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I
Executive Summary
II
Country Program Description:
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Introduction
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Country Context
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Accomplishments and Outcomes
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Implementation and Management Issues
III
Lessons Learned and Recommendations
IV
Subproject Highlights:
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Major Program Areas - I
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Major Program Areas - II
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Support Areas - I
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Support Areas - II
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Support Areas - III
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Support Areas - IV
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Non Subproject Highlights
VI
Attachments
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Glossary of Acronyms
SUBPROJECT HIGHLIGHTS


SUPPORT AREAS - PART 1


1. BRAZIL CONDOM SOCIAL MARKETING PROJECT

FCO #s 22447, 42447, 52446

Implementing Agency: Population Services International/DKT do Brasil
Date of Sub-Projects: July 1993 to April 1995
October 1995 to March 1996
October 1996 to March 1997
Target Population: Low-income populations and AIDSCAP target populations
Geographical Focus: Country Wide

Background

The Brazil Condom Social Marketing Project was implemented by DKT do Brasil, a legally established entity in Brazil and affiliate of Population Services International, to increase the direct availability of affordably-priced condoms to target populations and to promote the regular and correct use of condoms to reduce the sexual transmission of HIV/STI. This project was funded under a series of four Task Orders.

Objectives

  • Increase access to condoms to low-income populations and AIDSCAP target populations in several Brazilian regions.


  • Promote regular and correct use of condoms.


  • Collaborate for the decrease of STI/HIV transmission through condom use.

Accomplishments

a. Expand Prudence sales and distribution network

Prudence cumulative sales from July 1993 through May 1997 were 71,550,339 units -- of which 45,792,200 were in the AIDSCAP target areas of São Paulo, Rio de Janeiro and the Northeast. This represented 64 percent of total country volume.

AIDSCAP research indicates that where Prudence is present it outsells the market leader Jontex. In addition, AIDSCAP research, supported by Nielsen and Ministry of Health surveys, confirms that Prudence is the lowest-priced brand on the market.

Number of retail outlets selling Prudence as of May 1997

Brazil
AIDSCAP Target Areas
Drugstores
19,039
10,810
Food Stores
8,723
5,066
Non-traditional (includes motels, bars, etc.)
2,000
1,200
Total
29,762
17,076

(Source: Nielsen audit reports and DKT sales records)

The total condom market grew four fold from the time Prudence condoms were introduced. The aggressive introduction of the socially marketed brand forced local producers to respond to competition for the first time, thus increasing the number of promotional activities for condoms. This coincided with an increase in government spending for condom promotion and AIDS education. The total effort helped increase awareness of AIDS and prevention methods, leading to increased consumer use of the product.

b. Promote AIDS prevention and Prudence brand condoms

Television: A total of 6,000 15-second TV spots were aired with two themes: Lifesavers, which showed a circular flotation device on the side of a cruise ship that dissolved into a condom; and Weekend, which showed the things to pack for a weekend, including condoms. These same spots were also aired in select cinema theaters 4,000 times in São Paulo in the lower-income neighborhoods.

Billboards: The above-mentioned TV advertisements were also aired on backlit billboards for 15 days on the principal avenues of São Paulo in 1995.

Radio: A total of 3,400 spots were aired under the theme "True Act of Love" which were 15-second depictions of slices of romantic life.

Event Marketing: Due to the high cost of media advertising, Prudence switched to sponsorship of major events such as Carnival, and minor fairs (School, Post-Carnival, Discotheque). Starting in 1995, this became the major advertising effort for the brand.

IEC and Promotional Materials: A variety of promotional materials were developed, depending upon the event or activity.

c. Collaboration With NGOs

Crucial to the marketing efforts and success of Prudence has been the collaboration with NGOs. This effort was begun in 1995 and intensified over the past two years. A total of 63 NGOs, of which 41 are in AIDSCAP target areas, have collaborated with the social marketing project on a national basis. The NGOs allowed Prudence to directly access target groups such as homosexuals, commercial sex workers, transport workers, and students, creating a low-cost vehicle for sampling operations. Prudence is now the most sought-after brand for collaboration with samba schools, radio stations, universities, and other NGOs.

Three exemplary examples of NGO collaboration are:

  • APTA-BARONG: Together with AIDSCAP, Prudence sponsored this NGO which set up a mobile bar promoting condoms and safe-sex behavior, as well as other means of AIDS and STI prevention in the beaches and parks of São Paulo state.


  • CENTRO CORSINI: This Campinas-based AIDS prevention center operates an AIDS hotline and also serves as the consumer center for information for Prudence. AIDSCAP and Prudence jointly sponsored this activity.


  • ARCO IRIS: Although this NGO does not work in the AIDSCAP target areas but rather in Brasilia, this is a good example of a group working with a target segment. This NGO works the satellite cities populated by the lower-income population of the area. Working out of a van loaned by Prudence, this group sets up in a central area and begins disseminating AIDS information and sells condoms at an affordable price.

DKT do Brasil helped with a seminar sponsored by USAID and organized by Partners of the Americas in 1996, with the objective to train NGOs in social marketing. The DKT management group presented its project and expounded on the principles of social marketing. Unfortunately, as NGOs have to register as a commercial entity in order to engage in active selling of condoms, the social marketing activity is difficult to extend to these groups. As a result, these NGOs work in collaboration with DKT to provide their target populations with low-cost condoms and AIDS information, and jointly engage in activities that promote condom use.

List of Collaborating NGOs at AIDSCAP Target Areas

São Paulo

Rio de Janeiro

Northeast

 Other Regions of Brazil
APTA-Barong ABIA APA
Amavida (Amazonas)
Casa Sol Atoba - Mov. Homossexuais APRA - Assoc. Prev. Ref. AIDS
Associação Cidadania Plena (Paraná)
Centro Corsini Centro Social Arraial Do Cabo Centro Criança Adolescente
Centro Med. Prev. Mulher (Goiás)
Cepeo Confederação Das Mulheres Cepeo
Essor (Pará)
Col.Feminista Lésbicas ISER Congresso Epidem. AIDSCAP
Funai (Paraná)
CRI - Assoc. Criança Querida Fed. Associação as Mulheres Forum AIDS
Fund. Municipal Itumbiara (Minas Gerais)
GTPOS Fundação Bio Rio Fundação Desenvolvimento Comunitário
Fundação Acoriana (Santa Catarina)
GAPA Grupo da VIDA GAPA
Fundação Esperança (Pará)
Mapa Grupo Pela VIDA Grupo Dialogay
GAPA (Minas Gerais)
Ogban SESI Grupo Gay (Bahia)
GAPA (Rio Grande do Sul)
S.O.S. Adolescente Soc. Benef. Sao Camilo Grupo Gay (Pernambuco)
Gempac (Pará)
CEMINA Soc. Est. Drogadição JICA
Grupo Amor e VIDA (Goiás)
SESI Universidade Federal do Rio de Janeiro Kiyoshi/FICA
Grupo Arco-Íris (Brasília)
    Maria América da Cruz
Grupo Dignidade (Paraná)
    Rapra - Essor
Grupo e a VIDA Continua (Minas Gerais)
     
Grupo Pela VIDA (Paraná)
     
Grupo Solidariedade (Minas Gerais)
     
Grupo Vhiver (Minas Gerais)
     
I.D.T.V. Alfredo Matta (Amazonas)
     
Lar Espírita (Minas Gerais)
     
Mulher Saúde (Minas Gerais)
     
Universidade Federal Minas Gerais (Minas Gerais)
 Total = 13  Total = 13  Total = 15
 Total = 22

Total NGOS collaborating with CSM in Brazil = 63

Constraints

  • Condom quality regulations constitute a non-tariff barrier for importers.


  • Pre-collection of ICMS taxes and the taxation system itself increases the cost of doing business and forces up the cost of the product. It is estimated that 46 percent of the cost of a condom is composed of the various taxes.


  • Well-meaning but uninformed consumer defense groups add unnecessary and ultimately harmful pressure onto regulatory agencies to further restrict condom imports. The recent condom quality controversy initiated by the consumer defense group, IDEC, agitated the regulatory agency, INMETRO, to impose stricter in-country lot testing on all imported condoms, even those that were granted the ISO 9002 certification that, in theory, would have exempted these condoms from the required tests. IDEC commissioned tests based on unknown criteria, using erroneous sampling and testing methods, all contrary to ISO and Brazilian standards. Yet these were given credence by INMETRO. These actions severely limited imports over the following months, and precluded importers from participating in bids and regular selling, thus granting market opportunities to the higher-priced national brands. For the importers, and for Prudence, funds had to be invested to assure the consuming public of the brands' quality and integrity, thus routing resources away from productive educational uses.


  • High costs of advertising in electronic media prevents a more aggressive and widespread effort to educate the public about AIDS and STIs. For example, the cost of a 30-second prime-time spot on network TV is 65,000 USD.


  • Social charges double the cost of hiring personnel, limiting the scope of activities in all areas of operations. For every $1.00 in salary, the social charges are equivalent to $1.06.

Capacity Building

During April 1994, DKT do Brazil conducted a workshop on Condom Social Marketing for NGOs and governmental organizations from AIDSCAP geographic areas. The meeting discussed the basic concepts of condom social marketing and successful pilot experiences with NGOs in Brazil. Furthermore, the legal aspects of establishing a condom social marketing operation at the NGO level was also discussed with the technical assistance of a Brazilian lawyer.

In addition, issues related to the norms and regulations related to the quality control of condoms were also discussed. During the life of the project DKT do Brazil local staff provided ongoing assistance to NGOs to build their capacity in the development of CSM. In collaboration with AIDSCAP/Brazil a team of promoters was trained to develop activities on HIV/AIDS/STI prevention during special events. Field research protocol to evaluate the access of condoms at AIDSCAP geographic target areas was developed in close collaboration with AIDSCAP/Brazil. The results were analyzed and discussed to generate a rich and valid experience with relevant exchange of expertise between research teams and DKT do Brazil.

Lessons Learned/Recommendations

Because of high advertising costs, alternative channels for promoting condom use must be tapped. The most effective of these alternative channels has been local NGOs. DKT do Brasil works with over 40 NGOs countrywide, providing them with low-cost condoms and educational and promotional material. Samples are also given that allow the product to be promoted directly to those practicing high-risk behaviors. Sponsoring NGO activities allows for one-on-one interventions, and goodwill on the part of the various municipalities where the NGOs work.

Again, because of limited advertising funds, care must be exercised in choosing the promotional channels. Apart from the NGOs, sponsorship of special events, called "event marketing" has turned out to be effective for social marketing. During Carnival, DKT do Brasil sponsors several "samba schools" that parade in front of a multitude of spectators, drawing attention to the product. Although some research maintains that condom promotion during Carnival is a waste as samples get used like balloons, the objective of the activity is to draw attention to the product, its use and advantages. For example, Coca-Cola consumption does not necessarily increase during the Olympic Games it sponsors, but the after effect of product awareness is priceless. With the sponsorship of special events by Prudence condoms, they have become the third largest brand in the Brazilian market.

Sponsorship of special events should not be limited to big spectacles. Radio stations periodically sponsor dance nights at discos, and access to groups at the earlier stages of sexually-active life is obtained. Fairs at various schools provide the opportunity to promote AIDS prevention among the younger populations.

It is important to show strength and defend the product in the face of unjustified attacks by regulatory agencies. With the recent condom quality controversy that resulted in the tightening of regulations on imported condoms, the regulatory agency, INMETRO, was trying to show the public that it was in the forefront of protecting the consumer. However, the actions taken, primarily requiring in-country lot-testing of condoms from international factories duly accredited by INMETRO itself, served only to promote the interests of the local producers, and not to enhance safety. Furthermore, the consequences could have been less imports, thereby reducing product availability, and price increases on the part of the local brands, thus putting condoms out of the reach of low-income consumers. This would have led to an overall decline in protection for the Brazilian public. The fact that this did not occur was a result of DKT do Brasil's resolve to go to court and obtain an injunction against the new regulations, citing unfairness, unconstitutionality vis-a-vis Brazilian law, and the ineffectiveness of the new regulations regarding overall consumer protection. In essence, DKT do Brasil has served notice to the regulatory agencies that their actions must be based on the law, and not on the capriciousness of individual regulators.

Budget

Estimated AIDSCAP Expenses
Counterpart Contribution Agreed
Verifiable Counterpart Contribution
1,090,791
680,000
2,227,345


2. LOGISTICS MANAGEMENT

FCO # 42448

Implementing Agency: John Snow Incorporated (JSI)
Date of Sub-Project: April 1993 to November 1996

Background

The AIDSCAP logistics and management plan in Brazil was designed to support AIDSCAP interventions in target geographic areas to improve the logistics system, condom supplies and STI pharmaceuticals supplies. The main objectives were to increase the availability and accessibility of pharmaceuticals and condoms through improved logistics management within the public health system. The majority of prevention and treatment efforts, including government programs and NGO- and community-based interventions, rely on the public health system for STI and AIDS medications as well as condoms for free distribution. At the beginning of the AIDSCAP project the lack of essential commodities was a grave impediment to controlling the AIDS epidemic, especially in the target geographic areas. The logistics management component of the project was a multi-year collaboration of the government of Brazil, John Snow Incorporated (JSI) and AIDSCAP.

In addition, developing condom requirement estimates within the policy planning cycle was essential for National AIDS/STI Prevention Programs. The practices of condom requirement estimation and procurement included a review of condom requirement estimation methods. Furthermore, AIDSCAP assisted during three years the State Department of Health in Rio de Janeiro and São Paulo establishing and improving logistics cycles and management systems for essential commodities such as condoms, pharmaceuticals, and test kits for AIDS prevention and STI control efforts.

Strategy

The analysis of the logistic system found that condom requirements were often considered too late in the policy-planning cycle to assure an adequate condom supply. In addition, comparison data from most condom requirement estimation models showed a tendency to underestimate condom needs of population segments at high risk of HIV and overestimate the general population's demand for condoms. Two practical models were developed for use by national HIV/STI program planners:

  1. Policy Planning Model -- integrating condom requirements and procurement cycles; and

  2. Forecasting Condom Requirements Estimation Model (FOCUS) - a sensitive and reliable measurement of population segment differences in condom acceptance and use.

The management of logistics-essential commodities included a four-part strategy: a) The creation of an Essential Commodities Distribution System (ECDS) integrated vertically in the public health system under the control of AIDS Division Directors; b) implementation of an essential commodities management information system to control inventory and evaluate results; c) identification and training of AIDS Division Logistics Coordinators; and d) technical support for the public health system, forecasting, health planning and procurements of condoms and other essential commodities.

Results

After three years of activities the logistics management achieved the following results:

An in-depth operational field review survey in the State of São Paulo and Rio de Janeiro provided recommendations to improve logistics management systems in target geographic areas.

  • Installed FOCUS 2.0 and trained staff on its use.


  • Completed five-year commodity condom forecasting in São Paulo, Rio de Janeiro and Santos.


  • Completed five-year commodity forecasting for STI pharmaceuticals in São Paulo and Rio de Janeiro.


  • Establishment of the logistics positions of a HIV/AIDS/STI Logistics Coordinator in São Paulo and Rio de Janeiro.


  • Establishment of an HIV/AIDS/STI logistics unit in São Paulo as part of the AIDS state program.


  • Designed and sited logistics data collection forms which have been adopted as State of São Paulo and Rio de Janeiro Official Forms.


  • Trained 5 Logistics Coordinators in the US (two from at Federal level, one from São Paulo and two from Rio de Janeiro) during one month.


  • Designed, developed and installed the software prototype ECMIS and sited the commodity tracking system.


  • Adjusted ECMIS after testing per counterparts request in target geographic areas.


  • Developed a list of essential drugs for STIs and AIDS.


  • Reviewed warehousing conditions, transportation, staffing, stock management, and procurement procedures in São Paulo, Rio de Janeiro and Santos.


  • Developed a training curriculum for condom storage, inventory control and ECMIS.


  • Donated computers, printers and software to the State Department of Health in São Paulo, Rio de Janeiro and MOH.


  • Trained logistics personnel in the use of ECMIS data entry and management.


  • Developed essential distribution outlets (EDOS) list in the States of São Paulo and Rio de Janeiro.


  • Conducted training on logistics management for 262 professionals in São Paulo, Rio de Janeiro and Brasilia.

Sustainability

Logistics sustainability depends upon complex political decisions at the federal level regarding the overall logistics management of HIV/AIDS/STIs drugs and condoms in Brazil. Up to now the States depend upon federal decisions for shipment of commodities and there is no logistics coordinator at the federal level for HIV/AIDS prevention.

Constraints

The main constraint in the logistic component was the ECMIS technology which was not appropriately transferred by JSI. Constant problems with the software which could not be fixed in Brazil made AIDSCAP opt for another software created at the country office. This latter can be easily supervised and technical assistance can be given in-country.

Considering the size of the country and the profound federal problems with logistics it is clear that logistics needs are beyond the scope of work of this project and depends upon complex decisions at federal levels for the proper implementation of this area in Brazil.

Another constraint in the logistics areas was that Brazil did not adopt the IS0 4074 for the control of quality of condoms and the Logistics Training Manual was not translated to Portuguese.

Budget

Estimated AIDSCAP Expenses
Counterpart Contribution Agreed
Verifiable Counterpart Contribution
452,851
0
0


3. THE FEMALE CONDOM STUDY: THE FEMALE CONDOM AS A WOMAN CONTROLLED PROTECTIVE METHOD

FCO # 54047

Implementing Agency: Women, Children, Citizenship and Health
Date of Sub-Project: October 1995 to January 1997
Target Population: Urban Women
Geographic Focus: São Paulo

Background

This study, carried out in Kenya and in Brazil, was designed by AIDSCAP Women's Initiative and focused on women as the condom user. The study was conducted by the Institute of Health of São Paulo State Health Department and the NGO MCCS (Women, Child, Citizenship and Health) with technical assistance from AIDSCAP/Brazil.

Objectives

The main objectives of the study were to:

  • identify factors affecting use and non-use of the female condom;


  • determine ways in which introduction of the female condom affects women's ability to negotiate protection against HIV and others STIs; and


  • explore the role of peer groups in sustaining the use of the female condom.

These objectives were to be achieved through:

a) determining the range and the type of women's protective strategies;

b) assessing women's perceptions of the female condom as a protective device;

c) exploring the impact of the female condom on male-female sexual relationships;

d) assessing the strategies and practices to facilitate a user's ability to negotiate use and to act on her sexual choices.

Methodology

Urban women, sexually active, aged between 18 and 40, willing to not get pregnant and aware of HIV/AIDS transmission were recruited through women's organizations, community leaders and media sources to participate in the study. Women were alerted about the study by the media and through contact with institutions responsible for delivering health care to women and STI/AIDS patients. These also included university facilities and twenty Women and AIDS Prevention NGOs. In the process, members of the research team were interviewed on the female condom for TV and articles, several of which were published in newspapers and magazines. Forty-seven recruitment meetings were held with the participation of almost 400 women. All women who received a box of female condoms for a trial period were invited to return to a selection meeting, some two to four weeks later. Quantitative and qualitative methodologies were used for data collection.

Data was collected through initial and final exit interviews, two focus group discussions and two intervening peer group meetings with all of the women and a focus group discussion with consenting male partners. These data revealed factors of use and non-use, male and female perceptions of the female condom, and any changes in the nature of the sexual relationship that occurred as a result of the introduction of the device.

Women were categorized into age groups of 18-24 and 25-40, as well as high and low socio-economic status. Eight women's groups were formed of women who met these criteria and self-selected to enroll in the study.

Individual interview and focus group discussions were the primary mechanisms of data collection. Two focus group discussions were held, one at the beginning (FGD1) and the second near the end (FGD2) of data collection. All sessions were taped and recorded. Two peer support group discussions (PSG1 and PSG2) were held between FGD1 and FGD2. These served as support for the participants as they practiced use of the female condom. Initial and final interviews using a structured questionnaire collected demographic individual data and women's perceptions and experiences with the female condom. Each woman was given a coital log and a daily diary on which to register each sexual encounter and the means of protection adopted by the couple, i.e., male condom, female condom, other barrier method, withdrawal, or no method.

Results

A total of 394 women took female condoms for a trial, out of which 298 filled the self-answered recruitment form. Some 126 women (32 percent of the recruited) attended the selection meetings, but 11 did not meet the inclusion criteria. The 115 women eligible for the study (91 percent of those attending the decision meetings) answered the initial interview, and were allocated and scheduled for any of the eight study groups.

Women who had by the end of the project participated in at least one group session were considered included in the study (N = 103). Ninety-six women (93 percent) out of 103 answered the final individual interview. Activities to supplement the primary data compiled on the participating women were developed. One male coordinator and one male observer conducted three meetings involving 24 men.

In general, the coital log was adequately filled. Women less literate had greater difficulty, mostly in registering the day of the month. The lesser compliance to the instrument occurred in the younger, higher socio-economic status group, and 28 women did not return their diaries. Among the 103 participants the average age was 26.6 years and average education was 10.4 years. Ninety-four percent reported having a steady partner. Eighty-six percent of the women had only one sexual partner in the last 3 months. Forty-four percent were in the lower social classes. Seventy percent were white and 15 percent black; the others were mulattos. Most of the women (77 percent) work in paid activities and 17 women were temporarily unemployed.

Prevention Strategies

( I ) Use of Method

All women who were at the recruitment meeting were already using contraception: 28 percent used the pill, 51 percent used the male condom, and about 11 percent used other methods (such as IUD, diaphragm, injectables or withdrawal). About 7 percent of women had a tubal ligation or the partner had a vasectomy. The male condom had already been tried by 98 percent of the women. About 9 percent of women used other contraceptives, such as the pill and the Ogino-Knauss associated to the male condom. All participants were asked about their familiarity of male condom use and in the month prior to the study, 43 percent reported they had always used condoms with the main partner, 16.5 percent reported they had almost always used condoms, 9 percent reported that they sometimes used condoms. Thirty-two percent reported they did not use condoms at all. The use of barrier method was related to the desire to avoid pregnancy by 34.5 percent of the women. By 52.5 percent it was also associated with the need for protection against STI/AIDS. Only 9 percent reported the use of condoms solely as STI/HIV protection.

(II) Safer Sex Negotiation

The initial interview showed that STI and AIDS had been discussed with their partners before the project started. The majority of women (at least 60 percent) approached the issue directly within the relationship, 23 percent reported having talked about it with their partner when the issue was featured in the media or about cases that happened in their community or at their workplaces. It is important to underline that AIDS was the theme of the dialogue for 81 percent of the women and their partners.

Condom Use

The majority of the women (88) reported they negotiate the use of condoms with their main partners while a minority (7) only considered condom use for possible extra-marital relationships. Sixteen percent considered the condoms as an integral part of their sexual lives, and as a requirement for intercourse. However, for most of the women, the use of condoms is very recent. About 58 percent reported they were using condoms for the last year or less.

Group discussion showed that the way the female condom was proposed within relationships varied. Proposals, invitations and 'non-verbal seduction games' are some of the strategies adopted, in the perspective that the 'power of seduction' is the most efficacious feminine argument, especially for married women or those who have affectionate links with their partners. Some preferred to introduce the condom in a more direct way, although still through negotiation. Another strategy reported was to present it as a novelty, something erotic and not relating the female condom to STI/AIDS or to protection.

The negotiation under the form of demanding the use of condoms as a requirement for intercourse appears when the partners were recent, eventual, or when there was a second partner. For some younger women, it was difficult to introduce the idea of any kind of protection, since it might connote suspicion of his unfaithfulness, or a confession of her own. Some women had bad experiences of negotiating the condom, and the female condom appears as an alternative to negotiate from a more empowered position.

The participants considered that women are achieving similar positions as men in the areas of education and work, which is a perception compatible with the population trends. The younger and more affluent considered this 'equality' universal, while all of the less affluent participants gave hints that more effort is socially and culturally demanded of women. This difference suggests that greater economic resources minimize gender difficulties. Men are perceived as pleasure-seekers who can afford sex without commitment and without considering the possible moral and physical consequences of sex. Younger women of lower socio-economic status are those who stated most sharply the differences in consequence of men and women. All of them realized that the exercise of sexuality for women is socially sanctioned by love even though they stated that the access to a sexual life is an important source of freedom for women. Even the younger women of higher socio-economic status who feel themselves more 'equal' to men, feel that women are educated to fulfill a more passive and submissive role. Yet despite this role, the responsibility for seeking information about sexuality is the woman's, according to the participants. Women are the vehicles of information for men who supposedly have more taboos restricting talk about sex and their own anatomy.

To identify factors that determine the disposition and intention to adopt protection practices, the following variables were considered: the concern with AIDS; the need to use protection against HIV; and the use of condoms in the last intercourse. The association of these variables with age, socio-economic status, years of education, marital status, knowledge about AIDS, definition of intercourse and the importance of sex in their lives were explored.

No significant association was found between these indicators and socio-economic status, age, education and their basic knowledge about AIDS. However, there is an association between level of concern about AIDS and the way the women feel about and define their sexual encounters. Those that define sex solely as the expression of affection show a lesser concern about AIDS.

The feminine efficacy in obtaining protection for contraception and against STI/AIDS is elaborated from ambiguous parameters, given the fact that even the use of the female condom will depend on the agreement of the partner. Coexisting in the same woman can be traditional role standards and the need for love in a sexual relationship, and the need to control her body and make choices about her sexuality.

The feeling of 'empowerment' was reported by some of the women, although for the majority it is the partner's opinion that is going to stimulate or interrupt the use of the female condom. Especially the younger women of lower socio-economic status and but with a high level of cultural sophistication for their class/age, that referred to the female condom as belonging to them -- they showed great enthusiasm with the idea of an instrument that would allow them to decide about the prevention of STI/AIDS and unwanted pregnancy. They stimulated one another to notice the gender contradictions present in daily life, and mainly in negotiations to use the female condom.

The majority of women (70 percent) have basic and general information about STI and AIDS, but their information about HIV and its mode of transmission is more frequent than other STIs. About 30 percent have equivocal information. Previous experience of STI is denied by 85.5 percent although only 28 percent reported never having vaginal discharge or itching. Those who reported a discharge did not consider the episode as a STI, even when their partners also underwent some treatment. The majority of those that reported complaints or symptoms (63.5 percent) could not specify or did not learn the diagnosis, maybe because the health professionals who treated them diminished its importance, reinforcing the idea that these discharges are commonplace and normal.

When asked about their potential risk for STI and HIV, 84.5 percent reported a great need to use protection against HIV, 78.6 percent reported great concern of acquiring STI and 78 percent of acquiring HIV/AIDS. Only 15 percent and 13 percent respectively thought that they have a great risk. Probably this is related to the conception of AIDS in a society which views it as a disease affecting only various 'risk groups' (prostitutes, the promiscuous, homosexuals, IDUs, etc.) with whom women do not want to be identified.

(I) Perception of the risk for AIDS

A more refined perception of risk appears in women who, regardless of their social class or age, presented life histories that linked sexual experiences to STI or unwanted pregnancies. They expressed that their interest in the female condom is more related to curiosity and desire to participate in the project than to the prevention of STI/AIDS. At the same time, they make explicit that the use or lack of use of the female condom, as much as other methods of prevention, depends on their partners' agreement -- which resist more to the adoption of protective practices. This suggests that, for many women, the perception of lack of risks, or of the autonomy that the female condom confers, must be seen as relative.

The need to question the security of the steady relationships is verbalized, having as a presupposition the male unfaithfulness. Love, time of the relationship, and trusting the partner are factors that hinder the adoption of protection practices in the main relationship. Broaching the topic, together with the issues relative to faithfulness and betrayal, rise very diverse and ambiguous reactions, becoming one of the most polemical and central focuses of the discussions in all groups.

Use of the Female Condom

After an average of two months of follow-up, 92 women (96 percent) had used the female condom. A total of 72 women (75 percent) reported to be using the female condom, among those women, 24 (33 percent) were exclusively using the female condom, 38 women (53 percent) were using it alternately with the male condom and 10 women were occasionally using it associated with other contraceptive methods. At the exit interview a total of 24 women had stopped using the female condom for different reasons (9 women decided to use only the male condom, 5 had no partners, 4 preferred the pill along with the male condom and 6 women were using other methods). At the initial interview insertion was considered easy by 54 percent and difficult by 46 percent. At the final interview only 8 women continued to find insertion difficult. Most women's difficulties of insertion were overcome during the intervention process. After having used the female condom at least three times, 87.5 percent of women had no more problems of insertion.

The opinions of the women about the female condom were very positive and only two did not find any advantage. Their partners also had positive opinions about it, and 68 cited advantages in its use. Nevertheless, for 22 partners the use of the female condom was not considered good. The main advantages referred by the women were its comfort, the autonomy it provides, protection against STI/AIDS, and protection against unwanted pregnancy. For the partners, the most valued attributes were its comfort, the fact that it does not squeeze the penis (30 percent), and the fact that it does not interfere with his sensitivity (15 percent). Sixty-four percent of the women made no comments when asked about its negative aspects. Twenty-two percent did comment, however, on the aesthetics and this was the main complaint cited by the partners (23 percent). For 16 percent of the women, the way to manipulate it is another negative aspect, as they found it difficult and arduous. But an encouraging eighty-nine percent positively evaluated the female condom.

Almost all the women provided the female condom used it during the study and 83 percent discussed its use with the partner during the study. Sixty-two percent of those women used the method during more than half of their sexual encounters. Asked at the final interview, 75 percent of women "liked very much" using the female condom, 20 percent "liked" using it and only 5 percent "disliked" using it. Almost half of the women in the study (43.5 percent) preferred the female to the male condom, 37 percent liked it as much as they like the male condom, 11 percent preferred the male condom and 8 percent did not give their opinion. Eighty-seven percent declared they would be willing to pay for a method, including the female condom, that would guarantee protection. Eighty-two percent believe that female condoms will be well-accepted when available for sale.

Budget

Estimated AIDSCAP Expenses
Counterpart Contribution Agreed
Verifiable Counterpart Contribution
75,720
0
0


4. TRAINING: AIDS PROGRAMS IN PREVENTION AND ASSISTANCE

FCO # 56455

Implementing Agency: The Research Foundation of the State University of New York
Date of Sub-Project: April 1997 to July 1997

Background

An HIV/AIDS prevention workshop designed for specialists from Brazilian governmental and non-governmental institutions involved the planning, evaluation and implementation of AIDS prevention programs, financed by AIDSCAP, with funding from USAID, and implemented by the State University of New York (SUNY).

Participants for AIDS: Programs in Prevention and Assistance were selected from among Brazilian governmental, non-governmental and academic organizations attending to the needs of specific HIV-risk groups currently targeted for USAID assistance in Brazil. The workshop was designed to strengthen the capacity of these organizations to plan and implement effective HIV/AIDS prevention programs. The workshop, which was held June 2-26 1997 in Porto de Galinhas, Pernambuco, was an overwhelming success. The four-week calendar and the small number of participants (20) provided ample time and familiarity for a constructive interactive learning experience.

Objectives

The major performance objectives for workshop participants were as follows:

  • To effectively communicate current knowledge about transmission, epidemiology, clinical treatment methods, and prevention of HIV;


  • To apply a variety of behavior modification theories, appropriate to their target population;


  • To demonstrate ability to conduct individual and small group counseling and to use mass media for HIV prevention


  • To develop a specific program plan for HIV prevention, for subsequent implementation.

Accomplishments

Participants were selected from agencies attending to the needs of low-income women with stable partners, youth-at-risk, and patients with STIs. These risk groups are the focus of USAID assistance in Brazil, and were chosen as such based on recent epidemiological trends, as outlined in the May, 1996 USAID/Brazil HIV/AIDS Program Review. In addition to focusing on specific risk groups, USAID has chosen to concentrate a greater share of resources in the northeastern region of Brazil.

Many of the agencies from which participants were selected already conducted successful HIV/AIDS prevention programs while others were in the process of implementing such programs for the first time. The result of this diverse audience was a divergence of strengths and experiences, even though this diversity caused some misunderstanding and questioning of the methods used in the selection process. All parties agreed that the selection process could have benefited from a longer lead time, which, through more thorough dissemination, could have led to a larger pool of candidates. However, some of the choices which were questioned were far from random, and actually in keeping with the USAID strategy of maximizing impact via concentration of resources, i.e.: the inclusion of individuals with little or no experience in HIV prevention; the inclusion of a greater number of participants from Northeastern governmental organizations and NGOs, and; the exclusion of candidates with a great deal of experience in already established and respected AIDS prevention organizations.

The workshop was very highly rated by the participants, who indicated in their evaluations that they would enthusiastically recommend it to their peers. The ideas, information, and techniques presented in the workshop were valuable and appropriate to the work situations of the participants. All of the participants indicated that the workshop had been very valuable to them, and every single participant indicated that they would strongly recommend it to their colleagues (on a scale of 1-5 on their evaluation forms, this item drew unanimous fives).

Instruction in the following areas was considered particularly valuable:

  • needs-assessment techniques;

  • focus group technology;

  • active listening and feedback;

  • conflict resolution, and;

  • responding to difficult questions.

Constraints

The major constraint encountered during this training was probably the variation in backgrounds and experience among participants. Participants with a great deal of experience in planning and implementing HIV/AIDS prevention programs were grouped together with professionals with virtually no experience in HIV/AIDS prevention, and this can be awkward for participants and facilitators alike. While from an instructional standpoint differing abilities are always a challenge, these differences can be translated into strengths for the group as a whole, and to widen the perspective of the individuals. Given the context of this particular training event, the input of experienced professionals working in the Brazilian "realidade" was valuable to the success of the workshop, and greatly benefited those who were new to the field.

This constraint also contributed to the success of the workshop. Though, in many ways, it is easier to work with a group where all members have similar backgrounds, the richness of experience found in this diverse group was an asset.

As mentioned earlier, the selection process was another constraint. Actually, when SUNY conducted a similar workshop last year with Ms. Mota, SUNY was, at the time, a USAID/Brazil AIDS grantee. As a result, there was ample lead time for effective dissemination, and participants were chosen from a large pool of qualified candidates from targeted institutions. Unfortunately, in this instance, the Letter of Agreement governing this training activity was in place only two months prior to the start date of the training. This left a very limited amount of time in which to make the announcement, accept applications, analyze applicants, conduct selection meetings, and make travel arrangements for participants.

Lessons Learned/Recommendations

The selection process is crucial for the success of a training course. Implementing agency and stakeholders should be partners in strategy design.

Sites visits should be prepared in advance (i.e., of the three educational site visits the group made ASAS, an interactive center for people living with HIV and AIDS, was extremely well-received; Casa de Passagem, a project that targets girls in high-risk situations, was a disappointment, and will be excluded from any future agenda.

Limited time can influence results.

Heterogeneous groups can share experiences and give good results.

Budget

Estimated AIDSCAP Expenses
Counterpart Contribution Agreed
Verifiable Counterpart Contribution
100,641
0
0


5. MOH SUPPORT

Background

The MOH support component was included as part of the implementation plan for Brazil in order to provide technical collaboration to the NACP/MOH whenever requested to USAID/Brazil.

The following major activities were developed under the MOH support component:

  • AIDSCAP provided technical assistance for the development of a 15,000,000 USD proposal as part of the condom component for the MOH/World Bank Project, July 1992.


  • AIDSCAP provided technical assistance for the development of a proposal for condom supply logistics management and STI/AIDS pharmaceutical logistics management for HIV/AIDS/STI prevention programs in Brazil.


  • Provided technical assistance to the MOH/NACP for the development of AIDS and STI control projects, strategic and implementation plans of the state of Mato Grosso as part of the MOH/World Bank Project.


  • Supported the training of MOH staff in the area of logistics management.


  • Supported MOH to access and design information and computer systems.


  • Supported MOH staff in the area of condom social marketing site visits to condom factories in Asia and to Condom Social Marketing Programs.


  • Provided technical assistance to MOH/NACP for the selection of research proposals as part of the MOH/World Bank Project.


  • Supported the training of MOH staff in the area of needle exchange program during one month in USA.


  • Supported the participation of 41 professionals to attend the First HIV/AIDS Prevention Conference in Salvador, Bahia.


  • In collaboration with MOH, conducted the International Workshop on STIs in Salvador, Bahia.


  • Provided technical assistance in the areas of condom social marketing and in the private sector area.


  • Supported the participation of the MOH/NACP director at the IX and X International AIDS Conference in the years of 1993 and 1994 in Berlin and Yokohama.

Budget

Estimated AIDSCAP Expenses
Counterpart Contribution Agreed
Verifiable Counterpart Contribution
193,395
0
0


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