Unmet sexual health needs of young men in contemporary society regarding condom use: Qualitative study.

OBJECTIVE: In contemporary societies young men receive much misleading information about sex from friends, the media and the internet (porn) which can make them feel insecure and under pressure regarding sex. The purpose of this study is therefore to understand their sexual world better and learn about their sexual health needs, especially regarding condom use. METHODS: The study is based on two qualitative studies: focus groups and individual interviews. Recruitment of participants took place through schools, a Sexually Transmitted Infection (STI) Clinic and a Gay and Lesbian Organisation. The interviews were thematically analysed using the framework method. RESULTS: Forty-nine individuals, 18-25 years old, participated in both studies. The findings showed that the participants had a number of unmet needs regarding condom use which reduced this use. They described uncertainty regarding condom use by not prioritising them, showing lack of knowledge and communication skills. It was of high priority for them to seek sexual pleasure and not be disturbed in the process of having sex. CONCLUSIONS: The results suggest that young men have a great need to perform sexually and not to fail. This need represents insecurity in a sexual relationship. When insecurity, inability to communicate and feeling under pressure come together using a condom is not prioritised. These young men are in great need of holistic sex education that would enable them to become secure in mastering condom use.

Risky sexual behaviours among women of reproductive age in a high HIV burdened township in KwaZulu-Natal, South Africa.

BACKGROUND: Despite several intervention programmes in South Africa, risky sexual behaviours among women of reproductive age remain a public health concern, making them vulnerable to unintended pregnancies and/or sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection. The aim of this study was to investigate the predictors of risky sexual behaviours among women of reproductive age in a high HIV-burden township in KwaZulu-Natal, South Africa. METHODS: In a cross-sectional study, 471 women of reproductive age (18-49 years, mean: 25.83) in 10 public health clinics in Umlazi Township, responded to a structured questionnaire. Data were coded, entered into Epi Data Manager and exported to Stata for analysis. A Pearson Chi-square tests and logistic regression models (bivariate and multivariate) were employed to assess the level of the association between the predictor and outcome variables and the p-value < 0.05 was considered statistically significant. RESULTS: More than half (51.80%) of the women were aged 18-24 years and only a handful (18.26%) had a tertiary qualification. The majority were single (88.96%) and the unemployed accounted for 53.50%. This study found that women who had talked about condoms with their partner in the past 12 months were more likely (p = < 0.0001) to have used condoms during their last sexual intercourse. Older women (p = 0.035) were more likely to have used a condom at last sex, compared to younger women. However, women who were exposed to physical partner violence (hitting and/or slapping), those who had been diagnosed with HIV and those whose sexual partners were diagnosed with HIV, did not show a significant association with condom use at last sex. CONCLUSION: Exposure to physical partner violence and poor partner discussions about condoms are key deterrents to condom usage. Holistic interventions are required in order to address the risky behaviours, and consequently reduce sexually transmitted infections and/or unintended pregnancies.

Examining the Relationships Between Religiosity, Spirituality, Internalized Homonegativity, and Condom Use Among African American Men Who Have Sex With Men in the Deep South.

The Sexual Health in Faith Traditions Study evaluated the relationships between religiosity, spirituality, internalized homonegativity, and sexual risk behaviors among a sample of African American men who have sex with men living in the Deep South. Participants were recruited primarily from Black Gay Pride celebrations to complete a self-administered, paper-and-pencil survey. Structural equation modeling was used to determine relationships between key constructs and condom use for insertive ( n = 285) and receptive ( n = 263) anal intercourse in the past 3 months. Almost half of respondents reported using condoms "every time" when engaging in insertive (48.3%) or receptive (45.1%) anal intercourse. Religiosity and spirituality were differentially associated with dimensions of internalized homonegativity. While no significant direct relationships were reported between either religiosity or spirituality and condom use, dimensions of internalized homonegativity mediated significant indirect relationships. Findings suggest that religiosity and spirituality influence African American men who have sex with men's internalized homonegativity and, subsequently, engagement in safer sex behaviors.

A Randomized Control Trial for Evaluating Efficacies of Two Online Cognitive Interventions With and Without Fear-Appeal Imagery Approaches in Preventing Unprotected Anal Sex Among Chinese Men Who Have Sex with Men.

Fear appeal approach has been used in health promotion, but its effectiveness has been mixed. It has not been well applied to HIV prevention among men who have sex with men (MSM). The present study developed and evaluated the relative efficacy of three online interventions (SC: STD-related cognitive approach, SCFI: STD-related cognitive plus fear appeal imagery approach, Control: HIV-related information based approach) in reducing prevalence of unprotected anal intercourse (UAI) among 396 MSM using a randomized controlled trial design. Participants' levels of fear-related emotions immediately after watching the assigned intervention materials were also assessed. Participants were evaluated at baseline and 3 months after the intervention. Results showed that participants in the SCFI scored significantly higher in the instrument assessing fear after the watching the intervention materials. However, no statistically significant differences were found across the three groups in terms of UAI at Month 3. Some significant within-group reductions in some measures of UAI were found in three groups. Further studies are warranted to test the role of fear appeal in HIV prevention.

Assessing the potential of the Woman's Condom for vaginal drug delivery.

BACKGROUND: The Woman's Condom is a new female condom that uses a dissolvable polyvinyl alcohol capsule to simplify vaginal insertion. This preclinical study assessed the feasibility to incorporate an antiviral drug, UC781, into the Woman's Condom capsule, offering a unique drug delivery platform. STUDY DESIGN: UC781 capsules were fabricated using methods from the development of the Woman's Condom capsules as well as those used in vaginal film development. Capsules were characterized to evaluate physical/chemical attributes, Lactobacillus compatibility, in vitro safety and bioactivity, and condom compatibility. RESULTS: Two UC781 capsule platforms were assessed. Capsule masses (mg; mean±SD) for platforms 1 and 2 were 116.50±18.22 and 93.80±8.49, respectively. Thicknesses were 0.0034±0.0004 in and 0.0033±0.0004 in. Disintegration times were 11±3 s and 5±1 s. Puncture strengths were 21.72±3.30 N and 4.02±0.83 N. Water content measured 6.98±1.17% and 7.04±1.92%. UC781 content was 0.59±0.05 mg and 0.77±0.11 mg. Both platforms retained in vitro bioactivity and were nontoxic to TZM-bl cells and Lactobacillus. Short-term storage of UC781 capsules with the Woman's Condom pouch did not decrease condom mechanical integrity. CONCLUSIONS: UC781 was loaded into a polymeric capsule similar to that of the Woman's Condom product. This study highlights the potential use of the Woman's Condom as a platform for vaginal delivery of drugs relevant to sexual/reproductive health, including those for short- or long-acting HIV prevention. IMPLICATIONS: We determined the proof-of-concept feasibility of incorporation of an HIV-preventative microbicide into the Woman's Condom capsule. This study highlights various in vitro physical and chemical evaluations as well as bioactivity and safety assessments necessary for vaginal product development related to female sexual and reproductive health.

Diagnostic power of the noninvasive condom catheter method in patients eligible for transurethral resection of the prostate.

AIMS: The aim of this study was to determine the accuracy of the non-invasive condom catheter method for diagnosing B(ladder) O(utlet) O(bstruction) in patients eligible for T(rans)U(rethral) R(esection) of the P(rostate). METHODS: A group of 71 patients eligible for TURP on clinical grounds were invasively and non-invasively studied. On the basis of invasive pressure-flow studies they were stratified into obstructed, equivocal or unobstructed, according to the International Continence Society standard. Subsequently they were diagnosed non-invasively on the basis of a free flowrate measurement, or on the basis of the free flowrate measurement plus the isovolumetric bladder pressure measured with the condom catheter method. R(eceiver) O(perating) C(haracteristic)s were calculated. RESULTS: The A(rea) U(nder) the (RO)C for discriminating unobstructed/equivocal patients from obstructed patients was 0.68 in our population. This improved to 0.84 for the 50 patients in whom the isovolumetric bladder pressure was not underestimated by the non-invasive method. CONCLUSIONS: In our population of TURP patients, the low flowrates affected the accuracy of the condom method to a degree that it did not perform better than a free flowrate measurement, which performed remarkably well. By excluding measurements in which the condom pressure underestimated the isovolumetric bladder pressure this method may contribute to a more accurate, patient friendly diagnosis of BOO in these patients. In the present study this exclusion was done by comparison with an invasive pressure measurement. A practical non-invasive test would necessitate a non-invasive exclusion criterion, which might be based on the risetime of the condom pressure.

Intracluster correlation of STD prevalence in a community intervention trial in Kenya.

This study is a cluster-randomised, community intervention trial to measure the impact of female condom introduction on STD prevalence among Kenyan agricultural workers. The intracluster correlation coefficient of baseline STD prevalences at the 12 sites was 0.0011.

PIP: A cluster-randomized, community intervention trial to measure the impact of female condom introduction on sexually transmitted disease (STD) prevalence was conducted among Kenyan agricultural workers. The intracluster correlation coefficient (ICC) was used to measure the degree of homogeneity within clusters in comparison to total variability. The women in the sample population received condoms and were exposed to an STD prevention program through group meetings, video presentations, puppetry, and other folk media. They were also screened and tested for gonorrhea, chlamydia, and vaginal trichomoniasis. Tests were repeated after 6 and 12 months. The ICC of baseline STD prevalence at the 12 sites was 0.0011, and the proportion of women with STDs was higher at the control sites, which indicates a negligible clustering effect.

An assessment of care provided by a public sector STD clinic in Cape Town.

A study was undertaken in a Cape Town public sector STD clinic to evaluate the content and quality of care provided since it has been recognized that appropriate improvements in the management of conventional sexually transmitted diseases (STDs), including provision of correct therapy, health education, condom promotion and partner notification, could result in a reduced incidence of HIV infection. Our objectives were to assess patients' needs for health education and to assess the quality of STD management in terms of health education, condom promotion, partner notification, the validity of the clinical diagnoses and the adequacy of the treatments prescribed. The study subjects were sampled systematically, according to their gender. Patients included in the study were given a standardized interview and their clinical records reviewed. Specimens were collected for laboratory investigations. For each STD detected, the treatment was defined as adequate if drugs currently known to be active against that infection were prescribed. One hundred and seventy men and 161 women were included in the study (median age: females 22 years, males 26 years). While almost all patients believed their STD may have been caused by unprotected sexual intercourse, many also believed it may have been caused by other factors, such as bewitchment with traditional medicine. Only 21% of male and 37% of female patients received any education about STD transmission during the clinic visit, and only 25% of male and 36% of female patients received education about condom use. As a result of the low sensitivity of the clinicians' diagnoses, 16% of men and 61% of women left the clinic with at least one infection inadequately treated. The majority of patients were not receiving education for the prevention of STDs including HIV. Many were not receiving adequate treatment for their infections. The introduction of a syndromic management protocol in this setting would substantially reduce the proportion of inadequately-treated patients. However, syndromic protocols, and the means by which they are implemented, need to take into account problems with the clinical detection of genital ulcerative disease and candidiasis in women.

PIP: In South Africa's Western Cape Province, where sexually transmitted disease (STD) rates are high but HIV prevalence remains low, syndromic STD management in the public health services has been proposed as a strategy for curbing development of an AIDS epidemic. This study, conducted prior to the formal introduction of such a program, evaluated the quality of STD management at a local health authority clinic in Cape Town. 170 male and 161 female new clients presenting during the 6-week study period were enrolled. 76% of men and 81% of women reported they had never used a condom. Only 21% of male and 37% of female clients received health education concerning STD prevention during their visit. Contact slips to facilitate partner notification were provided to 28% of men and 25% of women. Condom use was discussed with just 25% of male and 36% of females. The most common clinical diagnosis made by staff was gonorrhea. According to the research physician's findings, 51 patients (40 men and 11 women) had genital ulcers, the majority of which were not detected by staff. Of 32 men and women diagnosed by staff clinicians as having no infections, 58% of men and 75% of women had at least 1 STD confirmed by laboratory testing. Overall, at least 16% of men and 61% of women left the clinic with 1 or more STD inadequately treated. These findings indicate that introduction of syndromic protocols in South Africa's public health services will not automatically improve STD diagnosis and treatment. Health education to correct misinformation about STDs, condom promotion and distribution, partner notification, and the validity of clinical diagnoses must be addressed.

Effects of a drinking event on behavioral skills and condom attitudes in men: implications for HIV risk from a controlled experiment.

This study experimentally tested the effects of a drinking event on HIV-related behavioral skills and condom attitudes. Sixty unmarried, heterosexual men were assigned to 1 of 3 conditions (sober, placebo, or alcohol). Participants who consumed alcohol demonstrated lower skill to negotiate for condom use relative to sober controls. More negative condom attitudes were expressed by participants with stronger sex-related alcohol expectancies, especially when these expectancies were triggered by subjective intoxication. Hierarchical regression analyses revealed that the experimental factors accounted for variance in behavioral skills and condom attitudes beyond that explained by known predictors of sexual risk.

PIP: 60 unmarried, heterosexual men of mean age 24.9 years were recruited from the community through newspaper advertisements and flyers to participate in a study to evaluate the effects of drinking-related and dispositional variables on the antecedents of safer sex behavior. 87% of the men were White, 72% drank alcohol 3-4 times per week, 75% had multiple sex partners in the past year (an average of 3.2 partners), 72% did not always use condoms, and all were told that they would be participating in an alcohol and communication study. The men were assigned to 1 of 3 conditions, sober, placebo, or alcohol, to experimentally test the effects of a drinking event upon HIV-related behavioral skills and condom attitudes. Men in the alcohol group received vodka and tonic drinks, men in the placebo group received all tonic drinks with a bit of vodka rubbed on the glass to make the subjects think that the drinks contained vodka, and men in the sober group received only tonic water. 20 men were in each group. All drinks were made in the presence of the subjects, with the tonic being poured from a vodka-labelled bottle in the placebo group. Participants were instructed to finish their drinks in 30 minutes, after which time they participated in role-play scenarios. The men who consumed alcohol demonstrated lower skill in negotiating condom use relative to sober controls and were more likely to consent to sex without a condom. More negative condom attitudes were expressed by participants with stronger sex-related alcohol expectancies, especially when those expectancies were triggered by subjective intoxication. Regression analyses determined that the drinking event, especially beverage content, accounted for variance in behavioral skills and condom attitudes beyond that explained by known predictors of sexual risk.

Umbanda healers as effective AIDS educators: case-control study in Brazilian urban slums (favelas).

During a 12-month period (November 1994-October 1995), Afro-Brazilian Umbanda healers (Pais-de-Santo) taught 126 fellow healers from 51 Umbanda centres (terreiros) located in seven overcrowded slums (favelas) (population 104-343) in Brazil's northeast, the biomedical prevention of AIDS, including safe sex practices, avoidance of ritual blood behaviours and sterilization of cutting instruments. A face-to-face educational intervention by healers, marginalized in society yet respected by devotees, which blended traditional healing-its language, codes, symbols and images- and scientific medicine and addressed social injustices and discrimination was utilized in this project supported by the Brazilian Ministry of Health, National Program in STDs/AIDS. Significant increases (P < 0.001) in AIDS awareness, knowledge about risky HIV behaviour, information about correct condom use, and acceptance of lower-risk, alternative ritual blood practices and decreases (P < 0.001) in prejudicial attitudes related to HIV transmission were found among mobilized healers as compared to 100 untrained controls. Respected Afro-Brazilian Pais-de-Santo can be creative and effective partners in national HIV prevention programmes when they are equipped with biomedical information about AIDS.

Teaching about the female condom.

Reality female condoms became available for over-the-counter purchase in the fall of 1994. Because the female condom is a new sexual barrier device, women need to learn how to use it correctly. Health care providers must also be knowledgeable about the correct use of the female condom so that they can teach women how to use it as a barrier method. To facilitate learning about the female condom, a curriculum was developed that included a quiz on knowledge about the female condom. Content validity was established through a content validity index completed by six content experts. This quiz was used to evaluate educational sessions offered to 42 persons in an urban college setting and 18 women in a community setting. The article describes the female condom along with the curriculum that was developed to teach its correct use and the reactions of potential users of the female condom.

PIP: The annual failure rate of the Reality female condom is 21% among inconsistent users compared with 5% among consistent, correct users, a finding that underscores the importance of training in the proper use of this device. This study evaluated a 60-minute curriculum aimed at describing the development of the female condom, demonstrating its correct use, and identifying conditions under which the female condom is the most appropriate choice of barrier method. Course participants included 42 New York undergraduate and graduate students (average age, 23.5 years) and 18 clients from a community-based agency (average age, 36.0 years). Administered, both before and after the training, was a 15-item true/false quiz assessing knowledge about the female condom. Content validity was established through an index completed by six content experts. Among college students, the mean score on the pretest was 10.9 (range, 5-15 correct); this score increased to 12.3 (range, 8-14 correct) at post-test, confirming a significant gain in knowledge as a result of exposure to the curriculum. Among community-based participants, the mean score declined from 10.3 at pretest to 7.8 among the 9 women who completed the post-test; although these women did not seem as comfortable as the students with the lecture format, the decline in knowledge is considered to reflect distractions created by other events occurring at the agency. The quiz is in the process of being modified to improve its validity and ensure that women with lower literacy levels than those in the present study can understand the questions.

Innovations in traditional Vietnam.

PIP: In Viet Nam, the 1990 designation of population as a top government concern resulted in a tenfold increase in spending on family planning (FP) and health. The Viet Nam FP Association has developed a number of innovative ways of promoting FP, including a telephone counseling service. The population of Viet Nam has doubled since 1960, and the average per capita income remains very low; thus, condoms and oral contraceptives (OCs) are prohibitively expensive for many families. The FP program provides free condoms, OCs, and IUDs but often runs out of supplies. Need for condoms is estimated at 200 million/year, but the two factories only produce 30 million. OCs are imported from Hungary and have a bad reputation among Vietnamese women. The most commonly used contraceptive is the IUD, but poor quality of care at insertion leads many women to suffer infections. Viet Nam has a high rate of legal abortion, with most procedures occurring in the first month of pregnancy. The FP Association has cautiously introduced sex education in the schools in a pilot program that will be continued nationwide. The Association also opened a special club for young people and one for miliary personnel. These clubs provide contraceptive information along with soft drinks and music. The government's two-child policy is widely accepted but must overcome the obstacles of large family preference in rural areas and of son preference.^ieng

The role of traditional healers in HIV / AIDS counselling in Kampala, Uganda. Key issues and debates: traditional healers.

PIP: Traditional medicine is the most widely established and available health care system in Uganda. The emergence of AIDS has presented traditional healers with a substantial challenge. The Traditional and Modern Health Practitioners Together Against AIDS Project was established in 1992 to create a framework for respectful collaboration between traditional healers and medical doctors. Project activities have included comparative clinical trials of herbal treatments for specific HIV/AIDS symptoms for which few modern treatment regimens are available and training to empower traditional healers in STD/HIV counseling and education for women. The training emerged from administration of a baseline survey on AIDS to 55 healers. On the basis of community recognition as a healer, inclusion in their client population of women with AIDS, use of herbal treatments, and interest in the project, 17 of the interviewed healers were selected to participate in the initial training. The 15-month AIDS training (3 days/month), developed with input from healers and community women, covers areas such as counseling, leadership, cultural beliefs and practices, sexuality, and gender relations. Since traditional counseling is largely dependent on the spiritual medium on which the healer bases the treatment, counseling was conceptualized broadly as "a helping relationship aimed at empowering an individual to take action to cope with whatever problem he or she may be confronted with." Over time, trained healers became able to discuss AIDS with all clients, without concerns of offending them. Interviews with 180 female clients of 9 of the trained healers documented changes in the knowledge, attitudes, and practices of both healers and patients. Especially notable was a new willingness on the part of traditional healers to demonstrate and offer condoms.^ieng

A targetted intervention research on traditional healer perspectives of sexually transmitted illnesses in urban Zambia. Current research.

PIP: Interviews with 81 traditional healers from 4 Copperbelt towns in Zambia (Chililabombwe, Chingola, Luanshya, and Mufulira) investigated healers' understanding of, attitudes toward, and management of sexually transmitted diseases (STDs). In general, Zambian traditional healers had detailed constructs of the physiology and infective processes underlying syphilis, gonorrhea, chancroid, and AIDS. STDs were considered to be caused by "dirt" or contamination residing in sperm or vaginal fluids and were closely linked to violations of moral codes. Healers shared complex nosologies based on distinctions between symptoms of different STD pathologies that were more inclusive than biomedical categories. Although condom use was not promoted, healers understood the importance of preventing an infective agent from passing from one person to another. Except for AIDS, STDs were considered curable by expelling the dirt through purgatives or emetics. Modern medicine was perceived as treating only STD symptoms, not curing. Most traditional healers insisted that the infected partner bring the other partner for consultation or treatment was withheld. Since these findings identified some areas of compatibility between indigenous and biomedical models of STDs, the Traditional Medicine Unit of the Ministry of Health and the HIV/AIDS Prevention Project of the Morehouse School of Medicine (Lusaka) established a program in which traditional healers receive AIDS training and learn to counsel clients on safer sex behaviors. Follow-up entails monthly meetings between health professionals and traditional healers. Since program initiation in June 1994, 800 traditional healers and 70 health professionals have participated. Traditional healers now sell condoms to their clients through a social marketing program.^ieng

HIV risk behavior, street outreach, and condom use in eight high-risk populations.

In this paper we examine risk behavior, exposure to street outreach, and condom use in samples of injecting drug users (IDUs) and high-risk youth. We used systematic sampling methods to produce representative samples of injecting drug users IDUs (five sites) and high-risk youth (three sites). The populations surveyed engaged in high levels of sexual risk behavior: 20% to 46% reported two or more sex partners in the last month. The majority (62% to 97%) knew someone infected with HIV. Condom use rates approached national health promotion goals for nonsteady partners but not for steady or main partners. Having a condom at time of interview was the most consistent predictor of condom use at last intercourse. Many of the respondents have been in contact with street outreach programs and many acknowledged some personal risk for HIV infection. However, most of the injecting drug users and high-risk youth interviewed (and their sex partners) were still at risk through unprotected sex.

PIP: Samples of IV drug users (IVDUs) and high-risk youth were surveyed to gain insight into their HIV risk behavior, exposure to street outreach, and condom use. The IVDUs were sampled from Atlanta, Philadelphia, Chicago, New York, and Los Angeles; 69-77% are male; they are predominantly Hispanic and Black; and more than 50% were older than age 40 years. The high-risk youth were sampled from Los Angeles, San Diego, New York, and San Francisco. They were aged 12-23 years and had been recurrently without shelter during the past year, or had been without permanent shelter for the past two months, or had derived their livelihood from dealing drugs on the street, prostitution, panhandling, and crime. 65-81% are male, approximately 50% in New York are White and 78% in San Francisco, 39-54% were age 20 or older, and 52-73% were currently living on the street, although only 10-32% had stayed in a shelter during the past year. At least 75% were supported at least in part by the street economy and 15-33% identified themselves as gay or bisexual. Many of the youth covered in the survey in San Francisco were on tour with the Grateful Dead folk rock music group. 20-46% reported having two or more sex partners in the last month, up to one-third reported having no sex partner in the past month, 62-97% knew someone infected with HIV, and 18-26% of the IVDUs and 11-41% of youth reported sometimes exchanging sex for money, food, shelter, or other things. Among respondents who had sex during the past month, 17-44% reported using a condom during vaginal sex with main partners, and 55-75% with other partners. The highest rates of condom use were for anal sex, followed by vaginal and oral sex. In most categories, however, the majority of respondents were not using condoms to protect themselves from HIV or other sexually transmitted diseases. Having a condom at the time of interview was the most consistent predictor of condom use at last intercourse. Many of the respondents had been in contact with street outreach programs and many acknowledged some personal risk for HIV infection.

Healers important tool in preventing AIDS in Malawi.

PIP: According to a report from the International Eye Foundation, traditional healers in Africa, even when illiterate, are vital to disseminating information about the prevention of acquired immunodeficiency syndrome (AIDS). Because of their position in the community as trusted health care providers, they are free to speak about sensitive topics, such as sex. In the study by Berger and colleagues, "Traditional Healers in AIDS Control," 334 healers from the district of Chikwawa attended a one-day course on AIDS. Prior to this, a random sample of 89 healers had been interviewed, using a standardized pre-tested form, about their AIDS and STD knowledge, attitudes, and practices. 85 of the 89 were reinterviewed 18 months later. 43 had been to the training session. Those who had received training were more likely to have changed their practices and initiated community public health activities. They were 2.5 times as likely to have counseled AIDS patients and families. Healers with large practices were more likely to have conducted community education than those with smaller practices. 83.3% of female healers (all illiterate), 66.6% of male illiterate healers, and 53.8% of literate male healers had distributed condoms. Of those healers attending the course, 48.8% had undertaken the 3 community public health activities (community education, talking to other healers, and condom distribution); 23.3% had initiated 2 of the 3 activities.^ieng

Market day midwives.

PIP: In August 1994 in Uganda, the Social Marketing for Change (SOMARC) project invited midwives to counsel clients and sell low-dose oral contraceptives (OCs), condoms, and the progestin-only OCs in local markets. They now sell these contraceptives from vendor stalls in busy markets, which allows clients to speak privately with the midwives. The midwives refer clients to their maternity clinics or to hospitals for other contraceptive methods and reproductive/maternal and child health (MCH) services. All Market Day Midwives have taken a 1-month family planning course and a course in quality of customer service. By the end of March 1994, 17 midwives served 22 marketplaces ranging from rural village markets operating once every 2 weeks to very busy, daily city markets. Some markets have 15 permanent stalls, while other midwives move within markets. Market Day Midwives have been able to add more than 1900 women to the list of women using the OC Pilplan. 65% of the new acceptors had not used any OC before Pilplan. 46% of them would be women considered to be high risk if they were to become pregnant (teenagers, women over 35, and women with many children). These midwives have been successful because they operate where the people are and they provide anonymity. Market Day Midwives have also brought in men who seek them out for family planning/sexually transmitted disease prevention services. They have sold more than 1000 Protector condoms. Another benefit of the market day approach is professional growth of the midwives. They often invest their earnings into new equipment and their private maternity clinics. They have learned the significance of advertising and the value of high-quality customer service. They look to expand into other markets and to integrate MCH products (e.g., oral rehydration) into their contraceptive business.^ieng

Obsession with targets.

PIP: Every year from January to March throughout India the entire Family Welfare Department is active to achieve targets for family planning. Experts on population have determined that India needs to achieve a couple protection rate (CPR) of 60% by the year 2000 to reduce the population growth rate and help stabilize the population. CPR is defined as the percentage of eligible couples effectively protected against childbirth by one or the other approved methods of family planning: sterilization, IUD, condom or oral contraceptive (OC) pills. It is estimated that there are 150-180 currently married eligible couples per 1000 population in India where the wife is in the reproductive age. Each state allocates targets: the number of sterilizations to be performed, IUDs to be inserted, and OC pills and condoms to be distributed for each district. The District Medical Officers are allocated targets who direct their subordinates to meet the requirements. The high rate of sterilizations performed as well as coercion and threats are part of target completion. At sterilization camps "motivated acceptors" are sterilized and left alone to bear the side effects. It is estimated that 72 condoms are required by a couple a year. Whether the couple uses the condoms at all is no concern for the target hunters. There have been newspaper reports of large quantities of OC pills and condoms being dumped into ditches. Targets of CPR have been reached with no significant effect on birth rate and growth rate. Deficiencies also exist in relation to the crude birth rate and annual population growth rate. 41.2% of the sterilization acceptors have four or more living children. Their inclusion in the records only boosts the CPR statistics with hardly any impact on the demographic scenario. More attention should be paid to quality rather than quantity and holistic health care especially for women and children.^ieng

Contraceptive social marketing in the Philippines. A new initiative.

PIP: By offering contraceptives at subsidized prices through pharmacies, drugstores, grocery shops, and other conveniently-located retail outlets, and promoting them with modern marketing techniques, social marketing programs can do much to reduce the unmet need for family planning. Users obviously benefit, while the family planning program benefits from advertising and marketing skills and some cost recovery. The Philippine Contraceptive Social Marketing Project (PCSMP) was formally launched in the Philippines in 1993 in response to the large unmet need in the country, and initial results are promising. The project was started with funding from the US Agency for International Development to provide affordable, quality contraceptives through the private sector to Filipino couples who choose to practice family planning. A 1988 survey found that only 22.4% of women aged 15-44 years were using modern methods of contraception and 13.8% were using traditional methods; approximately three million women therefore had unmet need for family planning. The PCSMP established an AIDS prevention component and a birth spacing component, enlisting the participation of oral contraceptive manufacturers Wyeth, Organon, and Schering, along with one condom distributor, Philusa. These companies lowered their product prices by 20% for the program. Despite objections from the Catholic church, sales of both oral pills and condoms increased in the first year. In its second year, the program will advertise Sensation condoms and the Couple's Choice Pills via television, through intensive distribution drives, consumer and trade promotions, and the continuous training of health professionals. The contraceptive injectable DMPA will be added to the Couple's Choice product line in April 1994. This method, too, will be heavily promoted.^ieng

Wear your hat: representational resistance in safer sex discourse.

Through an analysis of four posters used by the AIDS Action Committee of Massachusetts, this article asks how representation can effectively promote safer sex practices. The images under investigation have different targeted groups--one is aimed at African-American men, one at Latinas, and two at gay men. Using a frame-work that connects definitions of sex in the respective communities with differences surrounding gender, race, and class, the imagery is unpacked in order to expose the effects of safer sex representation. This essay then argues that the degree to which ingrained definitions of sex are challenged constitutes a determining factor in the success or failure of safer sex representations.

PIP: An analysis of four posters used by Massachusetts' Acquired Immunodeficiency Syndrome (AIDS) Action Committee underscored the need to comprehend the significance of sex roles and sex behaviors in diverse cultures. The first poster analyzed showed a shirtless, highly masculinized African-American man holding a condom. The accompanying message was, "Are you man enough to protect your lover?" Although this poster challenges convention by displacing responsibility for contraception and protection from infection from women to men, it reinforces the notion that Black men have the right to control over women. The second poster shows an Hispanic woman in combat gear holding a condom. The printed message is, "Forewarned is forearmed." Again, this message challenges the traditional subordinate role of Latinas, but the notion of female empowerment implicit in the poster is at odds with the target culture. The third poster, depicting two white males engaged in sex involving a condom, includes the message "Safe. Hot. Always." This poster seeks to promote safe sex practices through an appeal to a pornographic mode of representation, but its impact is dependent on the viewer's perception of pornography. The fourth poster portrays a group of six gay White men playfully carrying a box of condoms and sexual aids. The message reads, "Safe Company. We're putting the sex back into safe sex." Although the reinforcement of peer support for safe sex has merits, the poster's depiction of clearly middle-class men limits its appeal. Central to all these efforts is the question of how an audience can be effectively educated about the need for safe sex practices without resorting to cultural stereotyping and pseudo-homogeneity. Involvement of the target audience in the preparation of audiovisual materials is urged to overcome some of these complexities.