Playing Safer

    Playing Safer

    The first cases of AIDS in Brazil were diagnosed in São Paulo and
    Rio de Janeiro in 1983. Today the country has one of the highest numbers of AIDS cases in
    the world and more than twice as many AIDS cases than any other South American country.
    Today there is an increasing number of women, adolescents, and people with a low income,
    low level of education becoming infected with HIV. One way of reaching out is through
    community-based HIV prevention programs and the distribution of condoms.
    By Aparna Waegner and Dana Miller

    Thirteen-year old Wilson gave me a shy but knowing smile, "Me dá mais um?".
    "Can you give me one more," the dark, skinny little kid asked me. I couldn’t
    say, "no" to those pleading brown eyes. But I wondered why he kept returning to
    the booth to get more condoms. I was in the Northeast of Brazil, it was June, and the Festas
    Junias, were about to begin. Brightly colored balloons and colored flags decorated the
    street. Smells of roasted corn and corn pudding filled the air, as thousands of townsfolk
    started dancing to the sounds of forró music.

    This typical music of the interior spilled into the night with songs that celebrate the
    land, the parties, and lost love. Under a thatched palm leaf roof on a dance floor made of
    dirt, couples danced, singles mingled, and children laughed. It was the Festa de São
    João in the town of Cachoeira in the interior of the northeastern Brazilian State of
    Bahia.

    "Wilson," I asked, "what are these (condoms) for anyway?" He
    quietly answered, "For sex…to not get AIDS…for protection." Wilson let
    me know that he has two girlfriends, but he’s only having sex with one of them. That’s why
    he needs the condoms. But he also shares them with friends when they need them.

    To the people from the state of Bahia, or Baianos, the Festa de São João
    means good food, good music, and celebrating the night away. Although the Festa de São
    João has deeply religious roots, today the joyful atmosphere brings enormous
    frolicking that can mask the intense religious and cultural history.

    Young people are having sex in Bahia, and one way to help them lower their chances of
    getting a sexually transmitted infection like HIV (human immunodeficiency virus)/AIDS
    (acquired immune deficiency syndrome), or unwanted pregnancy is to provide easy access to
    condoms during the time of need.

    Like any successful Bahian party, romance and love play an important role.
    Unfortunately, in this time of uninhibited celebration, there comes the risk of
    unprotected sex. Condoms are not always available in semi-rural towns and cities of the
    Bahian interior, and they are often not affordable. As a result, this celebration can
    bring unintended consequences, such as the spread of sexually transmitted infections
    (STIs), like HIV, and unwanted pregnancies.

    During the 1998 Festa de São João, partygoers had a helpful hand to promote
    safer sexual practices…the Condom Carnival Project (CCP)- São João. Members of the
    CCP-São João assembled and distributed brightly colored condom bracelets and necklaces
    to the general public during the three-day festival. Each brightly colored packet
    contained one Prudence condom, pictorial instructions and written reminders on how
    to use the condom correctly. The CCP-São João brought the promotion of safer-sex to the
    city of Cachoeira for the Festa de São João, 1998.

    Atman International, a health education and communications consulting firm located in
    Los Angeles, California, coordinated the CCP-São João with support from Brazilian
    volunteers and with the participation of adolescents and administrators from the local
    schools in Cachoeira. The CCP-São João was sponsored by DKT do Brasil, the social
    marketing distributor of the Prudence male condom and the Reality female
    condom.

    AIDS in Brazil

    Before any AIDS cases were reported in Brazil, the media was covering the "gay
    plague" from North America. AIDS was considered a foreign disease; a disease of
    American homosexuals. As in most countries in the world, AIDS arrived in Brazil in the
    early 1980’s. By 1983, the first cases were being diagnosed in São Paulo and Rio de
    Janeiro, and fashion designer Markito became the first Brazilian public figure to die of
    AIDS-related illness. AIDS could no longer be considered a "foreign disease".

    In the Americas, almost 750,000 cumulative cases of AIDS have been reported, with more
    than 400,000 deaths from 1986 through December of 1996, according to the Pan American
    Health Organization (PAHO). Brazil, the largest country in South America with a population
    of approximately 150 million, has one of the highest numbers of AIDS cases in the world
    and more than twice as many AIDS cases than any other South American country .

    From 1980-1996, 140,000 cases were reported in Brazil. Prior to the December 1996
    report from the Brazilian Ministry of Health, the total number of cases were reported
    between 50,000 – 80,000, demonstrating the intense increase in recent cases in Brazil.
    Numbers just released by the Health Ministry show that AIDS continues to be a growing
    problem. Between September and November of 1998, 5070 new cases of the disease were
    reported, 787 more than for the same period in 1997. The latest report lists a total of
    145,317 cases of AIDS in the country since the disease was first detected.

    This increase may be the result of more accurate identification and reporting of the
    disease, in addition to the actual increase in the number of cases (U.S. Bureau of the
    Census, 1996; Ministério da Saúde, 1996). An estimated 500,000 Brazilians are infected
    with HIV and more than 60,000 have already died from AIDS (Reuters, 1996; Ministério da
    Saúde, 1996).

    Current trends reflect that more women, adolescents, people with a low income, low
    level of education, and urban dwellers are becoming infected with HIV in Brazil in
    proportion to the general population. One way of reaching out to the people in Brazil is
    through community-based HIV prevention programs, focusing on people who practice the
    highest-risk activities and receive little or no education about protecting themselves.

    Condom use

    Condom use during sexual intercourse is the most effective way to reduce one’s risk of
    acquiring HIV sexually. Data indicating condom use among different populations in Brazil
    are limited though. Most studies have been done by agencies interested in assessing condom
    use as a method of contraception as opposed to condom use a method of disease prevention.

    In 1996, the rate for condom use as a method of contraception for Brazilian women, ages
    15-49 and in union, was measured at 4.4%, and was 5.2% for men in union in this age group,
    according to BEMFAM. In the United States, the U.S. Survey of Family Growth found that 13%
    of women in union, ages 15-44, and 14% of unmarried women, rely on condoms for birth
    control. One reason for low condom use in Brazil could be the high prevalence of female
    sterilization (44%) and the use of oral contraceptives (41%).

    Despite the low rates of condom use in Brazil compared to the U.S., an increase in
    condom sales and the implementation of sex education programs suggest a positive change in
    addressing HIV/AIDS prevention. Condom use and promotion have been steadily increasing in
    Salvador, as in most of Brazil, in response to the growing number of HIV infections and
    deaths due to AIDS.

    However, several studies suggest infrequent and inconsistent condom use among
    adolescents, even when their knowledge about HIV and AIDS is high . There are many
    significant barriers to condom use among adolescents in Brazil, such as high-cost, lack of
    availability, social acceptability, knowledge about condom use, and low self-perception of
    being at risk for HIV.

    In a study that was presented at the XI International Conference on AIDS, in 1996,
    Rosalina Carvalho Silva presented her findings on the knowledge, attitudes, beliefs and
    practices about AIDS among 499 adolescents, 13 to 20 years old, in the state of São
    Paulo. Most of the adolescents demonstrated a high knowledge of AIDS transmission
    (approximately 90% answered the questions correctly) and presented a positive attitude
    about condoms (62%), yet only 32.2% reported consistent condom use, and 24% had never even
    used a condom.

    Results from the survey revealed the most common reasons why respondents did not use
    condoms were due to their beliefs that they were with a steady partner and thus had no
    risk of AIDS (60.9%), and when two people love each other the risk is low (35%).
    Therefore, it is evident that knowledge about condoms and HIV/AIDS is not sufficient to
    produce changes in behavior.

    Underserved

    Less-populated towns in the interior of many Brazilian states are often omitted from
    large urban-centered HIV/AIDS prevention campaigns leaving inhabitants without the skills
    and products needed to practice healthy sexual behavior. Obtaining funds to create and
    implement sex education programs in the interior is difficult because funders are often
    more interested in supporting projects that reach a larger number of people. However, this
    population cannot and should not be ignored.

    The northeast of Brazil is the poorest region in the country. Rates of contraception
    use are lowest in the northeast and the poverty rate is among the highest. Bahia is the
    largest and most populated state in the northeast of Brazil. Many young people in Bahia
    are at special risk of getting infected with HIV or other sexually transmitted infections
    and unintentional pregnancy due to limited financial resources, little or no education and
    high rates of sexual activity. These adolescents have a lot to gain by learning more about
    HIV/AIDS prevention and family planning through community-based programs. In particular,
    lower-income people living in the interior towns of the northeast are confronted with
    higher prices for condoms and less accessibility.

    Lori Miller, the Atman International Project Coordinator for CCP-São João agrees,
    "Today, people in urban areas are exposed to more educational materials, such as the
    Bahian Ministry of Health HIV/AIDS prevention and condom promotion campaigns. People in
    the interior do not have the same opportunities to hear these messages. Conducting this
    condom project during festivals of the interior can spread the message of HIV/AIDS
    prevention and condom use to residents of these smaller communities."

    The Project

    Popular street festivals in Brazil create an atmosphere in which people let loose of
    all inhibitions and celebrate life by dancing, drinking, and often engaging in sexual
    activities with non-steady partners. Safer sex messages can be integrated into the folia
    (frolicking) of festival through songs, posters, billboards, and colorfully decorated
    condoms.

    One of the biggest festivals in the northeast of Brazil, the Festa de São João,
    takes place in many small northeastern towns; each offering something unique. One of these
    towns is Cachoeira, located about 50 miles from Salvador, the capital of Bahia. Cachoeira
    was chosen as the site for the first CCP-São João because of its popularity to attract
    many visitors, attentiveness to reduce injuries by declaring fireworks illegal, and due to
    the enthusiasm and cooperation of the Secretary of Education and the public school system.

    The CCP was implemented in Cachoeira to educate a large number of people from both the
    interior towns and the surrounding cities during the popular street festival. Another goal
    of the project is to encourage local participants to reach out to other community members
    in efforts to prevent disease transmission.

    Lori Miller and her friend, Rhonda Brown, first conceptualized the CCP in 1993. Lori
    explains, "When Rhonda and I were living in Salvador, Bahia in 1992, we noticed that
    there were few AIDS prevention campaigns, despite the increasing incidence of HIV/AIDS. We
    developed the CCP to promote safer sexual practices prior to and during the carefree
    street festivals."

    Brazilian youth are of special concern to Miller, and the CCP educates young people
    about safer sex through a series of interactive activities. "There are thousands of
    adolescents who are sexually active and undereducated about the risks of unsafe sex. We
    want to concentrate on young adults and adolescents because this is the time when habits
    regarding sexual activity and condom use are forming," Miller explained.

    The CCP-São João was comprised of two main components: interactive sex education
    activities, and a larger-scale promotion of safer sex through condom promotion. The
    interactive component of CCP-São João focused on low-income adolescents, while the mass
    communication of safer sex messages were geared toward people of every age and background
    attending the festival in the town of Cachoeira.

    Thirty-five adolescents from public schools in and around Cachoeira participated in the
    interactive educational component of the CCP. Activities included discussions, videos,
    small group work, and role-plays. Issues were brought up to address self-esteem, human
    sexuality and condom use. The CCP enables adolescents to take an active role in their
    learning, and to share information they acquire with peers. One interactive activity had
    adolescents learn how to correctly apply and remove condoms using a model penis.

    Other sessions had adolescents act out "condom negotiation", the process of
    telling a potential partner about condoms and intent to use them. The Reality
    female condom was also introduced, presented and demonstrated using a female genitalia
    model.

    As part of the sex education program, adolescents made more than 2,000 condom bracelets
    and necklaces for distribution at the Festa de São João. The bracelet and
    necklace making activities created a fun and educational environment that fostered safer
    sex discussions among the adolescents and health educators.

    "The bracelets and necklaces are a fun and convenient way to keep a condom
    available at a crowded festa, and to spread the message of safer sex," Miller
    said.

    The condom bracelet is covered in transparent contact paper to keep the condom
    protected and dry. It can be worn as a necklace under clothing in case of rain, or it can
    be worn around your wrist as a bracelet. Condom necklaces and bracelets come in bright
    yellow, green, and blue—perfect for a Brazilian-style festa!

    Adolescent volunteers from the Santa Monica Police Activities League (PAL) in
    California made an additional 600 bracelets which were brought to Brazil, forming a unique
    cross-cultural partnership in which adolescents in the USA and Brazil worked in a similar
    capacity in the fight against AIDS. CCP staff and volunteers distributed approximately
    10,000 condoms in total.

    Results

    Before the education sessions, each participant responded to a questionnaire about his
    or her knowledge, attitudes and practices of condom use. This same questionnaire was
    administered a second time to the same adolescents after they participated in the CCP-São
    João and the festival.

    From the first questionnaire, 26.5% of the thirty-one participants were sexually
    active. The average age of participants when they had sex for the first time was 15.3
    years old, and the majority reported being between 13-15 years old. Of the participants
    who are sexually active, the majority (55.6%) reported they used a condom the last time
    they had sex.

    Most participants (87.7%) responded they intended to use a condom in the future;
    however, reasons for not using condoms included: disliking condoms, trusting their
    partner, being embarrassed, being in love, and not having a condom available. It is
    important to understand why adolescents do not use condoms because this information can
    help health educators integrate the needed information into the programs.

    Adolescents were asked about how they obtain condoms to determine knowledge and
    logistics of condom accessibility. The pharmacy was the most commonly reported place
    (53%), followed by mobile health units (16%), friends (11%), health clinics (7%), and
    street vendors (2%).

    People who reported that condoms are "very easy" to obtain increased after
    participating in CCP (from 43.3% to 52.4%). Participants who reported that condoms are
    "very difficult" to obtain decreased from 36.7% to 9.5%. Thus, participating in
    CCP seemed to positively impact the adolescents’ knowledge of where to obtain condoms.

    Oftentimes, adolescents say they plan on using a condom, but in the moment of passion,
    especially with a partner who doesn’t want to use one, they end up having unprotected sex,
    perhaps because they lack the skills of negotiating condom use. After participating in the
    CCP, adolescents reported an increase in their comfort level when negotiating condom use
    with a partner (participants who felt only "somewhat comfortable" increased from
    6.1% to 14.3%, and participants who felt "somewhat uncomfortable" decreased from
    45.5% to 38.1%).

    Participants’ responses revealed that adolescents over 16 years of age feel more
    comfortable negotiating condom use with a partner than their younger counterparts. The
    level of confidence respondents expressed in using a condom increased after participating
    in CCP. Respondents who reported using condoms with "a lot of doubt" or
    "with difficulty" dropped (20% to 14.3% and 10% to 4.8% respectively).

    Another significant change after adolescents participated in the CCP was an increase in
    the number of respondents who had talked with their friends about condom use in the past
    month. Before the CCP, the number of people who said they had spoken with friends about
    condom use was 47%. After the CCP, the proportion of participants who talked about using
    condoms with their friends jumped to 90%.

    The increase in discussion about condom use amongst friends suggests that CCP
    participants passed along the information they received to their friends who were not CCP
    participants; thus, spreading the message of safer sex. This direct sharing of information
    shows that even those adolescents who do not directly participate in the CCP may benefit
    from the project by learning from their peers who do participate.

    These data suggest that continued education among adolescents in Cachoeira, as well as
    in other cities in the interior of Bahia, would improve self-esteem and responsible sexual
    behavior. Future sex education projects are needed to examine the program’s effect over
    time, to monitor progress, and to help determine the best educational techniques.

    And Now?

    The CCP-São João provided information on sexual behavior and condom use trends among
    a selected group of adolescents in Cachoeira, Bahia. It is important to study behavioral
    trends in HIV/AIDS, and other public health problems, to help us understand how and why
    people practice high-risk behaviors.

    A better understanding of these behaviors offers suggestions for interventions aimed at
    preventing the further spread of disease. For example, many adolescents who participated
    in the CCP reported using condoms for protection and prevention, but they could not
    accurately describe from which diseases in particular they were protecting themselves.
    This result suggests the need for more education about sexually transmitted infections and
    HIV/AIDS.

    The success of the CCP in promoting safer sex was largely due to collaborative efforts
    between the community, school system, Atman International, DKT do Brasil and the media.
    The involvement of different community outlets resulted in a successful condom promotion
    campaign that reached a large number of people.

    Collaboration is especially important for smaller non-urban towns that are often
    overlooked by the state-sponsored health education programs found in more populated
    cities. A greater collaborative effort involving numerous community and corporate entities
    can successfully impact public health by providing a clear, targeted message. Individuals
    need correct and consistent messages to help them build healthy behavior habits.

    Hopefully, the future will hold support for more creative community-based sex education
    programs. The fight against the spread of STIs such as HIV/AIDS, and unwanted pregnancy
    requires continued condom promotion and efforts to reduce high-risk behaviors. HIV/AIDS is
    a disease that requires people to be informed with the facts concerning transmission and
    prevention. The CCP project does not intend to promote discrimination against people with
    AIDS. It is the intention of Atman International to increase support for healthy
    behaviors, and create solidarity in the fight against the spread of this disease.

    In order to contribute to decreasing the spread of STIs such as HIV/AIDS, it is
    necessary for individuals to adjust their beliefs and values to reflect the facts. We all
    need to recognize the threat of HIV/AIDS rather than viewing the disease as something,
    "that can’t happen to me".

    Communities need to support their children’s education about sex and condom usage.
    Adult community members also need to educate themselves about high-risk behaviors.
    Finally, it is necessary for the government to be supportive of community-based sex
    education programs and provide more health/medical services.

    For questions concerning this article or for additional information on the Condom Carnival Project contact Lori Miller by e-mail at:
    lorimm@earthlink.net

    Aparna Waeger will complete her Masters degree in Public Health at UCLA
    in 1998. Dana Miller received her Bachelor of Science degree in health sciences at Duke
    University in 1997. Lori Miller received her Masters of Public Health in International
    Health and Health Education from Emory University in 1997. For more information on Atman
    International, contact Sylva Dvorak at 310-573-2127, or by fax at 310-573-1288

    Bibliography:

    Lori Miller’s Thesis, "Effects of an Interactive Sex Education Activity on
    Knowledge, Attitudes and Practices of Condom Use Among Low-Income Adolescents in Salvador,
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    Barbosa, R.M., Lago, T.G., Klackman, S., and Villela, W.V. (1996). Sexuality and
    Reproductive Health Care in Sao Paulo, Brazil. Health Care for Women International.
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    Barros, R., Fox, L., Mendonca, R. (1993). Female-Headed Households, Poverty, and the
    Welfare of Children in Urban Brazil. Project of the Population Council and the
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    BEMFAM (1997). The 1996 Democratic and Health Survey in Brasil. Bem-Estar Família.

    Cromack, Luíza, Barros, C., Castro, D., Gonçalves, F., Fernandes, M.E.L. (1996).
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    from the XI International Conference on AIDS in Vancouver, Canada.

    Informações Básicas dos Municípios Baianos (1994). Governo do Estado da Bahia.
    Secretaria do Planejamento, Ciência e Tecnologia. Convênio CONDER/DEI. Salvador, Bahia,
    1994.

    International Primary Health Care Conference (1994). Poor Most at Risk from AIDS. Nursing
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    Mann, J., Tarantola, D., and Netter, T.W. (1992). AIDS in the World. Cambridge,
    Massachusetts: Harvard University Press.

    Ministério de Saúde (1996). Secretaria de Assistência à Saúde Programa Nacional de
    DST/AIDS. 1° Congresso Nacional de Prevenção das DST/AIDS. 18-20/12/96.

    Miranda, R. (1996). AIDS Avança entre os menos informados. O Globo (December 7,
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    National Center of Health Statistics (NCHS) (1997). United States National Survey of
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    Pan American Health Organization (1997). Division of Disease Prevention and Control,
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    Rafaelli, M., Campos R., Merritt, A.P., Siqueria, E., Antunes, C.M., Parker, R., Greco,
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    Raffaelli, M., Siqueira, E., Merritt, A.D., Campos, R., Ude, W., Greco, M., Greco, D.,
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    Reuter North American Wire (1996). "Brazil Launches AIDS Media Blitz for
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    Silva R.C. (1996). Knowledge, Attitudes, Belief and Practices about AIDS Among
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    Souza, R.P., Almeida, A.B., Wagner, M.B., Zimerman, I.E., Almeida, S.B., Caleffi, A.,
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    U.S. Bureau of the Census (1996). Population Division, International Programs Center. HIV/AIDS
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