Country watch: Cuba.

PIP: Health authorities in Cuba made a serious effort to fight HIV/AIDS in their country. In 1986, the government launched a National Programme of Control and Prevention of HIV/AIDS, aimed at controlling the epidemic and providing quality of care for HIV-positive people. Initially, people with HIV/AIDS (PHA) were interned in sanitariums to prevent HIV infection from spreading further. The sanitariums provided good medical and psychological support. However, ambulatory care was introduced in 1993, mitigating the mandatory character of the original system and focusing more on PHA. Additional services were made available to PHA in December 1998 with the creation of a National Centre for the Prevention of Sexually Transmitted Disease/HIV/AIDS, an integral part of the Ministry of Public Health. The center offers an AIDS prevention hotline and counseling services that include a pilot project, ¿Mobile Project¿, an outreach project for people at risk. The PHA Project was launched in March 1999 with a workshop for 30 PHA from Havana; a guide, "Living with HIV", was created to address the problem of unavailability of information concerning the disease. The guide discusses basic clinical information about HIV/AIDS; PHA and their social environment; nutrition, diet, and hygiene; sexuality; and legal aspects.^ieng

Country watch: Nicaragua.

PIP: The Association of Workers for Education, Health and Social Integration (TESIS) works with commercial sex workers to control HIV and sexually transmitted diseases in Nicaragua through free condom distribution and education. Education includes group work, individual counseling, and demonstrations of correct condom use. Condoms are also distributed to the motels frequented by commercial sex workers. When the Condom Social Marketing (CSM) project in Central America started, it sold condoms of the same quality as the ones offered by TESIS; thus the condom donors reduced their donations, and in turn, TESIS lost its normal quota for free condom distribution. Because of this situation, TESIS dealt with a condom promotion scheme at a lower cost for the poorest women. Condom quality did not deteriorate as products only came with simpler packaging. TESIS fills the gap which CSM missed.^ieng

Study of the vaginal tolerance to Acidform, an acid-buffering, bioadhesive gel.

Vaginal tolerance tests were performed with a new potential microbicidal and spermicidal product, an acid-buffering vaginal gel (Acidform) without or with nonoxynol-9 (N-9). The potential advantages over other vaginal products include keeping a low pH, decrease of the irritating effect of N-9 on the cervix or vaginal mucosa associated with greater retention of the product after application, and decreasing "messiness" as compared to other vaginal products. Three groups of six women were admitted and randomly assigned to use Acidform with 0%, 2.5%, and 5% N-9. Colposcopic evaluation for vulvar, vaginal, and cervical signs of irritation was performed and photographs were taken, following a specific World Health Organization protocol, at time 0, and after 24 h and 6 days of application of the gel. No irritation or symptom was reported by users of Acidform without N-9. A generalized and intense erythema in cervix was observed in 10 of 12 Acidform/N-9 users and abrasion occurred in nine of them. Vulvar irritation was seen in seven of these 10 volunteers. N-9 concentration in the gel (2.5% or 5.0%) was not related to the findings. No ulcer, exulceration, or de-epithelialization was observed. Acidform without N-9 was well tolerated by volunteers, but it was unable to protect the cervix, vagina, and vulva from the N-9 effects.

Improving sexually transmitted disease management in the private sector: the Jamaica experience.

OBJECTIVES: To improve the quality of sexually transmitted disease (STD) case management in Jamaica by providing comprehensive continuing medical education to private practitioners who manage 60% of all STDs on the island. METHODS: Six half-day STD seminars were presented at 3-4-month intervals and repeated in three separate geographic locations. All Jamaican practitioners received invitations. The subjects were as follows: urethritis, genital ulcer disease, HIV infection, vaginal discharge syndrome, STDs in children and adolescents, and a review seminar. The program effectiveness was evaluated with a written, self-reported pre-test and a telephone post-test that measured changes in clinical management. RESULTS: Six hundred and twenty eight practitioners attended at least one seminar. Comparing pre- versus post-test scores, there were practitioner improvement trends in all four of the general STD management categories: counseling/education (69.8-73.3%; P > 0.05); diagnostics/screening (57.2-71.0%; P= 0.042); treatment (68.3-74.5%; P> 0.05); and knowledge (66.4-83.2%; P= 0.002). Obtaining syphilis serologies during pregnancy rose from 38.3 to 83.8% (P= 0.001), and providing effective treatment for gonorrhea rose from 57.8 to 81.1 % (P= 0.002), but correct responses on treatment for mucopurulent cervicitis at the post-test was a low 32.4%. CONCLUSION: The introduction of continuing medical education for improved STD care targeting private physicians in Jamaica was successful based on high attendance rates and self-reported STD management practices. However, efforts should continue to address the weaknesses found in STD management and counseling and to reach the providers who did not participate. In the global effort to reduce HIV transmission by improving STD care services, continuing education programs that target the private sector can be successful and should be included as a standard activity to improve care and provide a public/private link to STD/HIV control.

PIP: The Jamaican Ministry of Health has estimated that over 60% of all sexually transmitted diseases (STDs) are managed within the private sector, where 800 (66%) of the country's 1200 registered physicians practice. To improve the quality of STD case management provided by these practitioners, the Medical Association of Jamaica organized a series of 6 half-day seminars repeated at 3-4 month intervals in three geographic locations between December 1993 and July 1995. Topics addressed included urethritis, genital ulcer disease, HIV/AIDS, vaginal discharge, pelvic inflammatory disease, and STDs in children and adolescents. A total of 628 private practitioners attended at least one seminar and almost half the physicians attended two or more. Comparisons of scores on a written pretest completed before the seminar and those from a post-test conducted by telephone after the seminar revealed significant improvements in all four general STD management categories: counseling/education, diagnostics/screening, treatment, and knowledge. The proportion of practitioners who obtained syphilis serologies during pregnancy rose from 38.3% to 83.8% and those providing effective treatment for gonorrhea increased from 57.8% to 81.1%. Overall, 96% of practitioners were providing some level of risk-reduction counseling at the time of the post-test and 74% were prescribing correct treatment regimens. Ongoing education and motivation by the national STD control program or the Medical Association are recommended to improve STD case management even further.

Approaches to control sexually transmitted diseases in Haiti, 1992-95.

Despite major obstacles, activities to control sexually transmitted diseases (STDs) were initiated in Haiti in 1992 in collaboration with local nongovernmental organizations. The approaches included review of available local data, assessment of STD case management practices and constraints, and development of specific STD control activities at the primary health care level, such as systematic screening of all pregnant women for syphilis and improved comprehensive syndrome-based STD case management. The activities included conduct of local studies, presentation and dissemination of results to key audiences, training of health care providers, improvement of local capacities, and consensus-building on implementation of STD control approaches. STD awareness and case management improved considerably; for example, 69% of the clinicians interviewed reported correct STD treatments in the north-eastern primary health care centres in 1995, compared with < 10% in 1992. At the end of the project, national STD case management guidelines were developed by consensus between the various organizations and the Ministry of Health. Lessons learned included the importance of local data generation and of communication and collaboration with various institutions for consensus-building, the need for continued training, and field supervision to ensure behaviour change among STD care providers. A national STD control programme should be implemented as soon as possible in both the public and private sector. External funding will remain critical to control this important public health problem in Haiti.

PIP: Mid-1992 was a time of considerable political and socioeconomic instability in Haiti. Haiti's first democratically elected president had been ousted by a military junta and both political crimes and human rights abuses abounded. No national sexually transmitted disease (STD) control program was in place and almost no data were available on the magnitude and scope of STDs in the country. In this context, and despite many obstacles, STD control activities were planned with the hope of eventually developing a national STD control program. US Agency for International Development-funded AIDSCAP HIV/AIDS/STD prevention initiatives were first launched in Haiti in mid-1992 in collaboration with local nongovernmental organizations (NGOs). Direct collaboration with the de facto government was not allowed until democracy was restored in October 1994. The authors describe the STD control approaches and interventions initiated under these circumstances, with lessons learned for potential application outside of Haiti. Approaches included a review of available local data, an assessment of STD case management practices and constraints, and the development of specific STD control activities at the primary health care level, such as the systematic screening of all pregnant women for syphilis and improved comprehensive syndrome-based STD case management. Local studies were conducted, with the salient results presented to key audiences; health care providers were trained; local capacities improved; and consensus built upon the implementation of STD control approaches. STD awareness and case management improved considerably, with national STD case management guidelines developed at the end of the project through consensus between various organizations and the Ministry of Health.

HIV, STDs, anal sex and AIDS prevention policy in a northeastern Brazilian city.

Data on HIV/AIDS, other STDs, and related sexual practices and AIDS prevention measures in São Luís, capital of Maranhão state, were collected in May-July 1995 using participant-observation fieldwork, including a number of face-to-face interviews in addition to archival research, and were updated by correspondence in 1996-1997 and a brief visit in February 1998. In contrast to the continuing severe AIDS epidemic in southern Brazil, public health statistics and public HIV testing recently instituted in São Luís suggest that HIV infection has remained largely concentrated among men who have sex with men, as well as a few, though growing number of cases of women evidently infected by such men. However, other STDs are endemic to the region, and could provide an increasing portal of entry for HIV infection. AIDS prevention education programmes have commenced in public schools and elsewhere in São Luís, but greater emphasis needs to also be placed on the prevention and treatment of other STDs. As in other regions of Brazil and Latin America, the reportedly common practice of anal sex among heterosexuals also represents a significant yet typically underemphasized risk factor for HIV.

PIP: Brazil has since the beginning of the AIDS pandemic consistently reported the second or third highest number of AIDS cases in the world. As of June 1996, most of the 82,852 officially reported AIDS cases were concentrated in the southeastern regions of the country, with the majority of Brazilian AIDS and HIV cases continuing to belong to the higher-risk groups of men who have sex with men, and IV drug users. By February 1995, 325 AIDS cases had been reported in Maranhao state. The incidence of AIDS cases in Maranhao state was 6.9/100,000 population, far lower than the 120.6/100,000 in the state of Sao Paulo. The majority of these cases were located in Sao Luis, the state capital. Data were collected in Sao Luis on HIV/AIDS, other sexually transmitted diseases (STDs), related sex practices, and AIDS prevention measures during May-July 1995 through participant-observation field work, face-to-face interviews, archival research, updated by correspondence in 1996-97, and a brief visit in February 1998. Public health statistics and findings from public HIV testing recently conducted in the city suggest that HIV infection has remained largely concentrated among men who have sex with men, with a few, but growing number of cases of women apparently infected by such men. The other STDs endemic to the region could facilitate the spread of HIV infection. Although AIDS prevention education programs have begun in public schools and elsewhere in the city, greater attention needs to be given to preventing and treating other STDs. As in other regions of Brazil and Latin America, the common practice of anal sex among heterosexuals is a significant risk factor for HIV transmission.

Integrating services involves cost issues.

PIP: This article discusses the integration of sexually transmitted disease (STD) care within family planning (FP) programs and the cost effectiveness of integrated services in development countries. Examples are taken from experiences in Colombia, India, the US, and Kenya. The 1994 International Conference on Population and Development urged the integration of reproductive health care within FP. The more than 330 million annual new STD cases increase HIV transmission and cause pain and infertility. Women are biologically more susceptible to STDs, are more likely to be asymptomatic, and face harsher consequences, including death. Women with STDs should avoid the IUD and use barrier methods. Maintaining laboratories, training staff, and supplying drugs can overburden strained health budgets, but may lower long-term medical costs, increase productivity in employment, and decrease pain and suffering. STDs are viewed by some US health professionals as a "best buy" for being one of the least expensive of the reproductive health options. A Kenyan study found that treating STDs and providing oral contraceptives saved money by collapsing treatment into one instead of two visits. The savings were in overhead and staff costs. Evaluations of cost effectiveness should consider local STD prevalence, cultural setting, client needs, and available resources. In some cases, referral of cases to STD clinics may be the most cost-effective. A US study found that chlamydia screening for all FP clients was more cost-effective than screening selectively. Another US study found that universal screening for chlamydia would provide long-term medical savings even if prevalence was only 2%. Developing countries have the lower-cost option of offering syndromic management of STDs for symptomatic women rather than lab tests. A program in India cut costs by educating and encouraging barrier methods.^ieng

Condom use increasing.

PIP: Condom use is central to the prevention of AIDS among people at risk for contracting HIV. As such, condom use is increasing dramatically even though many men say that they do not like using them. Condom sales through social marketing campaigns have increased dramatically in some countries, where tens of millions of condoms are sold annually. For example, during the period 1991-96, annual social marketing sales increased about five-fold in Ethiopia to 21 million, and nine-fold in Brazil to 27 million. These sales reflect the success of condom social marketing campaigns in making condoms accessible and largely affordable. There is also a greater general awareness of AIDS than there used to be, and communication campaigns have shown that condoms are an effective solution. More condoms still need to be used in the ongoing struggle against HIV/AIDS. The author discusses the factors which affect the limited acceptance of condoms, condom use outside of marriage, social marketing, and family planning programs.^ieng

Behavior affects consistent use.

PIP: Condoms must be used correctly and consistently in order to prevent sexually transmitted diseases (STDs) and pregnancy. However, consistent use demands sustained behavior patterns. In a project with International Planned Parenthood Federation affiliates in Brazil, Honduras, and Jamaica, the counseling of women has moved away from emphasizing contraceptive methods, side effects, and correct use, to the more broad context of women's sexuality and risk of STD infection as a means of promoting behavior change. Providers use a sexuality-based approach in which they confer with women about their current sex partners, past partners, whether their partners travel for work, whether they think their partners may have other sex partners, and how those factors relate to the risk of STD infection. The project has also aggressively taught men about STDs and condom use, and involves men in counseling. One study has found that people who choose condoms as their main contraceptive method need more counseling than people who use condoms as a backup method, since primary users may have underestimated the difficulty of using condoms at every act of sexual intercourse. Furthermore, counseling appears to increase condom use when it involves both men and women in a monogamous relationship.^ieng

Reproductive health programs for men.

PIP: The Groupe de Lutte Anti-SIDA (GLAS) (Group in Struggle Against AIDS) is an HIV prevention program in Port-au-Prince, Haiti, which taught HIV prevention to almost 20,000 mainly male workers aged 15-49 years. Before ending in 1996, GLAS offered one, hour-long session introducing HIV and other sexually transmitted diseases (STDs), and how to prevent them; instruction on how to use condoms; an open-ended discussion hour in which workers who had attended the first 2 sessions could ask questions about beliefs and rumors related to HIV/AIDS and STDs; and intensive psychological support groups using the transactional analysis (TA) educational approach to personal growth and change. The TA approach focuses upon teaching adults how to abandon self-defeating strategies, typically learned during childhood, and how to develop attitudes for managing life's problems. It promotes clear, direct communication. Participation in GLAS's program helped men understand the benefits of adopting HIV/STD risk reduction behavior.^ieng

Mothers can play big role in kids' condom use.

PIP: The US Centers for Disease Control and Prevention (CDC) estimate that half of all HIV infections in the US occur among people under age 25 years. HIV infection is the 6th leading cause of death among people aged 15-24 years. There are also 3 million other cases of STDs among teenagers every year, and up to 1 million US teens become pregnant annually. Research conducted by the CDC has found that teens whose mothers discussed condoms with them prior to their first sexual intercourse were 3 times more likely to use them than were teens who never discussed condoms with their mothers or who did so only after their first intercourse. Findings are based upon interviews with 372 sexually-active teens aged 14-17 years in New York, Alabama, and Puerto Rico, more than two-thirds of whom had discussed condoms with their mothers. Early discussion also increased condom use during subsequent episodes of sexual intercourse. When condoms were used at first intercourse, adolescents were 20 times more likely to use them during future episodes of sexual intercourse.^ieng

Sexuality education on the job.

PIP: The Asociacion Demografica Salvadorena (ADS) has been working with the UN Population Fund (UNFPA) in El Salvador since November 1995 to provide sexual and reproductive health services to the country's working classes. UNFPA funding is provided through the Salvadoran government. ADS has entered the commercial and labor sectors to provide sexual and reproductive health services, and expand related public education programs to marginalized working class urban residents of El Salvador's Zona Central. The project has thus far created 25 Reproductive Health Units (UDESAR) in a number of companies, overseen by trained personnel who offer family planning and counseling services, including family planning methods, and the detection of cervical/uterine cancer, breast self-examination, HIV/STD prevention, and the determination of reproductive risk. Volunteers trained by ADS in sexual and reproductive health from a gender perspective, including decision-making and raising women's levels of self-esteem and decision-making capabilities in family planning, safe sex, and general sexual health, help project leaders by educating and motivating co-workers. ADS's involvement in promoting reproductive health in El Salvador has also given the organization an opportunity to broaden its relationship with international agencies.^ieng

Combating sexually transmitted diseases.

PIP: Lack of funding forced APROFAM, the International Planned Parenthood Federation (IPPF)/Western Hemisphere Region (WHR) affiliate in Guatemala, to close its sexually transmitted disease (STD) diagnosis and treatment center, CODETS, in December 1995. CODETS was then the only center in the country providing HIV testing and counseling, STD diagnosis and treatment, and educational programs. Rather than attempting to secure funding to continue operating the CODETS clinic on an emergency basis, APROFAM decided to integrate the clinic's services into its family planning clinics. In April 1996, a 2-year integrated program was launched in APROFAM's Central Clinic, with funding from the Canadian International Development Agency. In 1997, integrated services were extended to other APROFAM clinics. All APROFAM clients at the Guatemala City clinics now receive HIV/STD education as part of the family planning counseling process, as well as free condoms. STD diagnosis and treatment services are also provided in a confidential and caring environment. The overall increased knowledge about STDs among APROFAM staff has helped them to identify STDs in many women who may have never known they were infected. The process of transition toward the provision of integrated services is described.^ieng

A comparison of prevalence rates of genital ulcers among persons attending a sexually transmitted disease clinic in Jamaica.

Two cross-sectional surveys were undertaken, from December 1982 to August 1983 and from November 1990 to January 1991, to estimate the prevalence rates of genital ulcer disease (GUD) in all patients presenting with a new sexually transmitted disease (STD) complaint to the STD clinic at the Comprehensive Health Centre in Kingston, Jamaica. Diagnosis of syphilis and human immunodeficiency virus (HIV) infection was based on results of laboratory tests, but diagnosis of the other STDs was based on clinical features. Data from these two surveys were compared, and reported national annual incidence data for GUD reviewed. In 1982/83 6.8% of 23,050 patients had GUD, men (9.3%) more often than women (4.2%; p < 0.001). In 1990/91 the prevalence rate was 12.8%, with increased rates for both men (18.2%) and women (6.8%; p < 0.001). In patients with GUD, a clinical diagnosis of genital herpes was made, in 1982/83 and 1990/91, respectively, in 16.8% and 7.8% of the patients; syphilis, in 12.9% and 18.8%; chancroid, in 12.4% and 13.3%; viral warts, in 5.7% and 6.3%; lymphogranuloma venereum, in 4.1% and 3.9%; and granuloma inguinale, in 3.6% and 2.3%. In men the rate for syphilis was 19% in 1990/91 and 8% in 1982/83 (p = 0.001); and for genital herpes it was 7% in 1990/91 and 17% in 1982/83 (p = 0.025). These reversals were attributed to intense media coverage of herpes in 1982/83. There was no difference in prevalence rates between the two surveys for these diseases in women, or for lymphogranuloma venereum, granuloma inguinale and genital warts in men and women. A clinical diagnosis could not be made in 44.4% of cases in 1982/83 (particularly in men), and in 47.6% of cases in 1990/91. GUDs facilitate transmission and adversely affect the prognosis of HIV. The increase in their prevalence has implications for the evolution of the local HIV epidemic, and should be addressed effectively by strengthening the STD/HIV control programme.

PIP: The prevalence of genital ulcer disease (GUD) was investigated in two cross-sectional studies of patients presenting to the sexually transmitted disease (STD) clinic at the Comprehensive Health Center in Kingston, Jamaica, between December 1982 and August 1983 (n = 23,050) and between November 1990 and January 1991 (n = 1001). The median age of participants was 26 years for men and 25 years for women; most were low-income inner-city residents. The prevalence of GUD rose from 6.8% (9.3% in men and 4.2% in women) in the 1982-83 survey to 12.8% (18.2% in men and 6.8% in women) in 1990-91. In 1982-83 and 1990-91, respectively, genital herpes was diagnosed in 16.8% and 7.8% of patients, syphilis in 12.9% and 18.8%, chancroid in 12.4% and 13.3%, viral warts in 5.7% and 6.3%, lymphogranuloma venereum in 4.1% and 3.9%, and granuloma inguinale in 3.6% and 2.3%. A clinical diagnosis could not be made in 44.4% of cases in 1982-83 and in 47.6% in 1990-91. Since GUDs facilitate the transmission of HIV, HIV prevention efforts must include the strengthening of STD control programs. All cases of GUD should be screened for both syphilis and HIV, with prompt treatment to reduce the period of GUD transmissibility. Jamaica has revised its national STD case management guidelines to include simplified algorithms for GUD management and strengthened STD surveillance and contact tracing. Changes in GUD prevalence over time may be a useful indicator for evaluating the impact of STD/HIV interventions.

Jamaicans begin to embrace safer sex.

PIP: Over the past decade, studies in Jamaica revealed widespread acceptance of sex outside of marriage or other stable relationships and a common perception that sexually transmitted diseases (STDs) are a natural and easily curable outcome of sexual activity. However, recent surveys suggest that these attitudes and behaviors are beginning to change. Jamaican men who once readily had 5 or more sex partners per year are choosing their partners more carefully and staying in relationships longer. Men and women report having fewer sex partners, while young male adolescents are waiting until they are older to begin having sex. This attitudinal and behavioral change may be attributed to the Ministry of Health's HIV/STD control program launched in 1987. The program is comprehensive, systematic, and sometimes uses an unorthodox approach to HIV/AIDS prevention. HIV/AIDS and STDs were linked in the integrated approach.^ieng

Sustaining youth peer HIV / STD prevention education.

PIP: This article describes an adolescent, peer-education training program in Jamaica that was developed and operated by the Red Cross Societies of Jamaica and the US and was funded by AIDSCAP. The program aimed to develop a training system to prepare youth peer educators in preventing the spread of HIV infections and sexually transmitted diseases. The goal was to increase knowledge about, change attitudes toward, and develop prevention skills for HIV/AIDS. The initial program was to be replicated on a large scale and be sustainable over time. The program was developed in response to the 1500+ Jamaicans diagnosed with AIDS and the 20,000 or so with HIV infections. Transmission is mostly heterosexual. 15% of girls and 47% of boys are sexually active by 14 years of age, and almost 50% of syphilis and gonorrhea cases are among adolescents. The national training program relies on peer educators, aged 14-19 years, who are literate to the 6th-grade level. Training sessions are conducted for 10-21 persons/session for 27 hours over 3 weekends. Training relies on engaging games and activities. Trainees are taught how to facilitate 14 specific activities, including the correct way to use a condom. Peer educators work together in groups of twos or threes among groups of 10-15 adolescents, aged 10-15 years. By the third year of operation, most of the systems and materials were in place and the program expanded; cost-benefit analysis revealed that costs were returned. The program has continued with a variety of funds and delivery systems and new funding will likely shift the program emphasis. The program has survived with the enthusiasm and support of the trainers. Other start-up programs should ensure the involvement of youth at all stages of development.^ieng

NGO participation boosts condom sales in Haiti.

PIP: An estimated 10% of Haiti's urban population and 4% of the rural population is infected with HIV. As recent as a few years ago, few commercial sales outlets for condoms existed in Haiti, even in the cities. Now, however, Pante condoms are accessible to Haitians at all hours of the day even in remote areas of the country. Pante is the brand name of the condom that Population Services International (PSI) introduced in Haiti in 1990, and began packaging, promoting, and selling a year later through a condom social marketing (CSM) program funded by the AIDS Control and Prevention (AIDSCAP) Project. The CSM program allows Pante to be sold at 10% of the cost of commercial condoms. Even in the context of political instability and economic crisis which followed the overthrow of Haiti's elected government in 1991, monthly sales of Pante during 1991-95 increased from an average of 3000 to more than 400,000, and more than 16 million units were sold over the 4-year period.^ieng

Can you bet your life on a condom?

PIP: A number of studies have demonstrated that when used consistently and correctly, both male and female condoms prevent unplanned pregnancy and the spread of sexually transmitted diseases (STDs). For example, in a study of US navy personnel who reported having vaginal intercourse with prostitutes who had a high prevalence of gonorrhea, none of the 29 men who reported using condoms during their sex acts contracted gonorrhea or nongonococcal urethritis. However, 14% of the 499 nonusers became infected. The preponderance of evidence from 10 studies of high-risk populations in 7 countries where both the level of condom use and HIV infection were prospectively measured showed the consistent use of male condoms to protect against HIV acquisition in the range of 50-100%. Additional evidence in support of condom use comes from two studies involving HIV-discordant couples. A European study of 123 such couples who consistently and correctly used condoms found that no HIV-uninfected partner became infected with HIV by their partners. Similarly, 1 of 42 seronegative partners in HIV-discordant couples in Haiti became infected with HIV after having consistently used condoms. In both of these studies, 7-14% of couples who used condoms either consistently or not at all became infected. Since the government of Thailand began promoting 100% condom use among prostitutes and their clients, there has been a decline in both the level of curable STDs reported to clinics and HIV prevalence among Thai military recruits. Male and female condoms are effective even under typical imperfect conditions, and their consistent use should be encouraged at every opportunity.^ieng

Can AIDS drugs be afforded?

PIP: UNAIDS has launched an 'HIV Drug Access Initiative' in the Ivory Coast, Uganda, Chile, and Vietnam; the pilot project will attempt to improve access to HIV drugs. Public and private sector efforts will be coordinated. The Glaxo Wellcome, Hoffman-La Roche, and Virco pharmaceutical companies will participate. Each country will 1) adapt its present system with regard to HIV and 2) establish both an HIV drug advisory board and a non-profit company which will import the drugs. Health ministries within each country will be required to find sources of funding for the programs. Uganda will probably use funds from its sexually transmitted disease (STD) program, which is supported by the World Bank; the Ivory Coast will combine corporate contributions, new tariffs, and non-profit insurance system monies into a 'solidarity fund.' UNAIDS funds will be used for oversight and evaluation. UNAIDS also released a review of 68 studies which examined the impact of sex education on the sex behavior of young people; it indicated that, in 65 of the studies, sex education did not increase the sexual activity of youth. UNAIDS concluded that quality programs helped delay first intercourse and often reduced the number of sexual partners, resulting in reduced rates of STDs and unplanned pregnancy. UNAIDS further concluded that effective sex education should begin before the onset of sexual activity, and curriculums should be focused. Openness in communicating about sex should be encouraged, and social and media influences on behavior should be addressed. Young people should be taught negotiating skills (how to say 'no' to sex and how to insist on safer sex).^ieng

Brazil launches anti-AIDS campaign for Indians. Education and prevention.

PIP: Anthropologists are educating Indian tribes regarding methods of preventing the spread of sexually transmitted diseases (STDs), particularly acquired immunodeficiency syndrome (AIDS), in a new Brazilian campaign. Estimates of the number of Indians who are infected with human immunodeficiency virus (HIV) vary because records do not categorize by race. While the National Indian Foundation (Funai) believes 20 of 320,000 Indians are infected, the Catholic Church's Indigenous Missionary Council (CIMI) states that 11 Indians have died of AIDS since 1989, and that another 4 are HIV-positive. According to Pedro Chequer, campaign coordinator, the Indian population is at low risk, but highly vulnerable to the spread of HIV infection; each tribe has different sexual mores, which must be respected, and its own language, which requires educational materials in that language. Based on recent studies, 10-15% of Brazilian Indians are infected with some form of STD. Indians at high risk, those living near urban areas or having regular contact with mining and forestry workers, particularly the wildcat golddiggers known as "garimpeiros," are being targeted. The use of army personnel, who are often the only non-indigenous people in isolated areas of the Amazon, in the campaign is being considered. The Ministry of Heath is also promoting studies of Indian culture and an education campaign in 1310 schools, reaching 62,000 indigenous students and 2504 teachers.^ieng