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

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

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

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.

An innovative HIV / AIDS research and education program in Puerto Rico.

PIP: The University of Puerto Rico's HIV/AIDS Research and Education Center was founded to promote research and to create programs to help prevent HIV infection through a decrease in risk practices. Specific Center goals are to create and launch research projects to identify the sociocultural factors behind risk behaviors, and to develop innovative educational programs and techniques based upon the research findings. Before the founding of the center, a survey of more than 7000 University of Puerto Rico students found that about 10% of respondents reported always using condoms during sex; male and female respondents reported averages of 6.1 and 2.5 lifetime sex partners, respectively; approximately 30% of the female respondents reported having engaged in anal intercourse; and Puerto Ricans have rigid sexual norms and polarized gender roles. These findings point to the need for meaningful HIV/AIDS interventions. The center has launched a 5-year project to relate contextual variables to the context of sexuality and gender roles in sexual negotiation and sexual practices in Puerto Rico. The center's education program is described.^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

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

Investing in the future in Brazil.

PIP: In 1991, a survey conducted in northeastern Brazil by BEMFAM, the International Planned Parenthood Federation's affiliate, revealed that 15% of female adolescent respondents had children or were pregnant and that the fertility rate for adolescents aged 15-19 was 41 births/1000. In addition, the fact that 33% of all cases of HIV/AIDS reported between 1980 and 1996 involved 20-29 year olds means that a significant number were infected as adolescents. BEMFAM responded by launching (in 1993) a school-based adolescent HIV/STD prevention campaign in Alagoas state (where BEMFAM found the school in a deplorable state of filth, with every surface covered with graffiti) and in Paraiba state. Today the school buildings are clean, the graffiti is gone, and students are learning to talk openly about their bodies and sexuality. The most innovative aspect of the program is that sex education is incorporated in every part of the curriculum instead of being isolated in a separate course. History teachers incorporate gender issues in their discussions; math teachers use AIDS statistics in class; and other teachers discuss such issues as personal hygiene, sexuality, and unwanted pregnancy. The school staff received 40 hours of training in sexuality, reproduction, HIV, sexually transmitted diseases, communication and leadership skills, gender, and self-worth. A serious implementation impediment is the fact that Brazilian teachers are rotated annually from school to school, and new staff must be trained each year. The project has had beneficial results for all involved and has earned the support of the community at large.^ieng

HIV prevention -- keys to success.

PIP: Successful HIV prevention programs have elements in common. For example, they begin with the interests and concerns of the groups they are trying to reach, involving them in project design and implementation. In Tanzania, people in about 1000 communities have become more involved in HIV prevention with the support of a district AIDS team which has helped them to identify their priorities. In northern Thailand, communities have developed more positive attitudes to people affected by HIV, by identifying sources of support within their own communities. One highly important issue for HIV projects is how to work with groups which are most at risk, who are often discriminated against by society, without stigmatizing them further. A project is being implemented in Brazil in which Brazilians of African descent who have not been reached by HIV prevention campaigns are spreading messages about HIV in their own community through activities based upon their culture and religion. A project is also helping young drug users in Costa Rica get serious about the threat of HIV/AIDS. Once a project has begun, it is also important that measures be taken to ensure its sustainability.^ieng

Overcoming prejudice.

PIP: People of African descent comprise a large proportion of Brazil's population. While racism exists in the country, it is commonly denied. Most Afro-Brazilians live in poor areas, with poor health care services, sanitation, schools, and transport. Since HIV is linked to poverty, Afro-Brazilians are more affected by HIV than is the overall population. Although Afro-Brazilians contribute to Brazil's culture, they do not benefit from that contribution. Recognizing this considerable social problem, Project Araye was created in 1996 to address issues of race and HIV. Building upon religious and cultural traditions, the project is staffed by Afro-Brazilians who are knowledgeable in both health issues and Afro-Brazilian culture. Project Araye supports a wide range of diverse community leaders in linking sexual health and HIV with other health concerns which affect Afro-Brazilians such as sickle-cell anemia, diabetes, and leprosy. One important challenge has been overcoming the target population's denial of HIV and encouraging Afro-Brazilians to accept that HIV also affects them. Community leaders include religious leaders, rap musicians, artists, and other people respected by various communities. Activities include visits to samba dance schools, Umbanda and Candomble temples, and street youth groups to provide HIV-related information.^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

Urban women educate their community on HIV / STDs, family planning and reproductive health.

PIP: To broaden the context of HIV/AIDS prevention interventions in an urban slum in Rio de Janeiro, Brazil, a model program was developed that involved training 12 low-income women to serve as paid community health agents. The 4-month training course covered the health education topics of reproduction, HIV/AIDS, family planning (FP), and reproductive health and was guided by the belief that women's vulnerability to HIV/AIDS is embedded in gender relations and that health education should be bolstered with promotion of individual autonomy among trainees. Trainees also conducted simple research to analyze the needs of their community and assessed and produced the health education materials they would use in the community. The HIV/AIDS intervention model developed by the women takes the form of three community meetings on 1) gender relations, 2) sexuality and HIV/AIDS prevention, and 3) AIDS. Women who attend the meetings are given cards that simplify their acceptance as FP clients at local health centers. The training empowered the 12 women and led to positive improvements in their lives. Because their community is controlled by drug dealers, the women had to overcome restrictions on their interactions with their neighbors. The training gave the women the courage to do this and to be recognized and accepted in their communities. While the paid project is completed, the women have continued offering educational sessions. Currently, the project staff is seeking funding to find ways to replicate this intervention model at a lower cost.^ieng