developed by SESI (Social Service of Industry) which is part of the National Confederation of Industries. SESI's very sizable budget is derived from a de facto tax of 1.5 percent on the payrolls of all members of the confederation; SESI fosters in many and diverse ways the welfare of employees especially in health, recreation and education. The São Paulo division of SESI between 1988 and 1990, in collaboration with the Department of Health, did awareness and information trainings in many large companies in São Paulo. According to the interview with the doctor in charge of the Department of Preventive Medicine of SESI, things "fell apart" around 1990 because of the lack of organization and materials. Only with the help of a $100,000 grant from the National AIDS Program (in turn supported by the World Bank loan), is SESI trying to start up again focusing on mid-size companies.
Despite this investment a number of business executives and SESI officials belonging to the Group for Social Action of FIESP (the Federation of Industries of the State of São Paulo) of the National Confederation of Industries felt it was money "down the drain." In any case, in terms of the issue of leveraging support from the commercial private sector for AIDS prevention, the SESI resources are effectively limited to employees in the formal sector and not groups likely to be identified as primary for prevention strategies.
The overall impression is that the companies do not really believe in HIV prevention programs. They have tended to focus less on prevention than on the consequences of HIV/AIDS for the company, especially the rights of those infected; the ways the company will or will not help them; and education against discrimination by co-workers.
The lack of belief in prevention programs is not surprising given that there seems to be few efforts in Brazil to develop indicators to monitor their effectiveness. Moreover, given the nature of the HIV/AIDS epidemic, it is hard to demonstrate cost effectiveness to persons who make decisions about investments based on expectations of measurable results in the short term. As an official of the Prevention and Training Unit of the Department of Health of the State of São Paulo commented, "The companies are concerned about profits. You have to convince them that spending something now helps with profits in the long run."
"Prevention is the government's responsibility" was the clear message from several of the company representatives interviewed. Several gave precisely the same statistic, namely, that employers in Brazil pay $1.08 in benefits for every $1 in salary and that anything else spent on HIV/AIDS prevention would be in addition to this already burdensome amount. Employers think that their responsibility starts and stops with providing health insurance for their employees. Again, care, not prevention, is the role of the employer.
Most of the companies interviewed do not provide condoms for their employees. Several stated that the employees are relatively "privileged" financially and therefore should simply buy condoms at the regular commercial places.
Corporate social responsibility and corporate philanthropy are not significant traditions in Brazil. When asked about making outside donations for the benefit of society, several persons interviewed emphasized that their companies are already doing enough by providing health services to their own workers and their dependents. Some commented that until recently the economy in Brazil was so bad that companies could hardly think of donations and public service. Now many companies are recovering, but they are spending heavily on rebuilding and updating the infrastructures which were neglected during the long period of economic bad times.
Donations seem to be often in-kind. Also, three of the publicly-owned companies interviewed referred to training programs they are running for poor youths. As part of the orientation given in those programs there is a lecture by a medically trained person or a social worker about STI/AIDS.
Two psychologists on the staff of a drug company are teaching NGO HIV prevention "as well as how to use our products" and ten doctors under contract do the same with other doctors. Also, the company is donating its protease inhibitor for ninety persons selected by the Department of Health in São Paulo.
The trade unions, both the locals and the major confederations, have not been pressuring companies to do AIDS prevention activities. Both business managers and the officials of the major labor confederations spoke about the lack of a "push" from organized labor. In company after company, interviewees said that the initiative for AIDS activities came from management and not from the union. One reason is that labor unions have bought into the widespread association of AIDS with male homosexuality. The director of a major labor confederation in São Paulo that includes the auto industry, food processing and construction, said that most workers did not consider themselves at risk because of the "machismo" factor.
Traditionally, unions priorities are the issues of wages and protecting jobs in the face of downsizings. If they play a role regarding HIV/AIDS, said one labor organizer, it is because the union believes that is a problem of discrimination in the workplace, including people being secretly tested for HIV. Labor organizations are thus not likely to pressure the commercial private sector to support AIDS prevention activities. And whatever pressures they might apply would likely be focused on workplace-centered activities and not on the more vulnerable populations outside the formal labor market.
There are some limited possibilities but there are also fundamental obstacles for NGOs to leverage support for HIV prevention work from the companies. A few NGOs working with HIV/AIDS have assisted companies, mostly the larger companies, with the development of internal HIV/AIDS policies and programs. Most of the work carried out has centered around talks and other presentations to sensitize management and workers, around the training of employees to give informational presentations to other employees, and around providing advice on legal and ethical issues and on HIV/AIDS-specific personnel policies. This work has occurred only within a few mostly large and multinational companies.
Most of these kinds of involvement by AIDS NGOs with companies appears to have been in the first half of the 1990s. One São Paulo NGO recalls that in 1988 it sent out over 7,000 letters to companies offering its services and received only two responses of any sort. More recently, the involvement of limited NGOs with companies seems to come from invitations to give talks during the SIPAT week .
Two factors constrain NGO leveraging of resources from the commercial private sector:
- Companies think that because NGOs are non-profit organizations they should not charge for their services.
- If a company pays money to an AIDS NGO, it expects specific services to be rendered in a quid pro quo way. Moreover, the tendency in these cases is to want to pay less than the cost of delivery of the service.
As a result of these attitudes, NGOs are not inclined to charge for their services and most lack the skills to sell their services in the private sector.
The experience of one NGO indicates some of the problems encountered in leveraging resources from corporations. In 1990, two high-profile persons with AIDS approached the top executives of a number of companies. The companies were persuaded to make donations to ABIA "for the fight against AIDS." (The donations eventually totaled about $120,000 plus some office equipment.) The NGO agreed to advise the companies, if they so desired, in establishing internal policies and programs. Before long, however, the NGO found that a number of the companies were demanding a level of services that exceeded NGO costs. Consequently, the project stopped 1993.
Opportunities and Constraints for Leveraging HIV/AIDS Resources
Two overall lessons emerge from the review of private-sector leveraging in Brazil. The first is that efforts to persuade the businesses to support HIV/AIDS prevention in areas most needed by society beyond the professional milieu are not likely to succeed when those businesses do not perceive HIV/AIDS and the associated internal company costs are unmanageable; have a plentiful supply of labor to draw on; are not convinced that prevention activities are cost effective in any foreseeable time period; have no tradition of social responsibility, especially vis-à-vis public health problems; or regard public health as the responsibility of the government which already receives their tax dollars.
The second lesson is the more optimistic message that businesses can be persuaded that prevention is in their self-interest and therefore worth the investment of resources. Among the opportunities which can be taken are:
- demonstrating to individual businesses through cost analysis and impact projections that HIV/AIDS may have a significant economic impact on future profits in the absence of effective prevention interventions;
- persuading media businesses to present prevention as a topic of public interest and concern, i.e., the examples of Claudia and Playboy which have each offered guidelines to support the argument that stories on aspects of HIV/AIDS will contribute to the company's profits;
- seeking alliances for public and private cost sharing in the development and implementation of prevention efforts, following the examples of other countries where governments have subsidized condom distribution at worksites;
- forming "prevention partnerships" between companies, especially ones with a direct commercial relationship. A company with HIV/AIDS prevention policies and/or programs can share with other companies their experiences, offer qualified members of their staff to do training, reproduce printed and audio-visual materials that have worked well with their employees, and perhaps contract a NGO with particular expertise to be part of the process;
- the use of senior management in businesses as peer prevention/policy educators, perhaps through regular business gatherings;
- involving most companies with philanthropic programs favoring the assistance of poor children and adolescents. Those companies may be persuaded to support STI/HIV/AIDS prevention programs that integrate sexuality, vocational counseling, skills building, substance abuse and personal fulfillment for youth; and emphasizing drug and alcohol dependencies as tie-ins for HIV/AIDS awareness and prevention programs because these are more of a serious concern than HIV/AIDS for many companies.
6) Fund Raising and Sustainability
a. The Campaign Wear for a Cure
The Campaign Wear for a Cure was launched in July 1996, by the Brazil's First Lady, Dra. Ruth Cardoso, at the Ministry of Foreign Affairs in Brasilia. This campaign was a result of an agreement between Associação Saúde da Família, the Fashion Industry, John Casablancas Model Agency and an American organization, Dishes. The Campaign was to sell T-shirts with a red ribbon on the front, and on the back several logos, including the AIDSCAP logo. Famous top international models, including Claudia Schiffer, and a top national model posed for the campaign for free. A video with the campaign launching was showed in the Fashion Industry Fair in July 1996 and on several TV channels.
From October until December 1996, approximately 60,000 Wear for a Cure T-shirts were sold in more than 1,000 outlets all over the country. This generated approximately 400,000 Reais (equivalent to 400,000 US dollars) for ASF. A series of shows and events happened in several regions of Brazil to promote the T-shirt campaign. A popular talk show sold -- in 5 minutes -- 17,000 T-shirts! This was considered a major accomplishment by the marketing industry in Brazil. The campaign was also advertised free in several magazines, newspaper and TV shows.
The funds raised through this campaign will be used in selected projects and activities for AIDS prevention and care. A Technical Advisory Group (TAG) composed by representatives from MOH, USAID, the Ford Foundation and the European community will be responsible for the selection of projects. An overhead to sustain the ASF during the inter-project period was allocated.
b. Other Donors
Levi Strauss Foundation
This foundation has committed small grants for ASF during the life of the project. They funded AIDS....Everything You Have Always Wanted to Know and Have Not Had the Courage to Ask, for female commercial sex workers. Two editions, one in 1993 and another in 1995, were published. This booklet has been used successfully in many CSW intervention projects all over Brazil, including in the AIDSCAP project. The Levi Strauss Foundation also funded the female body displays which were reproduced by the ASF and the creation of the male display. These displays were distributed during trainings for health professionals about HIV prevention and reproductive health. During the life of the project, the Levi Strauss Foundation committed a total of 42,000 USD.
British Council
The British Partnership co-sponsored the female and male body display project developed and described above. During the life of the project, the British Partnership committed a total of 14,000 USD.
Ford Foundation
A study, Male Motivation on Reproductive Health, is being conducted by ASF with financial support from the Ford Foundation. The total cost of this study is 52,000 USD and final data is under analysis.
c. Media Collaboration
ABRIL Editors
Playboy made a $30,000 grant for a survey on HIV/AIDS awareness of Brazilian men and their attitudes about condoms (conclusion: "they still don't use them") which served as the basis of a 12-page article in the January 1994 issue. The article carried with it prevention advice, condom instructions and references to sources for further information. ASF provided technical assistance. The value of the article calculated by the private sector company specialized on the area was 499,968. 61 USD.
Claudia, Brazil's largest circulation woman's magazine, was persuaded to publish two features on AIDS and a number of smaller articles (always indicated by a red ribbon) for which ASF was a principal consultant. A one-year campaign was developed in association with ASF. Articles on the Vancouver and Beijing Conferences were published during the campaign year. A cover page with the Brazilian flag and the red ribbon and pictures of the Wear for a Cure campaign were published for free in the magazine. A total of 1,974, 282.49 USD was committed to free space to introduce and reinforce prevention to adult and adolescent women. The main objective was to promote awareness in the female population. The magazine achieves a total of 3,500,000 readers monthly. The editor responsible for these articles said that the magazine publishes such social issue articles "not (only) because we have good hearts" but "as part of a strategic vision of modernizing the image" of the oldest women's magazine in Brazil. "More and more modern women won't read the magazine without this type of article," she explained. "These women want them there, even if they don't actually read such articles. We sell more magazines." Claudia is starting a Social Marketing Department to develop more articles on social issues. The March 1997 issue, for instance, devotes a page to an anti-drug campaign ("Show your son what you know about drugs"). The editor wants to try to convince the magazine to support research about AIDS and women in Brazil.
d. In-Kind Collaboration
W/Brasil and Ford Models
A publicity agency and a modeling agency contributed money and services toward the production of the booklet, AIDS....Everything You Have Always Wanted to Know and Have Not Had the Courage to Ask, for female commercial sex workers. Two editions were published (1993 and 1995). A total of 50,000 USD was committed to the production and printing of the first edition which was donated to the AIDSCAP program.
VARIG
VARIG is the major Brazilian Airline. During several international and national conferences VARIG donated the transportation of materials for free to AIDSCAP/Brazil. For example, in the STI Congress and HIV/AIDS Pan-American Conference held in Porto Alegre, Rio Grande do Sul, in 1996, a cargo transportation priced at 900 USD was transported for free. These materials were disseminated through the AIDSCAP Project during the conferences. VARIG also donated free transportation of materials to Chile in 1995, and to Salvador in 1997. Each cargo costs about 600 US dollars.
British Council
Tutoring to attend the English Language Course was given to ASF staff starting in 1995. Three staff from ASF had the opportunity to attend this course. It is estimated that the cost of the scholarship was more than 2,000 US dollars.
Time Voluntary basis
Several individuals donated their time to the AIDSCAP project working on a voluntary basis for important staff events, such as AIDS World Day Conference, Love Parade, etc.
