HIV continuum of care among trans women and travestis living in São Paulo, Brazil

ABSTRACT OBJECTIVE: To examine the HIV care cascade among trans women and travestis in São Paulo - Brazil, the most populous city in South America. METHODS: Using data from a cross-sectional study carried out between November 2016 and May 2017 in the city of São Paulo (Divas Research). Respondent driven sampling (RDS) was used to recruit 386 transgender women and travestis who participated in a HIV risk survey and were tested for HIV. The cascade was defined as HIV prevalence, HIV diagnosed, Antiretroviral (ART) Prescription, and currently on ART. A multiple analysis model was conducted to identify the association between sociodemographics and the cascade gaps. RESULTS: Of the trans women living with HIV, 80.9% were already diagnosed, 76.6% of them had been prescribed, of which 90.3% were currently on treatment. Those who were registered in care had a higher rate of ART (aPR 2.06; 95%CI 1.09-3.88). Trans women between 31-40 years old (aPR 1.65; 95%CI 1.09-2.50) and those older than 40 (aPR 1.59; 95%CI 1.04-2.43) had higher prevalence of ART. CONCLUSIONS: Our data suggest an increase in the testing and treatment policy implementation among trans women in the city of São Paulo, although gaps have been found in the linkage to care. However, young trans women and those not registered in health care service may benefit from efforts to engage this part of the population in care to improve HIV treatment and care outcomes.

Pre-Exposure Prophylaxis Counseling in a Community Sexual Health Clinic for Men Who Have Sex with Men in Lisbon, Portugal.

INTRODUCTION: Pre-exposure prophylaxis is defined as the use of antiretroviral drugs to prevent HIV acquisition in uninfected individuals. Recognizing the increasing use of informal pre-exposure prophylaxis in Portugal, CheckpointLX, a community clinic targeted to men who have sex with men in Lisbon, Portugal, began offering counselling and follow-up services prior to formal introduction. This study aims to characterize pre-exposure prophylaxis users attending CheckpointLX before formal pre-exposure prophylaxis introduction in Portugal, and those who were referred to pre-exposure prophylaxis in the National Health Service following formal approval of pre-exposure prophylaxis. MATERIAL AND METHODS: Data was collected by peer counsellors between May 2015 and September 2018 and inserted in a database. Medical care followed the European AIDS Clinical Society recommendations for pre-exposure prophylaxis eligibility, initiation and follow-up. For formal pre-exposure prophylaxis, the General-Directorate for Health's Pre-exposure Prophylaxis guidelines checklist was used. RESULTS: Until the end of May 2018, CheckpointLX had a total of 90 appointments for wild pre-exposure prophylaxis, of which 64 (71%) were first time visits. As for the 380 service users referred to the National Health Service, most were Portuguese (n = 318, 84%), and the mean age was 31 (8.9) years old. Condomless sex in the last six months with partners of unknown HIV status was the most common eligibility criteria (n = 59, 83%). DISCUSSION: Pre-exposure prophylaxis delivery should be complemented with effective information on the importance of immunization and education on safer practices of drug administration, in the scope of broader preventive sexual health care. CONCLUSION: Much remains to be done in Portugal to ensure that pre-exposure prophylaxis is available to those who need it the most. Offering pre-exposure prophylaxis at community clinics could be a first step.

Introdução: A profilaxia pré-exposição pode ser definida como o uso de medicamentos anti-retrovirais para prevenir a aquisição do VIH em indivíduos não infectados. Reconhecendo o uso crescente da profilaxia pré-exposição informal em Portugal, o CheckpointLX, uma clínica comunitária destinada a homens que têm sexo com homens em Lisboa, Portugal, começou a oferecer aconselhamento e serviços de acompanhamento antes da introdução formal. Este estudo pretende caracterizar os utilizadores da profilaxia pré-exposição que frequentam o CheckpointLX antes da introdução formal da profilaxia pré-exposição em Portugal, e aqueles que foram encaminhados para a profilaxia pré-exposição no Serviço Nacional de Saúde após a aprovação formal da profilaxia pré-exposição. Material e Métodos: Os dados foram colhidos por pares entre maio de 2015 e setembro de 2018 e inseridos numa base de dados. Os cuidados médicos seguiram as recomendações da European AIDS Clinical Society para elegibilidade, iniciação e acompanhamento da profilaxia pré-exposição. Para a profilaxia pré-exposição formal, foi utilizada a lista de verificação da Norma de Profilaxia Pré-exposição da Direção-Geral da Saúde. Resultados: Até ao final de maio de 2018, o CheckpointLX fez um total de 90 consultas para o wild pre-exposure prophylaxis, das quais 64 (71%) foram primeiras consultas. Quanto aos 380 utilizadores referenciados ao Serviço Nacional de Saúde, a maioria era de nacionalidade portuguesa (n = 318, 84%) e a idade média era de 31 (8,9) anos. Sexo sem preservativo nos últimos seis meses com parceiros com estatuto VIH desconhecido foi o critério de elegibilidade mais reportado (n = 59, 83%). Discussão: A dispensa da profilaxia pré-exposição deve ser complementada com informações eficazes sobre a importância da imunização e da educação em práticas mais seguras de administração de medicamentos, no âmbito de cuidados de saúde sexual preventivos mais amplos. Conclusão: Ainda há muito a ser feito em Portugal para garantir que a profilaxia pré-exposição esteja disponível para aqueles que mais dela precisam. Oferecer profilaxia pré-exposição em clínicas comunitárias pode ser um primeiro passo.

HIV-AIDS prevention in the conception of HIV-positive young people / Prevenção de HIV-Aids na concepção de jovens soropositivos

ABSTRACT OBJECTIVE To analyze the conception of seropositive young people on how to prevent HIV infection. METHODS This is a qualitative study using semi-structured interviews with HIV-positive young people whose diagnosis was made in adolescence 5 years ago or less. We followed a semi-structured script containing sociodemographic data and an open question on HIV/AIDS prevention. The interviews were recorded and fully transcribed, then analyzed with the support of the webQDA software. We used the categories that compose the concept of vulnerability as a theoretical basis for data analysis. RESULTS We interviewed 39 young people, 23 girls and 16 boys. Some perceive the prevention of HIV infection only as an individual issue, summarizing it to the use of condoms and self-care. Most of the interlocutors point out educational strategies as the most relevant for prevention but used in a permanent and non-punctual way. In schools, they believe it is necessary to include younger students and their family. Guidelines should be given by people who can use the language of young people and preferably by HIV-positive people, to show the reality of those who have AIDS. In the programmatic field, they suggest intensifying campaigns in the media, distributing condoms in large scale, producing vaccines and medicines that cure. No one mentioned the female condom, the rapid test, nor the availability of sexual and reproductive health care. CONCLUSIONS The qualification and expansion of communication strategies on sexuality in schools is urgent and essential in HIV and AIDS prevention in adolescence, contrary to the current trend of restricting the discussion of these topics in education policies.

RESUMO OBJETIVO Analisar a concepção de jovens soropositivos sobre como prevenir a infecção pelo HIV. MÉTODOS Estudo qualitativo por meio de entrevistas semiestruturadas com jovens soropositivos cujo diagnóstico foi feito na adolescência havia no máximo 5 anos. Seguimos roteiro semiestruturado contendo dados sociodemográficos e pergunta aberta sobre prevenção de HIV-Aids. As entrevistas foram gravadas e transcritas na íntegra, sendo analisadas com apoio do software webQDA. Utilizamos as categorias que compõem o conceito de vulnerabilidade como base teórica para a análise dos dados. RESULTADOS Entrevistamos 39 jovens, 23 do sexo feminino e 16 do masculino. Alguns percebem a prevenção da infecção pelo HIV apenas como uma questão individual, resumindo-a ao uso do preservativo e ao autocuidado. A maior parte dos interlocutores aponta estratégias educativas como as mais relevantes para a prevenção, mas utilizadas de forma permanente e não pontual. Nas escolas, acreditam ser necessário incluir alunos mais novos e a família. As orientações devem ser ministradas por pessoas que utilizam a linguagem dos jovens e de preferência por soropositivos, para mostrar a realidade da vida de quem tem Aids. No campo programático, indicam intensificação das campanhas na mídia, distribuição de camisinha em larga escala, produção de vacinas e medicamentos que curem. Não houve menção ao preservativo feminino, ao teste rápido, à disponibilidade de atendimento em saúde sexual e reprodutiva. CONCLUSÕES A qualificação e ampliação das estratégias de comunicação sobre sexualidade nas escolas é urgente e essencial na prevenção de HIV e Aids na adolescência, ao contrário da tendência que hoje se verifica de restrição da discussão sobre esses temas nas políticas de educação.

Incentives and barriers to HIV testing among female sex workers in Ceará / Incentivos e barreiras ao teste de HIV entre mulheres profissionais do sexo no Ceará

ABSTRACT OBJECTIVE Estimating HIV prevalence and describing the incentives and barriers for HIV testing among female sex workers. METHODS This cross-sectional study recruited 402 women aged 18 years or older, residing in Fortaleza, state of Ceará, Brazil, who reported having had sexual intercourse in exchange for money in last four months. The sample was recruited using Respondent Driven Sampling, between August and November 2010. RESULTS The 84.1% of the sample tested and the estimated prevalence of HIV infection was 3.8%. The sample was young (25 to 39 years ), single (80.0%), with one to three children (83.6%), had eight or more years of schooling (65.7%), and belonged to social classes D/E (53.1%). The majority worked in fixed locations (bars, motels, hotels, sauna - 88.9%), and prostitution was their only source of income (54.1%). About 25% of the sample did not know where to test in the public health sector and 51.8% either never tested or hadn't tested for over a year or more. The main reported barriers to testing were the perceptions that there was no risk of becoming infected (24.1%), and, alternatively, fear of discrimination if the test was positive (20.5%). Incentives for testing were the greater availability of testing sites (57.0%) and health facilities with alternative schedules (44.2%). CONCLUSIONS Prevalence for HIV was similar to that found in other Brazilian cities in different regions of the country, although higher than the general female population. Non-traditional venues not associated with the health system and availability of testing in health units during non-commercial hours are factors that encourage testing. Not considering oneself to be at risk, fear of being discriminated against and not knowing testing locations are barriers.

RESUMO OBJETIVO Estimar a prevalência do HIV e descrever os incentivos e barreiras à realização do teste para o HIV entre mulheres profissionais do sexo. MÉTODOS Este estudo transversal recrutou 402 mulheres de 18 anos ou mais, residentes em Fortaleza, CE, que informaram ter tido relação sexual em troca de dinheiro nos últimos quatro meses. A amostra foi recrutada por meio da técnica Respondent Driven Sampling, entre agosto e novembro de 2010. RESULTADOS A adesão ao teste de HIV foi de 84,1% e a prevalência estimada da infecção pelo HIV foi de 3,8%. A amostra era jovem (25 a 39 anos), solteira (80,0%), com um a três filhos (83,6 %), tinham oito anos ou mais de estudo (65,7%) e pertencia às classes sociais D/E (53,1%). A maioria exercia a profissão em locais fechados (bares, motéis, hotéis, sauna - 88,9%), e a prostituição era a única fonte de renda (54,1%). Cerca de 25% da amostra desconhecia onde o teste de HIV era realizado na rede pública e 51,8% nunca fez o teste ou se testou há um ano ou mais. As principais barreiras ao teste foram acreditar que não corre risco de se infectar (24,1%) e o medo da discriminação caso o teste fosse reagente (20,5%). Os incentivos foram relacionados à maior oferta de locais para o teste (57,0%) e de unidades de saúde com horários alternativos (44,2%). CONCLUSÕES A prevalência foi semelhante à encontrada em outras cidades brasileiras de diferentes regiões do país, apesar de superiores a de mulheres não profissionais do sexo. A disponibilidade do teste em locais não relacionados à saúde e a oferta nas unidades básicas em horário não comercial são fatores que incentivam a realização do teste. Não se considerar sob-risco, medo de ser discriminada e desconhecimento dos locais onde o teste é realizado podem ser uma barreira para a realização do exame.

Protagonismo de adolescentes na prevenção de doenças sexualmente transmissíveis / Protagonism of adolescents in preventing sexually transmitted diseases

Objetivo: Analisar o protagonismo de adolescentes escolares na prevenção de doenças sexualmente transmissíveis. Métodos Estudo qualitativo do tipo pesquisa-ação desenvolvido com dez adolescentes, com idade entre 15 e 16 anos, de uma escola pública. Os dados foram coletados em grupos focais, entrevistas e observação e analisados na técnica de análise do discurso. Resultados Os depoimentos revelaram que os adolescentes protagonizaram suas participações no planejamento da intervenção educativa, definindo e organizando o espaço educativo escolar, e confeccionando materiais e temas a serem utilizados nas ações de prevenção às doenças sexualmente transmissíveis, gerando um sentimento de domínio sobre o assunto. Conclusão Os participantes do estudo apresentaram protagonismo na elaboração de atividades de prevenção de doenças sexualmente transmissíveis no ambiente escolar.

Objective: To analyze the protagonism of school adolescents in preventing sexually transmitted diseases. Methods This is a qualitative action-research study, which was developed with ten adolescents (aged 15-16 years) from a public school. The data were collected from focus groups, interviews, and observation, being analyzed by using the discourse analysis technique. Results The adolescents testimonies revealed that they participated in planning of the educational intervention, and defined and organized the school environment. In addition, they prepared materials and themes for use in the preventive actions against sexually transmitted diseases, which generated a feeling knowledge on the subject. Conclusion The participants in the study showed protagonism in the school environment by preparing activities for prevention of sexually transmitted diseases.

Intervención en el conocimiento, creencias y percepción de riesgo sobre infecciones de transmisión sexual y el vih/sida / Intervention in knowledge, beliefs and risk perception about sexually transmitted infections and HIV/AIDS

INTRODUCCIÓN: las infecciones de transmisión sexual, en general, y de manera especial, el VIH/sida en los adolescentes y jóvenes, constituyen un serio problema de salud, y el riesgo de padecerlas está muy relacionado con el comportamiento sexual, las formas de protegerse, los conocimientos y la percepción de riesgo, entre otros factores. OBJETIVOS: incrementar los conocimientos sobre las infecciones de transmisión sexual y el virus de inmunodeficiencia humana/sida y obtener una modificación de las creencias y percepción de riesgo hacia dichas enfermedades en educandos de la Facultad de Tecnología de la Salud del Municipio Cerro, La Habana. MÉTODOS: estudio cuasi experimental, de intervención, en el centro educacional de la Facultad de Tecnología de la Salud, del municipio Cerro, mediante la metodología establecida en el manual; esta consta de técnicas afectivas, participativas, de animación y reflexión, con profesores promotores, previamente adiestrados sobre estos temas, los que posteriormente los replican hacia sus educandos. La muestra estuvo representada por 453 alumnos pertenecientes a cuatro especialidades de dicha institución. RESULTADOS: se evidencia un aumento en los niveles de conocimientos, creencias y en la percepción de riesgo, con índices de incremento en porcentajes de 38,6, 18,4 y 15,4 %, respectivamente. CONCLUSIONES: la metodología empleada propia del manual resulta útil para incrementar conocimientos y modificar las creencias y percepción de riesgo a partir de profesores previamente formados como promotores y facilitadores.

INTRODUCTION: in general, sexually transmitted infections, and specially, HIV/AIDS constitute a serious health problem in adolescents and young people, as well as, the risk of suffering them is close related to sexual behaviour, ways of protection, knowledge, perception risk, and some other factors. OBJECTIVES: to increase knowledge about sexually transmitted infections and human immunodeficiency virus/AIDS, and to achieve a change of mentality and risk perception in students of the Faculty of Health Technology from Cerro municipality, Havana in relation to these diseases. METHODS: A quasi-experimental study of intervention in the educational institution of the Faculty of Health Technology, in Cerro municipality, by means of the established methodology in the manual; in which participative, affective, animated and reflexive techniques were used with promoter teachers previously trained on these topics, who subsequently reply the topics to their students. Sample was constituted by 453 students belonging to four specialties of this institution. RESULTS: an increase in levels of knowledge, beliefs and risk perception is evidenced, with an increase of percentage indexes of 38,6, 18,4 and 15,4 respectively. CONCLUSIONS: methodology used in the manual is useful in order to increase knowledge, as well as, to achieve a change of mentality and risk perception through the assistance of teachers previously trained as promoters and facilitators.

Promotion of condom use in a high-risk setting in Nicaragua: a randomised controlled trial.

BACKGROUND: In Latin America, motels rent rooms for commercial and non-commercial sex. We investigated the impact of providing health-education material and condoms on condom use in Managua, Nicaragua. METHODS: In a randomised controlled trial, in 19 motels, we gave condoms on request, made them available in rooms, or gave condoms directly to couples, with and without the presence of health-education material in the rooms. In a factorial design we assessed condom use directly by searching the rooms after couples had left. FINDINGS: 11 motels were used mainly by sex workers and their clients and eight mainly for non-commercial sex. 6463 couples attended the motels in 24 days. On 3106 (48.0%) occasions, at least one used condom was retrieved. Condom use was more frequent for commercial sex than for non-commercial sex (60.5 vs 20.2%). The presence of health-education material lowered the frequency of condom use for commercial sex (odds ratio 0.89 [95% CI 0.84-0.94]) and had no effect on use for non-commercial sex (1.03 [0.97-1.08]). Condom use increased for commercial (1.31 [1.09-1.75]) and non-commercial sex (1.81 (1.14-2.81) if condoms were available in rooms. Directly handing condoms to couples was similarly effective for commercial sex but less effective for non-commercial sex (1.32 [1.03-1.61] vs 1.52 [1.01-2.38]). INTERPRETATION: In Latin America, motels are key locations for promoting the use of condoms. Making condoms available in rooms is the most effective strategy to increase condom use, whereas use of health-education material was ineffective. These findings have important implications for HIV-prevention policies.

Relationship of psychosocial factors to HIV risk among Haitian women.

This study describes the prevalence of HIV risk behaviors among low-income, Haitian women, identifies theoretically relevant mediating psychosocial HIV risk predictors, and provides formative data for developing culturally and gender sensitive interventions for this distinctive, high risk, and understudied population. Confidential interview surveys were administered to 101 women of Haitian descent while they awaited their medical appointments at a local low-income, community medical clinic. Moderately high levels of sexual risk behavior (i.e., unprotected sex with nonmonogamous partners; multiple lifetime partners) were reported. On average, these women reported a belief in their HIV susceptibility, relatively little HIV-related anxiety, somewhat inadequate levels of communication regarding safer sex practices, and lack of adequate confidence in their ability to negotiate safer behaviors in sexual encounters. Both personal and partner condom attitudes were unfavorable and these attitudes predicted condom use levels. It was concluded that interventions need to be developed for Haitian women to improve their attitudes toward condom use and their confidence in negotiating safer sexual practices. However, these interventions cannot be developed in a vacuum. Although it is crucial to consider the woman's individual attitudes and behaviors, it is also important to consider the male partner's attitudes toward sex and the woman's relationship with her male partner within the context of Haitian culture. Only by determining and targeting important potential motivations for safe sex within the cultural context can we most effectively reduce HIV sex risk behavior in Haitian women.

Sex education is key to combatting AIDS in Brazil.

PIP: About 60,000 children in Brazil were born from an AIDS-affected mother, and 16,000 were orphaned by AIDS. These stark figures were released by the Global Orphan Project and the Instituto Promundo at the EducAids conference. About 90% of childhood AIDS cases were a result of perinatal exposure, and the other 10% from unknown exposure. In response to these prevalences, the EducAids initiative, which aims to promote AIDS education in schools, was considering sex education for preschool children. The coordinator of the government's AIDS prevention program, Pedro Chequer, believes sex education for children as young as 4 years old would reduce AIDS among teenagers and help avoid unwanted pregnancies. The Minister of Health supported this concept. Jose Serra, the Minister of Health declared that it was not the aim of the ministry to avoid teenage pregnancy but to prevent early sexual intercourse. In 1997 the number of deliveries by girls aged 15-19 years had risen to 25.27%, from 21.41% in 1993. However, the number of deliveries for women over age 20 are falling. Pedro Chequer, EducAids coordinator, stated that despite these facts, campaigns for sex education would be opposed by the Roman Catholic Church.^ieng

[Social sciences and AIDS]. / Ciencias sociales y SIDA.

PIP: The social nature of AIDS and its transmission in the context of social relations that are intimate and resistant to social control, justify assigning the social sciences a significant role in fighting AIDS. The social sciences should be involved in conceptualizing, understanding, and modifying the processes favoring the spread of AIDS and hampering treatment. Various approaches have evolved in the response of the social sciences to AIDS, from a focus on behavior to increased interest in structural aspects and more recently to a concern with issues of power and vulnerability. The social sciences did not contribute much that was new at the Twelfth World Conference on AIDS in Geneva, but some results of previous social science research have been significant, such as affirmation that sex education does not speed initiation of sexual activity and definition of possible strategies for work with intravenous drug users. The work of social scientists has demonstrated the importance of the gender perspective and the need for mechanisms of qualitative and quantitative evaluation, true community participation, and respect for human rights in all actions related to the epidemic. The most immediate challenge for social scientists will be to find ways to reduce the vulnerability resulting from inequality.^ieng

Bahamas project gains valuable experience.

PIP: In December 1998, JOICFP and the Inter-American Development Bank entered into a contract to implement the Adolescent Reproductive Health Education Project in the Bahamas. Soon thereafter, three experts visited the Bahamas to provide short-term assistance in project development. Chizuko Ikegami, from Positive Living and Community Empowerment in Tokyo, evaluated the current status of HIV infection and responding national prevention activities. She concluded that the project should develop audiovisual material on HIV/AIDS/STDs (sexually transmitted diseases) using music popular with adolescents; expand on the available HIV/AIDS telephone counseling service; and incorporate material prepared by the World Health Organization for use in schools. Shirley Oliver-Miller, from the Margaret Sanger Center International, conducted a training course for project partners using an Experiential Learning Model. The training also involved choosing which existing materials could be adapted for field training in the Bahamas and adapting a prototypical "Christian Family Life Education" resource guide for facilitators. Hiroyuki Tanemoto, a computer consultant, determined which office equipment suppliers in the Bahamas could fulfill project requirements and conducted a computer training course for the project team. These consultations were coordinated by Harumi Kodama, acting JOICFP Coordinator, who also visited Mexico to observe programs there.^ieng

Changing the scenario in community care in Brazil.

PIP: The Grupo Pela Vidda (GPV) in Rio de Janeiro established the Rio Buddy Project in 1997 when it became clear that GPV could not provide medical assistance but would only provide other aid to people with HIV/AIDS (PHA). The project partnered with the nongovernmental organization Arco-Iris to manage the buddy project. The project relies on volunteers who are trained and supported by the project. The volunteers, about 20% of whom are PHA, must deal with stress and challenging situations in which counseling and emotional support are greatly and constantly needed. In 1988, GPV organized its first mini-training session for relatives of PHA. After the training, the buddies attend a monthly self-help meeting where they discuss the difficulties they experience in their work, their limitations, and the challenges they encounter. GPV and Arco-Iris provide counseling, self-help activities, information networks and contacts in the public health system that are helpful for referrals for special treatment and hospitalization. Benefits include free psychological support by private professionals through a partner project or lower-cost therapy. In the first 2 years, the Rio Buddy Project only targeted gay men, but as the epidemic started to affect women and heterosexual men, the demand changed and today female and male heterosexuals are also served by the project.^ieng

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

Factors associated with changes in sex behaviour among drug users in Puerto Rico.

Despite available strategies to prevent sex risk behaviours in Puerto Rico, heterosexual transmission of HIV continues to increase. Since 1990, heterosexual contact has been the fastest growing infection risk category among the island's general population, and the primary transmission route for women and children. To understand change in sex risk behaviours and factors related to change, 911 drug injectors and 359 crack smokers were recruited from the San Juan metropolitan area following a stratified cluster design. This study comprised a total of 1,004 (79.1%) drug users who were assessed at follow-up. Abstinence from sex behaviour increased from 54.6% to 61.1% (p < 0.01), use of condoms during vaginal sex also increased from 26.4% to 36.9% (p < 0.01). In multivariate analysis, significant predictors of abstinence were gender, injection drug use, HIV seropositivity and not having a steady partner. Predictors of using condoms during vaginal sex were HIV seropositivity, STD diagnosis and participation in an HIV preventive programme. These findings indicate that additional HIV preventive efforts are needed to reduce sex risk behaviours among drug users who have a steady sex partner, as well as among drug users who are HIV-negative.

PIP: Factors associated with changes in HIV risk behaviors were investigated in a prospective study of 911 injecting drug users and 359 crack smokers recruited on the basis of a stratified cluster design in metropolitan San Juan, Puerto Rico, in 1992-93. The findings presented in this paper are based on the 1004 drug users (79.1%) who were available for a follow-up interview 6 months after the baseline interview. Respondents were randomly assigned to receive a standard HIV prevention intervention (pretest counseling, optional HIV testing, and provision of HIV results) or the standard intervention plus a site-specific enhanced intervention entailing access to condoms and needle hygiene equipment, development of a personal risk reduction plan and training in the skills required to implement it, and ongoing contact with outreach workers. Overall, abstinence from sexual behavior increased from 54.6% at baseline to 61.1% at follow-up (p 0.01) while condom use during vaginal sex rose from 26.4% to 36.9% (p 0.01). In multivariate analysis, significant predictors of abstinence were male gender, injecting drug use, a positive HIV test at baseline, and not having a steady partner. Significant predictors of condom use were HIV seropositivity and a sexually transmitted disease diagnosis. Participation in the enhanced compared to the standard HIV prevention program was associated with an odds ratio of 1.29 (95% confidence interval, 0.95-1.74) for abstinence and 1.97 (95% confidence interval, 1.18-3.29) for condom use in vaginal sex.

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.

Measuring condom use among sex workers in the Dominican Republic.

The purpose of this paper is to assess the internal consistency of self-reported condom use among sex workers in Puerto Plata and Santo Domingo, Dominican Republic. We examined the responses to questions about condom use among 4 cross-sectional samples of sex workers. We compared measures based on: (1) questions using always-to-never scales; (2) questions about use with the past 5 clients; and (3) questions about use in the past week obtained from a retrospective coital log. In each sample, more women reported 'always' using condoms with clients than with each of the past 5 clients. In 3 of the 4 samples, only about half of the women who reported 'always' using condoms used condoms with the most recent 5 clients and with all clients in the past week. Internal consistency was significantly higher when the comparison was limited to use with the most recent 5 clients and use in the past week. Self-reported measures of condom use can be difficult to interpret. Assessing the internal consistency of several measures of use provides insight into the strengths and weaknesses of each measure.

PIP: Although evaluations of interventions to curtail the spread of HIV rely, to a large extent, on self-reported changes in behavior, the validity of self-reported condom use is difficult to assess. The internal consistency of self-reported condom use was investigated among four convenience samples of commercial sex workers in Puerto Plata (n = 408) and Santo Domingo (n = 604), Dominican Republic, interviewed before and after targeted HIV/AIDS educational programs. Three measures of condom use were assessed: 1) a measure based on reported frequency of use with new clients and regular clients using an always-to-never scale, 2) a measure of use with the most recent 5 clients, and 3) a measure based on a retrospective coital log of use with clients in the past 7 days. In each sample, more women reported "always" using condoms with clients than with each of the past 5 clients. The largest discrepancy was found in the second Puerto Plata sample, where 153 women (76%) reported always using condoms with clients, but only 96 women (47.5%) reported using condoms with each of the past 5 clients. "Sometimes" users were significantly more consistent in their responses than "always" users. Internal consistency was significantly improved (83-89%) when the comparison was limited to use with the most recent 5 clients and use in the past week.

Cultural feasibility studies in preparation for clinical trials to reduce maternal-infant HIV transmission in Haiti.

A cultural feasibility study is defined as one that investigates scientific as well as ethical, behavioral, and social issues in the design of clinical trials. The value of such a broadly defined assessment is illustrated through the presentation of two case studies conducted to prepare for clinical trials to reduce maternal-infant HIV transmission on Cité Soleil, Haiti. The first study addressed issues surrounding a trial of breast-feeding and exclusive bottle-feeding among HIV seropositive mothers. The second study focused on the implementation of a double-blind trial of HIV immune globulin and standard immune globulin to be administered to infants of seropositive mothers shortly after birth. Both cases used focus group interviews with mothers and in-depth interviews with key informants to investigate AIDS-related beliefs, acceptability of trial participation, risks to subjects, and community reactions and repercussions to the trial. Findings point to the difficulties posed by attempts to conduct trial involving complex research designs in socially disadvantaged populations. Recommendations highlight the need to consider the community-wide impact of a trial, and the need to undertake extensive educational preparation of participants to ensure informed consent and adherence to protocols.

PIP: Cultural feasibility studies use ethnographic methods to explore ethical, behavioral, and social issues inherent in the design of proposed clinical trials. This approach was applied in advance of clinical trials aimed at reducing maternal-infant HIV transmission in Cite Soleil, Haiti. The first focused on conditions that would be necessary to conduct a trial of breast feeding versus exclusive bottle feeding by HIV-positive mothers; the second investigated the feasibility of a double-blind trial of administration of a high- titer antibody preparation--HIV immune globulin (HIVIG)--to infants of seropositive mothers shortly after birth. Study methods included focus group discussions with mothers and in-depth interviews with key informants about AIDS-related beliefs, acceptability of trial participation, risks to subjects, and community repercussions. Concerns identified included the potential negative effect on breast feeding promotion efforts in Haiti, the scarcity of economic means to sustain safe bottle feeding, the risk of being labeled HIV-positive by virtue of study participation, the potential for the HIVIG trial to reinforce the misconception that a vaccine effective against AIDS exists, and problems explaining the concept of a double-blind study and accepting random assignment to treatment and control groups. As a result of these studies, it was decided to conduct the infant feeding study in a community with higher rates of exclusive bottle feeding and lower infant mortality than exist in Cite Soleil. The HIVIG trial could be conducted, but only after extensive community education to ensure informed consent. An objective assessment of subject comprehension was developed for this purpose.

Planning peer education programmes in the workplace.

PIP: In Guatemala, the HIV/AIDS epidemic is expected to have a vast negative impact on private enterprises as employees battle the disease in themselves and in family members. In response, the Guatemalan Association for the Prevention and Control of AIDS (AGPCS) developed a program to train private sector employees in peer health education. The program began by informing employers about the potential impact of HIV/AIDS on the private sector. Then AGPCS designed a workshop consisting of 11 two-hour weekly modules to provide up to 30 participants with information on sexually transmitted diseases, AIDS, and related issues. The first business to take advantage of the program was a 7000-employee clothing factory that continues to implement HIV prevention strategies. However, concern about the loss of employee time impeded other companies from participating. AGPCS, therefore, increased its flexibility and gave employers the option of sending employees to fewer seminars on topics the employers choose. This new approach led to 31 workshops in 1997 and 28 by August 1998. Also, in 1998, one company hired AGPCS to present 20 workshops to all of their employees. Efforts are made to evaluate workshop effectiveness and to facilitate follow-up activities. Peer education is an important part of the program, and potential peer educators are provided with a manual, extra training, and follow-up help. The training has helped companies develop work-place AIDS policies, and the AGPCS project has become sustainable.^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