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Brazzil
January 1999
Behavior

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.

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:

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