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Final Report for the
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Table of Contents I. Executive Summary (See Below) II. Country Program Description III. Lessons Learned and Recommendations IV. Subproject Highlights A. Major Program Areas B. Support Areas I. Executive Summary Brazil became an AIDSCAP priority country in 1992, following completion of the USAID funded AIDSTECH and AIDSCOM projects. A locally registered NGO, Asociação Saude da Familia, was established to serve as the AIDSCAP/Brazil Country Office. With a population of approximately 158 million, Brazil is the largest and most populous country in Latin America and the fifth largest and most populous country in the world. The country's size has masked the seriousness of its HIV/AIDS epidemic: although HIV prevalence is below 1 percent in the overall population, Brazil ranks second in the world in cumulative AIDS cases reported, with 116,389 cases (reported by mid-1997) and an estimated 448,000 individuals living with HIV. Core groups such as men who have sex with men (MWM) and injecting drug users (IDU) have experienced high rates of infection throughout the epidemic. In 1994, seroprevalence among MWM in Rio de Janeiro was 24 percent of the cumulative AIDS cases, and injection drug use accounted for another 19 percent. Sentinel surveillance has documented HIV prevalence as high as 65 percent among IDU in several cities. HIV prevalence is also high among commercial sex workers (CSWs) and sexually transmitted infection (STI) clinic attendees. However, during the past five years, the epidemic has been characterized by a shift of new infections to the general population, particularly to women and adolescents. The male-to-female ratio decreased from 6:1 in 1991 to 3:1 in 1996. AIDS is now the leading cause of death among women aged 20 to 34 in São Paulo state. The number of cases due to vertical transmission has increased as more women of reproductive age have become infected. The Ministry of Health's (MOH) National Program on Sexually Transmitted Diseases and AIDS (NACP) has been the primary institution responsible for STI/HIV/AIDS control and prevention in Brazil. The NACP works in association with the country's 27 state governments, municipal governments and non-governmental organizations (NGOs) to reduce the incidence of STI/HIV/AIDS in Brazil and to strengthen the public and private institutions involved in control and prevention. The USAID-funded AIDS Control and Prevention Project (AIDSCAP) complements the NACP efforts to contain the spread of sexually-transmitted HIV infection in the key states of São Paulo and Rio de Janeiro, where 69 percent of Brazil's HIV infections are concentrated. The goal of the AIDSCAP project was to reduce the incidence of sexually-transmitted HIV infection in Brazil. AIDSCAP/Brazil identified three strategies to achieve this goal:
Program Accomplishments The AIDSCAP/Brazil country program achieved noted successes in all three strategies -- training health care providers; designing mass media and interpersonal communication campaigns; and influencing policy to increase exponentially access to affordable condoms. AIDSCAP trained approximately 2,000 health care professionals from Rio, Santos, Ceará and Bahia in the syndromic management of STIs, and published in Portuguese nearly 10,000 copies of the acclaimed manual, Control of Sexually Transmitted Diseases: A Handbook for the Design and Management of Programs. In addition, AIDSCAP supported the development of a newsletter with updates on STI diagnosis and treatment for health professionals. AIDSCAP supported the development of a Health Information System (HIS) in the states of Santos and Rio de Janeiro and supported the decentralization of STI services and the creation of new clinics. In Santos, the number of STI treatment facilities increased from one to 22 clinics. STI treatment is now available at every public health facility in the state. BCC campaigns emphasized appropriate treatment-seeking behaviors among target audiences -- which, in turn, increased the utilization of STI services. STI drug logistics were also improved through AIDSCAP's technical support to the MOH. The BCC component of the AIDSCAP/Brazil project targeted male and female CSWs, MWM, STI clinic attendees and their partners, men away from home (MAFH), women and adolescents. General audiences were reached through mass media campaigns. BCC activities utilized media such as videos, brochures, posters, radio programs and street theater to communicate messages about STI/HIV/AIDS prevention to the target audiences. AIDSCAP received support from the Brazilian postal service and the MOH to create an AIDS Awareness postal stamp. The stamp showed the red ribbon superimposed on a condom. The popular women's magazine Claudia collaborated with AIDSCAP by publishing a series of monthly articles about HIV/AIDS, allowing prevention messages to reach Claudia's readership, which is estimated to be 700,000 women per issue. Behavior change messages included partner reduction, consistent and correct condom use, and seeking appropriate and timely treatment for suspected STIs. During the life of the AIDSCAP project, more than 16,000 people were trained and more than 1.3 million people were educated. In addition, 7.8 million educational materials were distributed. The condom promotion component of the AIDSCAP/Brazil project exceeded its goals for distribution and sales. AIDSCAP contracted with DKT do Brasil to develop and market Prudence condoms. Prudence condoms were marketed on television, radio and billboards, and promoted by AIDSCAP's other implementing agencies. This affordably-priced and well-advertised condom created competition in the condom market, which forced other condom manufacturers to aggressively promote their condoms. As a result, annual condom consumption increased from 50 million to 200 million between 1992 and 1996. Prudence is now the third largest selling brand of condoms in Brazil. During the life of the AIDSCAP project 14.8 million condoms were distributed free of charge and 72 million were sold through condom social marketing (CSM) programs. Of these 45.7 million condoms were sold in AIDSCAP target areas of São Paulo, Rio de Janeiro and the Northwest. In addition, a position paper written by DKT do Brasil is credited with the President's decision to decree a year long "tax holiday" on the 60 percent duty levied on imported condoms. The duty was reimposed after one year, but at a more affordable rate of 10 percent. During the five years of the project, AIDSCAP worked to develop policy dialogue related to the HIV/AIDS epidemic. AIDSCAP/Brazil assisted implementing agencies in the design, production, presentation and dissemination of sub-project outcomes at national and international conferences and through local media. AIDSCAP/Brazil also worked with the private sector to leverage an estimated 6.8 million US dollars in in-kind contributions from the mass media. To complement USAID support, AIDSCAP/Brazil worked to secure additional funding for prevention activities from other donors, such as the European community, the World Bank and various foundations, including the Ford and Levi Strauss foundations. A cross-cutting initiative in the AIDSCAP country program was the institutional development of NGOs and public sector institutions. The country office built capacity by training NGO and government representatives to properly manage, monitor progress and evaluate interventions. Several components of the AIDSCAP/Brazil program have been scaled up and are being used as models for HIV/AIDS prevention activities in other parts of the world. Constraints Despite endorsement from the Brazilian MOH and the World Health Organization WHO), some physicians have resisted adopting the syndromic approach to managing STIs. Brazilian medical schools continue to promote etiologic diagnosis over syndromic management. A study of 162 STI clinic patients found that syndromic treatment guidelines were used for only 50 percent of male and three percent of female patients. In the future, studies validating the effectiveness of the syndromic approach in the Brazilian setting may promote acceptance of this strategy. While efforts to improve logistics have increased the availability of essential STI drugs, problems with supplies continued to affect many STI and primary care clinics. This undermined the implementation of syndromic case management, because the syndromic approach is dependent upon drugs being available at the patients first point of contact with the health system. In a country as large as Brazil it is not feasible to pay for mass media HIV/AIDS prevention campaigns. However, AIDSCAP/Brazil overcame this potential constraint by leveraging private sector in-kind contributions. Behavioral Outcome Data In order to evaluate the effectiveness of the interventions, pre-and post-intervention surveys with several target groups were conducted on knowledge, attitudes, beliefs and practices (KABP) associated with STI/HIV/AIDS. Initial findings were that awareness of HIV/AIDS was nearly universal among all target groups, but knowledge of specific means of prevention and the perception of personal risk was much lower. Qualitative data from in-depth interviews and focus-group discussions was also used to inform the development of BCC messages and materials. Post-intervention surveys showed improved KABP around STI/HIV/AIDS among the target groups. Among MWM in Rio, knowledge that condom use can prevent HIV transmission increased from 71 percent to 93 percent. While few MWM reported partner reduction, many reported increased condom use or avoiding penetrative sex with casual partners. The proportion of MWM reporting consistent condom use increased from 60 percent in 1993 to 89 percent in 1995. Among CSWs, knowledge that HIV can be transmitted through vaginal intercourse increased from 79 percent to 95 percent, and consistent condom use with clients increased from 57 percent in 1991 to 93 percent in 1997. More than 96 percent of CSWs interviewed had condoms with them at the time of the interview, but many CSWs reported that alcohol use sometimes interfered with their ability to enforce condom use with clients. CSWs' steady-partner condom use increased substantially, from 12 percent to 22 percent, but remains very low. In follow-up surveys, adolescents reported fewer misconceptions about HIV/AIDS. Awareness of the asymptomatic nature of HIV infection increased from 76 percent to 90 percent in this population, although knowledge that other STIs can be asymptomatic was much lower. Consistent condom use increased from 25 percent to 40 percent among adolescent females and from 40 percent to 77 percent among males. This is a significant increase over control areas; the most recent Demographic and Health Survey (DHS) indicates that nationally only 20 percent of Brazilian women aged 15 to 19 use condoms. The percentage of CSWs reporting STIs dropped from 27 percent to 16 percent from 1993 to 1997. Between 1994 and 1996, self-reported STIs decreased from 13 percent to 4.5 percent among female adolescents girls and from 14 percent to 6 percent among male adolescents. |
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