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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,
Bahia, Brazil", 1997. Rollins School of Public Health of Emory University, Atlanta,
Georgia.

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of Adolescent Health. 14: 336-339.

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