"After fighting many times, I got my husband to use a condom. I screamed and wailed. I told him that his penis was thicker and more pleasurable [with a condom]. He has been using condoms now for three months. Now I feel more secure and indeed feel pleasure."
As this Brazilian woman's experience demonstrates, it is difficult for many women to talk to their partners about condoms--but not impossible. Discussing their concerns with other women and practicing ways of communicating with their partners can help women gain the confidence and skills they need to negotiate safer sex.
This woman's successful negotiation with her husband came after she had participated in three group discussions at one of the clinics of the Sociedade Civil Bem-Estar Familiar no Brasil (BEMFAM). The major nonprofit family planning and reproductive health provider in Brazil, BEMFAM offers these group sessions as part of a larger project that includes integration of HIV/STD prevention with clinical services, school-based and community-based prevention projects, and STD diagnosis and treatment.
BEMFAM developed its integrated project in response to the rapid expansion of the AIDS epidemic among Brazilian women during the early 1990s. The male-to-female ratio of reported AIDS cases in Brazil was 9 to 1 in 1987, but by 1994 it was 4 to 1.
The project began in 1991 with formative research and a pilot intervention. Funded by the U.S. Agency for International Development's AIDSTECH and AIDSCOM projects, this research and pilot phase included interviews with BEMFAM clients and tests of a group intervention approach with women attending a BEMFAM clinic and a community health post in Rio de Janeiro.
Two issues emerged from the research that would be central to the development of interventions. First, although women know how HIV is transmitted, those who are married or in consensual unions do not perceive themselves to be at risk. Women believe that if they stay with one partner, they will be protected. Second, women do not talk to partners about sexuality and condoms because they are afraid of raising questions about fidelity. Condom use within a relationship is only considered appropriate for pregnancy prevention.
During the pilot intervention, participants expressed a need to continue sharing experiences. They felt that the group discussions had positive repercussions on their lives, helping them become more conscious of the importance of preventive health practices.
BEMFAM responded to these needs by developing a women's group intervention project to facilitate dialogue about sexual health. With support from IPPF/WHR, the Women's Project began in 1993 in the states of Rio de Janeiro and Pernambuco. It was later expanded to the state of Rio Grande de Norte and, through the support of the Ministry of Health, to the state of Maranão.
All women who attend each clinic on a given day are invited to participate in a one-hour group discussion with eight to 15 participants before receiving medical services. Almost all clients who are invited agree to participate. Groups are facilitated by a BEMFAM staff member who has received special training.
Two novela-style booklets developed during the research phase--Acorda Adelaide (Wake Up, Adelaide!) and Conversando é que a Gente se Entende (Communicating for Better Understanding)--help stimulate discussion. The booklets use stories and characters that clients can relate to their own lives. In one, a condom breaks because the couple doesn't know how to use it properly. In another, a woman convinces her partner to put on a condom by offering to try erotic ways of using it.
All participants learn how to use condoms correctly by putting them on realistic penis models. They anticipate situations in which they would be able to discuss and negotiate condom use with their partners. Facilitators stress the importance of condom use for HIV/AIDS, but also help women recognize the importance of taking care of their broader reproductive and sexual health needs.
In the group discussions, women talk about faithfulness and unfaithfulness, lack of sexual pleasure, and the STDs they contracted from their husbands. They often address their fears about raising the subject of condom use with their partners. Participants also express indignation at their own and other women's submissive attitudes toward sexual relations. While some women's comments confirm this submission to male dominance, others are able to assert their independence.
These group discussions have a different effect from individual counseling. The group setting permits women to gain confidence and practice more assertive behavior in an environment that is not threatening. It also gives them an opportunity to share their life stories, which helps them recognize that they are not alone in their feelings. This identification with others' experiences empowers women to take control of their health and sexual lives.
Behavior change is a difficult process, but we are already beginning to see positive results. Some women report that they intend to talk with their partners, that they believe they have the skills to do so, and that they intend to use condoms correctly.
From October 1994 to July 1995, 3,464 clients participated in group discussions and 40,688 condoms were distributed. Almost three out of four participants accepted condoms offered after the group session. Approximately 18 percent returned to the clinic for additional condoms.
-- Rita Badiani and Julie Becker
Rita Badiani is coordinator of BEMFAM's Planning Department and its Women's AIDS Prevention Project.
