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AIDS action  >  Issue 36-37 - Sex
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AIDS action  -  Issue 36-37 - Sex

HIV and safe, healthy sex

Issue Contents
 

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HIV and safe, healthy sex

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Sex: a sensitive issue

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Talking about our bodies

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Female reproductive organs

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Male reproductive organs

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The menstrual cycle

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Sex and getting pregnant

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Common infections

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Preventing unwanted pregnancy and infection

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Contraceptives

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Condoms

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Putting it into practice

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Resources

 

 

 

AIDS action  Issue 36-37         Page 1   2  top of page

  Issue 36-37 March - August 1997

HIV and safe, healthy sex

Understanding how the body works is key to being able to make choices about sexual and reproductive health, including HIV prevention.


If a woman wants to become pregnant, how can she reduce her risk of HIV and other sexually transmitted infections? When a young man is growing up and worried about his future, how can you expect him to be concerned about HIV?

Many HIV prevention projects focus on HIV and other sexually transmitted infections without considering people's broader reproductive and sexual health concerns. HIV prevention depends on people being able to make choices about their sexual behaviour. This means understanding how their bodies work, knowing what choices are available to them, and having the confidence and skills to discuss and make changes in their sexual and reproductive lives. 

HIV educators, family planning workers, youth counsellors and others need to be able to respond to a range of questions and concerns in a sensitive and supportive way. This special double issue of AIDS Action provides basic facts about the reproductive system, fertility, sexually transmitted infections and contraceptives, and looks at the links between HIV, sex and reproduction.
 
Talking about sex can be difficult. Sex is a private matter and people often feel embarrassed talking about it. This issue also contains tips for communication and activities to find out what people know already and help them learn.

You may find that not everything in this issue is necessary for the people you are working with. This is a 'pick and mix' issue for you to pick out what is useful, adapting it if you wish.

 

In this issue
 

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Sex: a sensitive issue Page 2

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Talking about our bodies Page 5

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Female reproductive organs Page 6

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The menstrual cycle Page 7

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Sex and getting pregnant Page 8

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Common infections Page 9

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Preventing unwanted pregnancy and infection Page 10

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Contraceptives Page 14

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Condoms Page 16

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Putting into practice Page 18



AIDS action  Issue 36-37    1   Page 2   3  top of page

  

Sex: a sensitive issue

Health workers and educators need to understand what influences people's attitudes to sex. They may need to improve their skills in discussing sensitive issues.

People's attitudes to sex and their existing knowledge may be very different from yours. It is important to find out about these and avoid making assumptions.

People's priorities Your main aim may be to prevent HIV infection, advise on family planning, or educate young people about sexual relationships. However, the people you are working with may have other priorities. They may be worried about non-health issues such as finding work, or they may have more urgent health problems. You need to find out what their concerns are and discuss sexual health issues within this context.

Stages of life People have different needs for sexual health information at different stages in their life. Pre-teens need to know about puberty. Adolescents may be worried about their changing bodies and what their  first sexual experience will be like. Some women may want to have children, others may want to avoid pregnancy. Older men may be worried about losing their fertility and masculinity. The lifeline activity below can help to identify needs at different stages of life.

Common beliefs and myths People learn about sex from a variety of sources, such as their families, friends, church, school, clinic, or books and films. Most people obtain a mixture of accurate and inaccurate information. Some inaccurate information can be harmful. You need to find out what people know and discuss any misunderstandings sensitively. 

Culture and religion There are many cultural practices connected with sex. Some are helpful. For example, traditional patterns of 'courtship' and discouraging early sex can make it easier for young people to learn about their sexuality and to get to know their sexual partners. Others are harmful. For example, female genital mutilation (female circumcision) increases the risk of reproductive tract infections and difficulties in childbirth.

 

Activity

To identify key stages in peoples lives and understand different needs for sexual and reproductive health information and support at different times.

Drawing a lifeline:
Ask each participant to draw a line across a sheet of paper representing the lifespan of an imaginary woman or man from birth to old age. Ask them to mark key events in the person's, sexual and reproductive life, such as first period (if a woman), first sexual experience, pregnancy or pregnancy of partner, or sexual problems. Ask them to discuss the lifeline with another participant of the same sex. The lifelines can then be presented to the group and discussed. Allow participants to express their feelings. Encourage people to discuss the different influences on their lives, such as parents, friends, family and religion. Then list and discuss the imaginary woman's or man's needs for health information. 

To identify key stages in peoples lives .and understand different needs for sexual .and reproductive health information and .support at different times.

 

HIV+
Living well with HIV
People with HIV need information to enable them to live well, enjoy a healthy sex life, and protect themselves and others from HIV infection. 

Like anyone else, they need information about sexual activities that reduce the risk of infection or reinfection. They may need support to accept their HIV status and feel confident about having sexual relationships. They may also need support to decide whether to talk about their HIV status with their partner, and how to do so. Pregnant women with HIV need information about nutrition and treatment, and how to reduce the risk of HIV transmission to the baby. People who teach cultural values in their community have a key role to play in promoting safer sex practices.



AIDS action  Issue 36-37    2   Page 3   4  top of page

  

 

Relationships between women and men Relationships between women and men are influenced by culture and religion. This can make it difficult for people to change their sexual behaviour. For example, in many societies young people often feel under pressure to have sex; women are praised for having children; men have more power than women and may use violence or pressure to prevent them from practising safer sex. People need not only information, but also skills to challenge attitudes and practices that put them at risk of unwanted pregnancy, infections and violence.

Reasons for having sex People have sex for different reasons. Many have sex for positive reasons - as an expression of love, for their own or their partner's pleasure, or to have children. Sex can also be less enjoyable - because of threat of violence or economic necessity. Women are often worried about getting pregnant, or not being able to have children. HIV has made a big difference to whether people can enjoy sex, because of worries about becoming infected. Health workers and educators need to promote positive reasons for having safer sex and help to reduce worries about HIV and other infections. For example, you can explain that using a condom can help a man to keep his erection for longer, or prevent a woman from having an unwanted pregnancy.

Sexual practices People engage in many sexual activities apart from vaginal intercourse. For example, some people have anal intercourse to avoid pregnancy or for pleasure, without realising that this involves a risk of transmitting HIV or another sexually transmitted infection (STI). Many men and women masturbate (stimulate their genitals with their hands or other objects) for pleasure.
 
Many people have a range of sexual desires and practices. Not everyone is only sexually attracted to the opposite sex (heterosexual). These issues need to be acknowledged if you are going to provide useful safer sex information and support. Be careful not to impose your own views about how people should behave sexually (unless they are engaging in practices that may be harmful). People may avoid telling you the truth if they fear disapproval.
 

Practising putting a condom on a bottle makes it less embarrassing. It also helps people remember how to use condoms and have more confidence about discussing safer sex.


Communication skills Talking about sex can be difficult. Sex is a private matter and many people feel embarrassed talking about it. Sexual partners often find it hard to talk to each other about sex.

You need to consider what communication techniques are appropriate. This depends on whether you are working one-to-one or with a group, what people you are working with, what organisation you are working for, and what your role is. 

Good communication is a two-way sharing of information. It involves finding out people's views, listening carefully to what they say and understanding their situation. The way you ask questions is important. 'Closed' questions require only a 'yes' or 'no' answer. They often begin with: have, has, did, do, are, will. They are useful if you need to find out simple information. For example, 'Do you use condoms?' However, they are very limited. If you ask only closed questions, people will have little opportunity to say anything other than 'yes' or 'no'.

'Open' questions often require more than a 'yes' or 'no' answer. They encourage people to describe what they have done, why they do something, or what they understand. Open questions often begin: what, how, how much. For example, 'How do you protect yourself against sexually transmitted infections?' or 'What concerns you most about sex right now?'

Listening is an important skill. Talking to someone without listening can stop them seeking your advice again. Good listening involves giving your full attention to the person who is speaking, concentrating on what they are saying, not interrupting, and checking that you have understood. It helps to avoid misunderstandings and encourages people to speak fully because they know they will be listened to. Listening helps you to understand someone's situation and give advice that is realistic for them.

Think of a time when you wanted to tell someone about something you were worried about. How did you begin to talk about it? How could it have been made easier? What did the other person do to make it easier or more difficult? Use this to think about how you can make it easier to discuss sensitive issues with other people. When giving advice, use plain language that the person will understand. Health workers learn about the body and disease in technical terms. When these terms become familiar, it is easy to forget that other people may not understand them. Visual aids such as drawings or diagrams are a great help to communication. If possible, demonstrate how something works (such as fitting a condom) and give people the opportunity to practise it themselves (by using a model penis, for example).

 

Activity

Sweet and sour
To understand that people have different sexual orientation

Ask participants to divide into three groups: those who like sweet things, those who like sour things and those who like both sweet and sour. Ask which group has 'normal' taste. Explain that sexual orientation is similar - some people are attracted to people of the opposite sex, some to the same sex, and some to both sexes. It is not a matter of normal or abnormal.

Safe and unsafe
To find out what people already know about safe and unsafe sex. 

Ask people to list different ways of giving or receiving sexual pleasure.

Ask them to divide the lists into safe and unsafe. The lists are presented by each group followed by a discussion.





AIDS action  Issue 36-37    3   Page 4   5  top of page

  

 

Activity

True or false?

Use this quiz to test your own knowledge, or use it with groups to find out theirs. You can add more questions of your own.

Which statements are true and which are false? 

  1. If a woman has a sexually transmitted  infection (STI) during pregnancy, it can make her baby sick.

  2. A woman who is menstruating is sick.

  3. A sexually active girl or woman cannot become pregnant during the 'safe time' of the month.

  4. Masturbation is totally harmless, and many people masturbate at some time during their lives.

  5. A woman will not get pregnant if her partner pulls his penis out from her vagina before he ejaculates.

  6. People with HIV do not need safer sex information.

  7. Women can always tell if they have a sexually transmitted infection.

  8. People can get infected with HIV and not know. 

  9. Married couples may be at risk of sexually transmitted infections. 

  10. If a woman's menstrual cycle is irregular, she cannot get pregnant. 

  11. Condoms provide excellent protection against pregnancy and HIV/STIs.

  12. If a woman douches (washes inside her vagina) after sex, she will not get pregnant.


Answers

  1. True. Syphilis, HIV and genital herpes can be passed from mother to baby. Chlamydia and gonorrhoea can cause eye infections in babies (page 10-11).

  2. False. Menstruation is not an illness, although many women get backache or stomach cramps (page 8).

  3. True, but it is not easy to recognise the safe time (page 15: Natural family planning).

  4. True (page 2-3: Common beliefs and myths, Sexual practices).

  5. False, because some sperm may be released before ejaculation (page 15: Withdrawal).

  6. False. People with HIV are often sexually active and need information like anyone else (page 2: Living well with HIV).

  7. False. STIs are often hard to detect in women (page 10-11).

  8. True. HIV itself has no symptoms (page 11).

  9. True. Married couples may have other sexual partners. You need to assess each individual's risk of infection (page 12 and page 19: Patricia's plan).

  10. False. A woman can become pregnant around the time of ovulation regardless of the length of her cycle (page 9).

  11. True. Condoms are the best protection if used properly (page 12).

  12. False. Douching does not protect against pregnancy; it can increase the risk of infection (page 6).


Adapted from Talking Together (see page 20

 

Case Study

Acceptable behaviour
In a training exercise for family planning staff, participants were asked to consider a list of sexual behaviours, such as unprotected vaginal sex, vaginal sex with a condom, oral sex with a woman, oral sex with a man, group sex, anal sex, sex outside marriage, and prostitution. Participants were asked to decide whether each behaviour was acceptable for themselves, acceptable for others, or not acceptable for anyone. They then discussed how it felt for someone else to decide that an activity that they enjoyed was unacceptable. 

Source: Population Council





AIDS action  Issue 36-37    4   Page 5   6  top of page

  

Talking about our bodies

People use different words to describe their reproductive and sexual body parts, depending on who they are talking to. It is best if you use words that people find acceptable. The activities on this page are designed to help you to find out what words people use, what they already know, and what they may have misunderstood. Be careful to correct any misunderstandings sensitively and not to make people feel ignorant. The activities can also help people to feel more confident when talking to health workers about their bodies.

 

Activity

Naming parts of the body
To help people learn about their bodies. This activity is best done in same-sex groups.

Invite a volunteer to lie on the floor or a large sheet of paper. Ask another person to draw round the volunteer's body to produce an outline of the body. Ask the volunteer to return to the group. 

Ask the group to draw the external reproductive parts of the body on a separate sheet of paper. Stick this sheet over the outline of the body to create a flap. Ask the group to label the external sexual and reproductive body parts using their own words.

Under the flap, on the original sheet of paper, ask the group to draw the internal reproductive organs. Ask the group to label the internal parts. Discuss the drawings and labels and correct any misunderstandings sensitively.

Alternatively, show the group the drawings and lists of words on pages 6 and 7, and explain anything that is not clear. If people feel uncomfortable using the words used, ask them which words they would prefer to use and write these on the drawings.

 

Activity

Words people use

To find out what words people use to describe their bodies.

Read out the following terms (or add terms of your own)
Vagina Penis Anal intercourse Oral sex Breasts Masturbation Semen Kissing Vaginal intercourse

Ask the group, individually or in pairs, to describe these terms in their own words. Write their words on a large piece of paper or blackboard. Then ask participants where or how the words would be used and by whom - friends of the same sex, health workers, husbands or wives, children, etc.



Case study

Flipcharts or booklets are very useful. This booklet, produces by Rural Women's Social Education Centre (RUWSEC) in southern India, uses flaps glued onto the page to show the external part internal reproductive organs. (see also page 18: Working with men.)
 

Flipcharts or booklets are very useful. This booklet, produces by Rural Women's Social Education Centre (RUWSEC) in southern India, uses flaps glued onto the page to show the external part internal reproductive organs.
Flipcharts or booklets are very useful. This booklet, produces by Rural Women's Social Education Centre (RUWSEC) in southern India, uses flaps glued onto the page to show the external part internal reproductive organs.



AIDS action  Issue 36-37    5   Page 6   7  top of page

  

Female reproductive organs

Every girl's and woman's body looks different. In areas where female genital mutilation (circumcision) is practised, women's reproductive parts will look different. They may not have the clitoris, and the inner and outer labia may look different.

Women should wash the outside of their genital area daily. The vagina has a natural cleansing mechanism and should not be washed inside. Washing inside (douching) can increase the risk of infection, especially if done before sexual intercourse.

 

Pubic hair Grows around the vulva after puberty.
Clitoris Small bump at the top of the inner labia, riled with nerve endings. It is very sensitive to touch. Stimulating the clitoris can be pleasurable and lead to orgasm.
Vulva The different parts of the vulva make up the woman's outside reproductive organs:
Outer labia Two folds, or lips, of skin which protect the vulva
Inner labia Two smaller folds, or lips, of skin which lie between the outer labia
Urethral opening Small opening below the clitoris through which urine passes out of the body
Vaginal opening Opening below the urethral opening and above the anus. It leads to the vagina, cervix and uterus. It is through the vaginal opening that menstrual blood passes out of the body, the penis may enter during sex, and babies are born
Anus Opening between the buttocks and below the vulva. Faeces (body waste) leave the body through it.

Female reproductive organs

 

Female reproductive organs

Uterine (fallopian) tubes Two tubes that connect the uterus to the ovaries. An egg is released from one of the ovaries each month, and passes along a uterine tube into the uterus.
Ovaries Two glands, one at the end of each uterine tube, which produce eggs and female sex hormones.
Uterus or womb Hollow sac of muscle, shaped like an upside-down pear, where an embryo develops into a baby during pregnancy. 
Cervix Mouth of the uterus, connecting it to the vagina. It has a very small opening and is kept moist by mucus. A woman can feel her cervix by putting two clean fingers into her vagina and reaching up and forward. The cervix feels round, hard and smooth, with a small bump in the middle.
Vagina A moist tube of muscle, normally about 8cm long, which connects the vulva to the inner reproductive organs. It is very flexible. It secretes slippery mucus during sexual arousal.


The vagina and cervix are the lower reproductive tract. The uterus, uterine tubes and ovaries are the upper reproductive tract



AIDS action  Issue 36-37    6   Page 7   8  top of page

  

Male reproductive organs

Every man's reproductive organs look slightly different. If a man is circumcised, his foreskin is removed. Penis may vary slightly in shape and size. Many men have concerns about the shape or size of their penis. However, all penis function the same way regardless of their shape or size. 

Men should wash their genital area daily. They should clean the area behind the foreskin if they have not been circumcised. This help to prevent infections.

 

Male reproductive organs

Pubic hair Grows around the penis after puberty.
Penis Made up of spongy tissue. Normally soft, but fills up with blood and becomes stiff (erect) when a man is sexually excited.
Foreskin Small piece of skin which covers the glans. It is removed when a man is circumcised.
Scrotum
Sac that holds the two testicles. 
Glans Head of the penis. Sensitive to touch. 
Urethral opening Opening through which urine and semen pass. Unlike women, men have the same opening for urine and sexual fluids. It is not possible for urine to pass through the urethra at the same time as semen is being ejaculated.

 

Male reproductive organs


Vas deferens Tube that carries sperm from the testicles to the urethra before the man ejaculates.
Prostate gland Small gland which produces a thin fluid which forms part of the semen.
Seminal vesicle Small sac at the back of the prostate gland where the thick milky fluid in semen is produced.
Urethra
Tube through which urine and semen (including sperm) pass out of the body. 
Testicles Glands (which feel like two small balls) which produce sperm and the male sex hormone.
Epididymis Area where sperm are stored in the testicles. 





AIDS action  Issue 36-37    7   Page 8   9  top of page

  

The menstrual cycle

Understanding women's menstrual cycle helps people to know how a girl or woman can get pregnant.

Puberty is when girls' and boys' bodies develop into women's and men's bodies, and when they become capable of having children. This change happens gradually over several years, usually starting at 9-12 years of age and continuing until 16-18 years. Girls usually start puberty a year or two before boys. Some changes are visible and others happen inside. Changes are emotional as well as physical. They include:

Girls and boys: Grow taller quickly, underarm hair starts growing, pubic hair starts growing, skin becomes more oily. 
Girls
: Breasts develop, hips widen, uterus and ovaries mature, ovulation begins, menstruation begins. 
Boys: Voice deepens, facial hair starts growing, chest hair may start growing, penis and testes mature, sperm production begins, ejaculation occurs, including release of semen during sleep (wet dreams).

Menstruation 
The average menstrual cycle lasts 28 days. Many women have cycles that are longer or shorter than average. Cycles can also vary in length from one month to the next. They are usually irregular for the first 2-4 years after puberty starts. Each month an egg in one of the ovaries ripens and is released. This is ovulation. Ovulation usually occurs 12-16 days before the next period. The egg travels down the uterine tube into the uterus. This takes about 3-5 days. At the same time, the uterus develops a thick lining of tissue and blood to protect and nourish a fertilised egg.

If vaginal intercourse takes place around ovulation and no contraceptive is used, the egg may become fertilised by a man's sperm. This is conception. Occasionally two eggs are released at the same time, or one egg divides into two. If both are fertilised they produce twins. If the egg is not fertilised, the egg and the lining of the uterus pass out of the body through the vagina.

This is menstruation (period or monthlies). Menstruation usually lasts 4-8 days. 

The vagina secretes a natural, odourless discharge to keep it clean and moist. The discharge changes in consistency during the cycle. Around ovulation - and during sexual arousal - it is transparent and slippery. At other times it is thicker and stickier. Immediately after ovulation, a woman's temperature drops slightly, then rises by about 0.2-0.4° C. It stays higher until just before the next period.  Many women get signs each month before they start their period - gaining a little weight, having mild stomach pain, getting facial spots or feeling tense. During their period they may have backache or stomach cramps. Regular exercise and rubbing the lower back or stomach can sometimes soothe the discomfort. 

In most societies, women know that regular periods are a sign of good health. However, in some societies, periods are felt to be embarrassing or shameful, and women are expected to behave differently when menstruating. For example, they may have to avoid saying prayers, cooking, or eating certain foods. However, there is no physical reason why women should stop their normal activities.

Hygiene Hygiene is important during menstruation. Women can use cloths or special pads held in their underpants or with a belt, or tampons (absorbent, cylindrical cotton pads inserted into the vagina).

Cloths should be changed regularly and disposed of or washed in clean water and dried properly before reusing. Pads or tampons should be changed at least every eight hours. Poor menstrual hygiene can cause bacterial infections (see page 10).

Missed periods
 
Periods can be missed for several reasons: 

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breastfeeding during the first few months after giving birth

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teenage girls whose cycles are not yet regular 

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older women who are approaching the menopause (when they stop having periods)

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poor nutrition, stress, or conditions such as anaemia

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pregnancy.


A few women never have periods because of hormonal imbalances, genetic abnormalities or illness.

Period problems 
Some women have heavy or painful periods which can often be treated. Some reproductive tract infections, such as chlamydia, can cause irregular bleeding. Some contraceptive methods can make periods heavier, such as the IUD, or lighter, such as the pill. Cervical and uterine cancer can cause unusual bleeding, including in women past the menopause. 

Women with HIV sometimes find that their periods stop, become irregular, or become heavier and longer. They may get attacks of thrush and herpes more often during periods. 

 

Activity

Beads to count the days
To teach women about their cycle.

Make a necklace of 28 beads, using different colours to represent different stages of the cycle: a red bead for the first day of their cycle (first day of menstruation), brown beads for the days immediately before and after their period (when they are least likely to be fertile), and blue beads for the days around ovulation (when they are most likely to be fertile). Mark off the days with a piece of string or an elastic band. Use the necklace for demonstration and discussion.

 To teach women about their cycle.

Explain that each woman's cycle is slightly different. Emphasise that counting days alone is not a reliable method of preventing pregnancy (see page 15: Natural family planning). Women may find it useful to make their own necklaces to keep track of their cycle.



AIDS action  Issue 36-37    8   Page 9  10  top of page

  

Sex and getting pregnant

Understanding how pregnancy occurs helps people to know how to conceive or prevent unwanted pregnancy. 

 

Understanding how pregnancy occurs helps people to know how to conceive or prevent unwanted pregnancy.

Pregnancy problems 

Miscarriage
A full-term pregnancy lasts for 40 weeks from the first day of the last period. A pregnancy may end spontaneously before reaching full term (miscarriage). This is quite common in the first three months, usually because there is something wrong with the embryo. 

Ectopic pregnancy Sometimes a fertilised egg gets stuck in the uterine tube and begins to develop there (ectopic pregnancy). This is usually caused by a blocked tube. The woman may feel a sharp pain in her side or abdomen soon after her period is due. The pain gets worse and worse. Ectopic pregnancy is very dangerous. It needs to be treated immediately in hospital as an emergency.

Infertility Some couples have difficulty conceiving and some (about one in ten) may never conceive. Infertility can be caused by:
 

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blocked uterine tubes, usually caused by a sexually transmitted infection such as PID (see page 10), or an infection resulting from septic abortion or following childbirth 

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problems with ovulation or sex hormone production

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not enough healthy sperm 

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no known reason (about one in ten cases).


If a couple are having difficulty conceiving, it may be because they are not having sex during the fertile stage of the woman's cycle. The couple can be taught how to recognise this stage, for example, by keeping a record of the woman's menstrual cycle and observing changes in mucus and body temperature (see page 8). Infertility can be very distressing. Couples who cannot have children may need support and information. Treatment is available. but is often expensive and not always successful. Women are often blamed for infertility. In fact, a roughly equal number of men and women have problems with fertility. It is important not to blame the individual.

Young women Young women face greater health risks from pregnancy when their bodies are not fully developed. If the woman's pelvic area is too small for the baby to pass through, the baby's head can tear the vagina, making an opening between the vagina and intestine or urethra, causing urine or faeces to leak (vesicovaginal fistula). Young women are also more likely to risk illegal and unsafe abortion.

Pregnancy and safer sex Getting pregnant involves a risk of transmitting HIV/STIs if either partner has been exposed to infection from another relationship. To reduce the risk of infection, a couple wishing to conceive can use condoms except during the fertile stage of the woman's cycle.

 

HIV+
Pregnancy and HIV

Any HIV-positive woman seeking information about pregnancy should be informed about the HIV-related risks to herself and her baby, and how these can be reduced. Women who are already sick with HIV-related illnesses may find that pregnancy makes their health deteriorate. Most healthy HIV-positive women are as likely to have a healthy pregnancy as other women. About one in three babies born to HIV-positive women in developing countries are HIV infected. The risk of transmission from mother to child can be reduced by:
 

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minimising unprotected intercourse when trying to get pregnant

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having protected intercourse during and after pregnancy

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making delivery safer, such as preventing prolonged labour

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giving anti-HIV drugs to the woman immediately before and during delivery and to the baby immediately after birth (which needs to be done under medical supervision)

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considering safe alternatives to breastfeeding, if possible, or stopping breastfeeding as early as is safe.



AIDS action  Issue 36-37    9   Page 10  11  top of page

  

Common infection

There are a number of infections affecting the reproductive tract in men and women, most of which can be easily treated.

Reproductive tract infections (RTls) fall into three groups:
 

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sexually transmitted infections (STIs), such as HIV, gonorrhoea, syphilis, chancroid, chlamydia, pelvic inflammatory disease (PID), genital herpes and genital warts, which are spread by bacteria or viruses during vaginal or anal sex. Gonorrhoea, syphilis and genital herpes can also be spread by oral sex. There is some evidence that HIV can also be spread by oral sex. 

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bacterial infections that result from changes in the body during menstruation, illnesses such as diabetes, pregnancy, or use of medicines such as antibiotics. These include candida (thrush) and bacterial vaginosis (trichomoniasis or trich), which are also sometimes transmitted sexually.

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bacterial infections that result from medical interventions such as insertion of IUDs, internal examinations, or during birth.


The World Health Organization estimates that there are 333 million new cases of sexually transmitted infections each year. The total number of RTls is even higher; because many have few symptoms, or people think that the pain or discomfort caused by them is 'normal' and so do not report them to health workers. 

Women are particularly vulnerable to reproductive tract infections. RTls are often more difficult to detect in women because they have few visible symptoms. If left untreated, they can be not only unpleasant and uncomfortable, but can also lead to serious problems such as infertility. It is important that sexual partners of people with RTls are examined, and any infections that are transmitted sexually are treated, to prevent the infection being transmitted back and forth between partners. However, this can be difficult, because it may mean acknowledging that one or both partners has had another sexual partner. Young people of both sexes are particularly vulnerable to STIs. 

Young people aged 15-24 have the highest rates of new HIV infection in most countries.

Most RTls carry a lot of stigma. They are not openly discussed. People who think they may be infected may be too afraid to talk about them. It is very important that people know how to prevent RTls, recognise symptoms, and have access to sympathetic and effective treatment.

Common symptoms include: unusually thick or smelly vaginal or urethral discharge, genital sores, anal sores, genital itching, pain when urinating or during sexual intercourse, painful swelling in the lymph glands or groin, and lower abdominal pain. 

STIs that cause open sores, such as syphilis, chancroid and genital herpes, are not only dangerous themselves, but also greatly increase the risk of HIV transmission. There is also some evidence that other infections that cause discharge from the urethra or vagina, such as gonorrhoea, may increase the risk of HIV transmission. Other STIs and RTls are not life-threatening, but can cause discomfort, pain during sexual intercourse, or damage to the reproductive system.

Diagnosis and treatment of all RTls is therefore important for people's sexual health. Many health workers are now trained to recognise RTls by their symptoms, and can treat more RTls effectively at local clinics. The following are the most common reproductive tract infections:

Gonorrhoea (the clap)
One of the most common STIs, caused by bacteria. It often has no symptoms in women. Symptoms may include abdominal pain and (in men) urethral discharge or (in women) smelly, pus-like vaginal discharge. It can lead to pelvic inflammatory disease (PI D) (see below). It can cause infertility and can cause infection in babies during birth, leading to eye infections or blindness. Gonorrhoea can be identified by a laboratory test. It can be cured with antibiotics.

Syphilis Viral infection that can cause genital or anal ulcers. The virus can be spread from a pregnant woman to the fetus, as well as through sexual contact. If left untreated for some years, syphilis can lead to nerve damage and death. It can be cured with antibiotics.

Chancroid Bacterial infection common in tropical countries. It is transmitted sexually. It causes painful ulcers on the genitals, which can be difficult to distinguish from syphilis ulcers. Chancroid can be identified by a laboratory test. It can be cured with antibiotics.

Chlamydia Very common bacterial infection, which can lead to pelvic inflammatory disease (PID), a more serious infection. The bacteria exist in the mucous membrane of reproductive organs such as the vagina, cervix, urethra or anus. They cause inflammation leading to heavy vaginal discharge, pain when urinating or during sex, bleeding after sex, or pain in the abdomen. Men may have discharge from the penis or pain when urinating. Chlamydia can cause infection in babies during birth, leading to eye infections or blindness. Chlamydia often has no symptoms in women. It often goes undetected and untreated, increasing risk of PID. Chlamydia is detected by a blood test or a sample taken from the area that may have been infected. It can be cured with antibiotics.

Pelvic inflammatory disease (PID) Affects women only. It affects the cervix, uterus, ovaries or uterine tubes. It is caused by various bacteria or viruses, most commonly chlamydia and gonorrhoea. With correct diagnosis of the bacteria causing it, it can be cured. Symptoms include pain in the lower abdomen and back, fever and vomiting. If PID is not treated, more severe symptoms, such as bleeding between periods and unusually painful periods, may develop and may eventually lead to infertility. Diagnosis is difficult. It needs a pelvic examination, taking swabs from the cervix or inspecting the pelvic area by a laparoscopy (a surgical procedure requiring general anaesthetic). PID can be cured with antibiotics. As PID is usually caused by infections that are transmitted sexually, such as chlamydia, it is essential that women's sexual partners are also examined and any STIs treated.



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Genital herpes Caused by the herpes simplex virus which is transmitted sexually. It causes small, painful blisters on the genitals which turn into ulcers. The ulcers disappear but usually come back from time to time. Once someone has the virus there is no way of getting rid of it, although the ulcers may be absent for several months. Some people with herpes show no symptoms. The virus can be transmitted to a baby during birth, if the woman has ulcers. Treatment with acyclovir can make the ulcers heal faster. Rest, sleep and a good diet make them less likely to come back.
 

It is important that health workers such as these traditional healers learn how to recognise sexually transmitted and reproductive tract infections.


Genital warts Caused by the human papilloma virus which is usually transmitted sexually. The warts are small, fairly flat bumps which appear on their own or in clumps. Once someone has the virus, it may continue to be present in the body although warts may not appear again. In women, the virus has been linked to the development of cervical cancer. Warts are very common and are very easily passed on during sexual activity. They are 'burnt off' using special chemical compounds. Other methods such as freezing or laser treatment can also be used.

Thrush (candida)
Thrush looks like a white coating growing in moist parts of the body, such as the vagina or throat, or under the foreskin in uncircumcised men. It is one of the most common vaginal infections. A person with thrush can transmit it to their sexual partner. Most women have thrush at some time in their life. It is common in babies and in adults who are tired and stressed, diabetic, taking antibiotics or have a damaged immune system because of HIV infection. It causes itching or pain. Thrush is easily treated with anti-fungal drugs. Live yoghurt, eaten or applied to the affected areas, can prevent and treat thrush. (Live yoghurt contains bacteria which stop the thrush from growing.) Some people recommend avoiding sweet foods, white flour and starchy foods.

Bacterial vaginosis Thin, greenish vaginal discharge with an unpleasant smell, caused by bacteria. It can be passed on by sexual contact. Some women do not notice any symptoms. Men can be infected without any symptoms. Bacterial vaginosis is easily treated with antibiotics. There is some evidence that infection with vaginosis increases the risk of co-infection with other STIs.

 

HIV+
HIV-related infections 
The human immunodeficiency virus (HIV) is a sexually transmitted virus that damages the immune system. HIV itself has no symptoms, but makes people more vulnerable to a wide range of infections, including reproductive tract infections. HIV itself cannot be cured. However, infections caused by HIV can be treated, although they are often more difficult to treat in people with HIV, RTI and STI symptoms often appear differently in people with HIV.

People with HIV often get severe, recurring candida (thrush) in the mouth and genitals. Thrush can also develop in the throat. This can be serious as it can interfere with eating or breathing.

A recent trial has shown that the risk of oral and vaginal thrush can be reduced in HIV-positive women. A group of women received one 200mg dose of fluconazole a week. After two-and-a-half years the risk of oral thrush was reduced by 50 per cent and of vaginal thrush by 38 per cent and there was no resistance to the drug.

Source: Gynaecological conditions: information for women with HIV, Anna Poppa, 1995, Body Positive Opportunistic infections series



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Preventing unwanted pregnancy and infection

There are many reasons why people may not wish to conceive, such as birth spacing, woman's age or social and financial reasons. Preventing infection is equally important.

People wishing to prevent pregnancy also need to protect themselves against HIV and other sexually transmitted infections (STIs). Protection against both unwanted pregnancy and HIV/STIs is known as 'dual protection'.

Sexual activities that do not involve intercourse, such as masturbation or oral sex, protect against pregnancy and have a lower risk of infection than unprotected intercourse.

For couples who wish to have sexual intercourse, and who know that they have no infections, the most effective form of dual protection is to have sex with each other only, and to use any effective contraceptive.

For everyone who does not know whether they or their partner has an infection or is at risk of acquiring one, the only effective dual protection is a male or female condom, with another contraceptive if desired. Some women want to use a more reliable form of contraceptive as well as condoms, such as sterilisation, the IUD or hormonal methods such as the contraceptive pill.

Giving people choices
It is important that both HIV educators and family planning workers discuss protection against both pregnancy and infections. For example, women who are pregnant or sterilised are often not given information about how to prevent infections. Women who sell sex are often given condoms by AIDS programmes to protect themselves against HIV/STI infection, but are often not given information on how to prevent unwanted pregnancy effectively. People should be offered as wide a choice of methods as possible to protect themselves from both unwanted pregnancy and infection. A wide choice usually results in better and continued use, because people can choose the method that suits them best and change methods to meet their changing needs and circumstances. People wishing to prevent unwanted pregnancy and HIV/STIs need:

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information about what contraceptive methods are available, including traditional methods, how they work and possible side effects 

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information about HIV and STIs, so that they can assess their risk and decide how to protect themselves 

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information on how and why to use condoms and possibly another contraceptive method also, and support to continue using them 

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a regular supply of contraceptives, including condoms

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the opportunity to change contraceptive methods if they wish 

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counselling and medical attention if contraceptives fail or produce side effects.


Assessing risks 
Choosing a contraceptive is not straightforward. People may face pressure not to use contraceptives and often have limited choice of methods available. They need to weigh up difficulties in using contraceptives against the risk of becoming pregnant or infected with HIV/STIs.

Women Many women feel pressured to have sex for many reasons. For example, sex may be seen as a wife's duty or a way of showing love for her partner. Women may know that condoms would protect them against pregnancy and STIs, but fear violence if their partner suspects them of infidelity when they suggest using condoms. They may feel that violence from their partner is a greater risk to their health than infection.

Men need to know about contraceptive methods and understand the importance of condoms, so that they can avoid a partner's unplanned pregnancy and protect themselves and their partner from HIV/STIs. 

Some men choose to use condoms because they find that condoms delay ejaculation, which increases their own and their partner's pleasure.

Women and men need support to develop skills to put their choices into practice. This may include supporting them to resist pressure from partners to have unwanted sex, and to practise ways of negotiating saying 'no'. 

If you are giving advice to someone who may be at risk of unwanted pregnancy or HIV/STIs, the following questions may be helpful:

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What do you know of HIV and other STIs?

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What do you think are the common symptoms?

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What questions do you have about HIV/STIs? 

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What are your worries about HIV/STIs? 

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Do you think that you might be at risk of HIV/STIs? Are you in a stable relationship?  Do you have other sexual partners?  Has your partner ever had other sexual partners?

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Do you know how to prevent HIV/STI transmission?

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Have you ever had an STI before? Do you have any signs or symptoms now?

 

Activity

Choose your own contraceptive 
To find out what people already know about contraceptive methods and encourage them to think about the advantages and disadvantages of different contraceptive methods. You will need a sample or drawing of each contraceptive method (or you could write the name of each on a card or sheet of paper). Write four questions on a large sheet of paper or board:

How do you think this works?
What do you think are the benefits? 
What do you think are the risks?
Will this reduce or increase the risk of  HIV and SRI transmission?

Divide the group into small groups of three or four people. Give each small  group one of the sample contraceptives or drawings and ask them to answer the questions. Discuss and correct any misunderstandings.

After this, you could ask the group to develop a flipchart on contraceptives as a tool to communicate with the community. Each sheet can include information on one contraceptive in the form of an illustration and some text.



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Which contraceptive method? 
Each contraceptive method prevents conception in a different way, with a different effect on the user's body. All modern methods except the male condom and vasectomy (male sterilisation) are controlled by women. The following questions may help people decide which method to choose: 
 

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Which method will protect you from HIV and other STIs, if this is important? 

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Will you be able to use the contraceptive correctly every time? For example, would you remember to take the contraceptive pill every day?

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Will you need to hide the fact that you are using contraceptives? 

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Will you have the support of your partner in using contraception? 

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How often will you need contraception? 


Barrier methods - condom, diaphragm or cap - may be appropriate for people who are not having sex regularly. Condoms are appropriate for people who want to protect against infection. Methods such as the contraceptive pill or IUD may be appropriate for people who have sex regularly. Permanent methods - sterilisation - may be useful for people who are sure that they want no more children. 

Both men and women should be offered as wide a choice of contraceptive methods as possible and have the opportunity to decide what is best for them and their partners.


Abortion
Abortion (or termination) is when a pregnancy is ended on purpose before the fetus has fully grown. Women who have an unplanned pregnancy are often under a lot of pressure from other people either to have an abortion (for example, if their partner does not want a baby) or not to have an abortion (for example, if their religion does not allow it). 

Many women need counselling or support when deciding whether to have an abortion or not. Whatever the law on abortion in your area, and whatever a woman's personal beliefs, it is important to recognise that many women have abortions, whether at home or in hospital, legally or illegally. 

Abortions which are chosen by the woman and carried out properly by trained health workers in a well equipped health centre or hospital are usually safe. Abortions carried out by untrained people - even experienced traditional midwives and abortionists - or at home, can be very dangerous. Many cases of septic infections or haemorrhage, leading to infertility or even death, are the result of unsafe abortion.

Sources: Contraceptive method mix: guidelines for policy and service delivery, 1994, World Health Organization
Contraceptive update: a handbook for health workers, 1996, IPPFAR/PATH 

 

Contraceptives, HIV and drugs
Some drugs that are used for treating common infections interact with contraceptive drugs and make them less reliable. For example, rifampicin is often used to treat tuberculosis (TB). However, rifampicin increases the breakdown of oral contraceptives (the pill) in the body, reducing its effectiveness.

Women with HIV-related illnesses such as TB, and other women taking treatment for infections, need to consider the impact of these drugs on their contraceptive decisions. Health workers must know about interactions between contraceptive methods and other drugs and consider the most healthy option for the woman.



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Contraceptives

 

DESCRIPTION

PROTECTION FROM PREGNANCY PROTECTION FROM HIV/STIs AVAILABILITY ADVANTAGES DIS-
ADVANTAGES
CONDOM
 

Latex tube which is rolled onto the man's erect penis before having sex. The man ejaculates into the condom. The condom is more effective in preventing conception if used with a spermicide. Sometimes condoms are already lubricated with a spermicide. If not, they can be lubricated with a water-based lubricant. Very good, if used properly and consistently. Very good, HIV and other infections cannot pass through. Widely available in most countries from bars and shops as well clinics. Inexpensive. Rarely any side effects (a few people get irritation from latex). Only need to use when having vaginal or anal sex. Some people choose to use condoms during oral sex. Can be difficult to use without teaching. Men need to agree to use. Can break if used wrongly or beyond use by date, or if there is a lot of friction (for example during 'dry sex', or if an oil-based lubricant is used.
FEMALE CONDOM
 

A soft, thin polythene tube which covers the inside of the woman's vagina, similar to the male condom. It can be used with a spermicide. Very good, if used properly and consistently. Very good, HIV and other infections cannot pass through. Not widely available. Expansive in most places. No side effects. Only need to use when having sex. Some women can use without men knowing. Not easily available in most countries. Expensive. Can be difficult to insert.
DIAPHRAGM and CAP
 

Rubber 'cap' that fits over the woman's cervix to prevent sperm entering. Needs to be fitted initially by a health worker. A diaphragm or cap is put into the vagina before having sex and left in for at least six hours, but not more than 24 hours after sex. It is then washed for re-use. It should be used with spermicide. Very good if used properly. No protection against HIV. Some protection against some STIs such as
genital warts.
Not available in every county. Only need to use when having sex. Can be re-used For two years. Does not need access to health worker after initial fitting. Needs trained health worker to fit. Some women find it difficult to insert and take out. Needs to be refitted every two years, after pregnancy, or if the woman gains or loses weight.
SPERMICIDES
 

Chemicals designed to kill sperm in the vagina and prevent sperm from entering the cervix. They take the form of foam, vaginal film, cream, gel or pessaries. They should be used with barrier methods (condom, female condom, diaphragm or cap). Poor if used on own. No evidence yet of reducing HIV risk. Some protection against bacterial infections. Widely available. Only need to use while having sex. Does not need access to health worker. Some people are allergic.
CONTRACEPTIVE PILL (the pill)
 

Daily pill containing hormones that prevent ovulation (release of an egg from an ovary).  Excellent if taken correctly. None. Available in most areas from family planning clinics. Do not need to think about it while having sex. Can switch to another method if necessary. Need to be prescribed by a health worker. Needs to be taken daily. Needs to be taken daily. Some side effects. Many conditions in which it should not be prescribed.
HORMONAL IMPLANT (often known as Norplant)
 

Six small, thin tubes inserted under the skin in the woman's upper arm. The tubes slowly release a hormone which prevents ovulation. They must be inserted and removed by trained health workers. Effective for up to five years. Excellent. None. Widely available in some countries.  Do not need to think about it while having sex. Can be used without man knowing Long-lasting Can cause irregular periods. Some conditions in which should not be used. Must be removed by trained health workers.
INJECTABLE CONTRACEPTIVES
 

The most common injectable is DMPA (or Depo-Provera). Injection given at a clinic every three months. It prevents ovulation. Excellent. None. Widely available in some countries.  Do not think about it while having sex. Can be used without man knowing. Can cause irregular periods. Need access to health worker every three months. Cannot stop immediately if side effects. Many conditions in which it should not be used.



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DESCRIPTION

PROTECTION FROM PREGNANCY PROTECTION FROM HIV/STIS AVAILABILITY ADVANTAGES DIS-
ADVANTAGES
INTRAUTERINE DEVICE (IUD)
 

Small piece of plastic or copper that Excellent is put in the uterus (womb) by a trained health worker. It has a fine string attached to it that the woman can feel to ensure that it is still in place. The IUD prevents fertilisation.

Excellent. None. Increased risk of pelvic inflammatory disease (PID) following insertion or via string. Available in most areas from family planning clinics, but often only to women who have had children Do not need to think about it having sex. Women can check that it is in place herself. Heavier periods for some women. Needs access to health worker to insert or remove. Some conditions on which should not be used, especially history of STIs.
NATURAL FAMILY PLANNING Only having sex during the stages of  the menstrual cycle when the woman cannot get pregnant. It involves recognising these stages, including body temperature and changes on cervical mucus. Good if used properly. None. Can be used by any couple who know about woman's cycle. No side effects. Couples share responsibility for family planning. No expense. Requires commitment of both partner. Requires careful observation and record-keeping.
FERTILITY AWARENESS

Using a woman's knowledge of her menstrual cycle to decide when to use a contraceptive and when to have unprotected sex. A woman who wishes to become pregnant may have unprotected sex at the stage in her cycle when she can become pregnant, but use a barrier method (condom, female condom, diaphragm or cap) at other times to protect against HIV/STI transmission.

Good if used properly. Very good when using a barrier contraceptive. None during unprotected sex. Can be used by any couple who know about the woman's cycle. No side effects. Couples share responsibility for family planning. No expense. Requires commitment of both partner. Requires careful observation and record-keeping.
BREASTFEEDING Breastfeeding on demand can reduce the risk of pregnancy in the first six month by delaying ovulation. Most breastfeeding women start to ovulate after six month, even if they have not had a period. Good if breastfeeding exclusively on demand for the first six months.  None. Almost all women who have given birth can breastfeed if given support. Free. Not reliable after six months. Women with HIV may prefer not to breastfeed.
WITHDRAWAL This is when the man takes is penis out of the vagina before ejaculating (coming). Poor, because sperm may be releases before ejaculating. None. HIV has been found in semen releases before ejaculating. Available to all men. Useful if no other method is available. Man needs to think about it while having sex. May not be able to withdraw before ejaculating.
STERILISATION
(VASECTOMY)
This involves cutting the vas deferens in men to prevent sperm from joining semen or cutting or blocking the uterine tubes in women to prevent the egg and sperm from meeting. Excellent. None. Available from some health clinics by trained doctors. Do not need to think about it having sex. Requires operation under local anaesthetic (men) or general anaesthetic (women). Not easily reversible. Small chance of infection after operation.
EMERGENCY CONTRACEPTION
 

Can be used after unprotected sex if  the woman may have become pregnant. It takes the form of pills or an IUD. Pills should be taken within 72 hours of unprotected sex. The IUD can be inserted up to five days after unprotected sex.

Excellent if taken within time limits.

None.

Not widely available. Important option after safe sex 'accidents'.

Either method must be given by a trained health worker. May not be acceptable to some people who regard emergency contraception as abortion. 



AIDS action  Issue 36-37    15  Page 16  17  top of page

  

Condoms

Unless both sexual partners are sure that they have no infections, they should use condoms to protect themselves from unwanted pregnancy and HIV/STIs if they are having sexual intercourse. 

Condoms are widely available in most countries and easy to use with a little practice. However, people can find them difficult to use for the first time, or they may feel embarrassed about using them.


Lubrication
Lubrication helps to prevent condoms from breaking. Female condoms and some male condoms are lubricated already. If lubrication is needed, spermicides or water based lubricants such as glycerine should be used. Oil-based lubricants such vaseline or butter should never be used on the male condom, because they will cause damage.

How to use a male condom
A new condom should be used each time a couple has vaginal or anal sex. The condom should be put onto the erect penis before the penis comes into contact with the partner's genital or anal area.

 

How to use a male condom


1
Check the expiry date on the condom packet. Take the condom carefully out of the packet.


2
Place the condom on the tip of the penis when it is hard and erect, but before it touches the partner's genitals. Make sure that the rolled-up condom rim faces outwards.

How to use a male condom

3 With the other hand, pinch the tip of the condom to remove any trapped air, and unroll the condom to cover the penis.

4 After intercourse, withdraw the penis carefully, but before it becomes soft. Hold the rim of the condom against the penis, so that semen does not spill out.

How to use a male condom

5 Slide the condom gently off the penis, and knot the open end.

6 After using the condom, throw it away safely.


If the condom is put on incorrectly, it should be discarded because semen may have leaked onto it
If the condom breaks during sex, it should be taken off immediately, and a new one put on.

 

Activity
Handling a condom


For groups to learn how to use a condom. 

If you are working with a mixed group of men and women, and people feel embarrassed about practising using condoms, ask them to divide into same-sex pairs.

Give a condom to each person and ask them to check that it is not past its expiry date. Ask everyone to take the condom out of the packet. Encourage them to stretch and play with the condom. Give everyone a few minutes to talk to their partner about what they feel about handling a condom. 


After feeding back people's comments to the whole group, demonstrate how to put on a condom, for example, on a model penis, carrot or banana. Ask people to try doing the same thing themselves.

Encourage discussion about what was difficult and what might help them use condoms with a partner.

The right way
Write down each stage in putting on a condom, using a separate piece of card for each stage. 

Give cards to different people in the group. Ask them to place their cards in the right order on a large piece of paper, or stand in a line in the right order, holding up their cards. Ask the group to discuss the right order. 



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The female condom is relatively new and not widely available. It costs much more than the male condom. However, many women who have had a chance to use the female condom, and have learnt how to use it properly, like it. For example, in Côte d'Ivoire, sex workers said that they preferred the female condom to the male condom for use with their clients. They encouraged each other to use it and demonstrated how to insert it with close friends. They also persuaded their boyfriends or husbands that the female condom was good to use. 

The female condom can be put in any time from several hours before having sex to immediately before the penis comes into contact with the vagina. It can also be used during anal sex. 

The manufacturers recommend that a new female condom should be used each time a couple has sex. However, some women report that they have successfully re-used the female condom after washing and re-lubricating it. The female condom is made of polythene, a more durable material than latex used for the male condom. 


How to use a female condom
 

How to use a female condom


1
Open the packet carefully.

2 Hold the small ring (at the closed end of the condom) between the thumb and middle finger. (Some women prefer to take out the small ring before insertion to make the condom more comfortable. )

How to use a female condom

3 Find a comfortable position, either lying down, sitting with your knees apart or standing with one foot raised on a stool. Squeeze the small ring and put it into the vagina, pushing it inside as far as possible with the fingers.


4
Put a finger inside the condom and push the small ring inside as far as possible. (It is also possible to insert the condom by putting it onto the erect penis before intercourse.) 

How to use a female condom

5 Make sure that part of the condom with the outer ring is outside the body. The outer ring will lie flat against the body when the penis is inside the condom. 

When the penis enters the vagina, make sure that the penis is inside the condom.




6
Immediately after sex, take out the condom by gently twisting the outer ring and pulling the condom out, making sure that no semen is spilt.



7 After using the condom, throw it away safely.

 

Case study

'Socks for sex'
 

Nmba and zouk music to give instructions on how to use condoms

Young people in Côte d'lvoire were asked how they could be persuaded to use condoms.

They said that information about condoms should be attractive and not only associated with HIV/AIDS. Young people should be taught about other HIV prevention methods, such as temporary abstinence and being faithful to their partner. Condoms should not be promoted as a life-long choice - their use would vary depending on circumstances.


The young people helped to develop educational materials that responded to their concerns. These included a cassette using rap, Nmba and zouk music to give instructions on how to use condoms (which they called 'socks'). 

The cassette also answered some common fears, such as the fear that using condoms for a long time made people infertile

Source: ORSTOM, Departement Sante, 213 rue La Fayette, 75480 Paris. France.



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Putting it into practice

AIDS Action looks at some projects that have responded to the need for a broad range of sexual and reproductive health information. 


Case study
 
Straight Talk 
'Delay sex as long as possible' is the main message of Straight Talk, a Unicef-funded sexual health communication project for secondary school students in Uganda. 

Straight Talk is a 100,000 circulation monthly newspaper distributed through the national daily, The New Vision, and direct to schools, colleges, youth clubs and NGOs. This message was chosen because a WHO study showed that it was more realistic than telling young people not to have sex at all. 

Straight Talk recognises that sex education is not enough, and that pressure from family and friends is equally important. It provides facts and information, discusses feelings and values, and advises on skills and behaviour. Advice from young people to each other, in the form of readers replying to each other's problems, has proved very popular.

Topics are selected from readers' letters, of which almost 3,000 a year are received. The most popular topics relate to boy-girl relationships - such as 'How do I know if he loves me?' - problems with parents, questions about the body - such as menstruation for girls, and erections and wet dreams for boys - and requests for practical advice. HIV and STIs are covered in each issue because of their importance.

'Delay sex as long as possible' is the main message of Straight Talk, a Unicef-funded sexual health communication project for secondary school students in Uganda.


The project has highlighted some important challenges. For example, most young readers have sex to win approval from each other, rather than for pleasure. Girls have great difficulty with assertiveness, often agreeing to unprotected sex that they don't want.

The Straight Talk team also carry out school visits in response to requests from head teachers, and because some students do not understand the newspaper easily. The team answer questions raised by students, get the students to act role plays, and provide private counselling. Local-language editions of Straight Talk and a Straight Talk radio programme have also been started. 

Because not all children attend secondary school, the next stage is to launch a Straight Talk project for 10-14 year-old primary school children. Children's right to protect themselves against sexual abuse will be a major theme.


Case study

The Rural Women's Social Education Centre (RUWSEC) is a grassroots women's organisation in rural southern India, addressing issues related to women's wellbeing through women's empowerment. In 1990, RUWSEC started working with men.

Over the years, RUWSEC has initiated 'life skills' education programmes incorporating sexual health issues for rural out-of-school adolescents, middle-school students and factory-employed young women. We found that men were feeling threatened by the focus on women. They were often violent with their partners. Even female project workers faced problems with their husbands.

We were aware that men faced pressures from peers and the community to 'control' women - forbidding them to spend money or go out without permission, for example. We started by talking to the husbands of project workers. A meeting was held for husbands only, followed by a mixed meeting. Meetings are now held once a year for workers and their husbands. These have led to two male volunteers setting up a men's programme. working with their wives who work with women. 

The programme starts with sessions on husband-wife relationships; how the body works: differences between men and women: inequalities and relationships. The sessions do not start by talking about sex - this is brought up automatically. We use quizzes about issues such as abortion, maternal mortality and contraception. We teach about sexually transmitted infections and provide low-cost treatment. We also distribute condoms. 

The men raise many concerns, such as masturbation, penis size and impotence. We use peer education to deal with men's concerns. We get men to write anonymous letter to an imaginary 'agony aunt'. The letters are discussed. Sometimes they are used in the local newspaper to start discussions on difficult issues such as incest, rape and domestic violence. We run classes on reproductive and sexual health for young men at school. Peer educators do house-to-house visits to talk about reproductive and sexual health. One sign of success for the project is that many men say after the training, 'I talk better with my wife.'

TK Sundari Ravhdran, RUWSEC. 12 Pena Melamaiyur Road, Vallam Post, Chengalpattu, Tamil Nadu, India



AIDS action  Issue 36-37    18  Page 19  20  top of page

  

 

Case study

Patricia’s plan
The following story describes typical family planning sessions before and after HIV/STI prevention was integrated into the programmes of three family planning associations affiliated with the International Planned Parenthood Federation in North and South America. 

Patricia, a street vendor, arrives at the family planning clinic. A counsellor warmly greets her and leads her to a private area. The counsellor asks Patricia a series of questions and listens attentively. Patricia says that she has never used family planning. hut hears from a friend that the pill is a good method. 

Year: 1993 The counsellor describes different family planning methods - how to insert a diaphragm, what to do if you miss a pill, how to use a condom. She explains that condoms should be used when you start taking the pill, until it becomes effective, and that they are useful if you forget to take a pill. The counsellor shows Patricia different pills and discusses the price. Patricia leaves with a three-month supply of pills. 

Year: 1996 The counsellor finds out about Patricia‘s situation. They discuss her family, partner and previous partners. They discuss the fact that her husband travels for work. The counsellor asks Patricia if he might have other partners. Patricia says that he probably does. She and the counsellor agree that this could be putting her at risk of HIV or another STI. The counsellor explains which sexual activities are safe and which are risky. 

The counsellor explains that condoms can be highly effective against pregnancy, HIV and STIs. She demonstrates, on a penis model, how to use a condom. She mentions some ways to make condoms more appealing to Patricia’s partner. The counsellor asks whether Patricia and her husband have ever discussed their sexual life. She and the counsellor discuss strategies for bringing up the subject in a non-threatening way. The counsellor briefly reviews the different family planning methods. Patricia leaves the clinic with a three-month supply of pills and a free sample of condoms to try. 

Source: Quality/Calidad/Qualite, Population Council. Contact HIV/STI Prevention Program, IPPF. Western Hemisphere Region, 120 Wall Street, 9th Floor. New York. NY 1005, USA.
 

Family planning workers in Jamaica learn how to discuss HIV/STI prevention as well as contraception.


Case study

Changing behaviour
SISEX is a Mexican NGO that supports community organisations to carry out sexual health education aimed at changing behaviour.

Sexual health education meets people's needs for education across a range of topics including sexual and reproductive health, HIV/STI prevention, violence prevention, and gender issues. It is not just about teaching - it is also about creating the right atmosphere for learning, and developing people's skills. Supporting people's willingness and ability to change is even more important than providing biological information. Sexual health educators need to encourage people to understand their sexual health and want to improve it. We have found that the best way to create openness in a group is for the educator to form part of the group, sharing their problems and experience as well as their knowledge.

Sexual health educators must be willing to examine their own sexuality, in order to develop the sensitivity and respect needed to help other people explore their sexuality and change their behaviour.

We organise training workshops for educators, in which educators do the same exercises as the groups that they will be facilitating. This means that the workshops develop from their own experience. 

Before starting any educational  activities, we find out about people's specific concerns. using questionnaires and interviews, to ensure that we respond to their needs and do not simply follow our personal agenda. We start with exercises on issues such as self-esteem, communication, power, decision-making, conflict management and basic emotional needs. These help people to develop assertiveness as part of the longer process towards changing their behaviour. We use body exercises, such as breathing calmly and deeply, to help to reduce tension and create energy. Group members, including facilitators, describe their own experience,  beliefs and knowledge. The groups work in an atmosphere of respect in which they can feel comfortable about reviewing their sexuality.

Patricia Nava, Coordmator, SISEX. Priv. Valencia. Col. San Andres Tetepilco. CP 09440, Mexico.



AIDS action  Issue 36-37    19  Page 20      top of page

  

Resources

NEW! Family planning handbook for health professionals covers family planning, infertility, unwanted pregnancy, sexually transmitted diseases and contraception for young people. 
Free to those experiencing currency restrictions, £14/US$24 to others from Distribution Unit, IPPF, Regent's College, Inner Circle, Regent's Park, London NW1 4NS, UK.

An introduction to sexual health is for trainers in sexual health. Contains a frame-work and activities for planning, implementing and evaluating sexual health courses. 
Available in English, French and Spanish for Sw.fr.20 from International Federation of Red Cross and Red Crescent Societies, PO Box 372, CH-1211 19, Geneva, Switzerland.

Learning about sexuality describes programmes that have integrated sexuality and gender issues into family and reproductive health programmes. 
Free to developing countries from Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA.

List of free materials in reproductive health lists free materials on family planning, mother and child health and reproductive and sexual health. 
Available in English, French and Spanish, free to developing countries, US$10 (English) or US$9 (French/Spanish) from INTRAH Publications, University of North Carolina, School of Medicine, 208 N Columbia Street, CB 8100, Chapel Hill, NC 27514, USA.

Medical and service delivery guidelines for family planning covers contraception and counselling, reproductive tract infections, emergency contraception and pregnancy diagnosis. 
Free to those experiencing currency restrictions or £12/US$20 to others from Distribution Unit, IPPF (address above). French and Spanish editions due early 1998.

Sexual healing
is a guide for women with HIV about sexual and reproductive health, and healthy sexuality. 
Available for £0.50 from Terrence Higgins Trust, 52-54 Grays Inn Road, London WC1X 8JU, UK.

The South African Women's Health Book discusses growing up and growing older, reproductive health problems and becoming a parent. Women's Health Workshop Package contains a workshop guide and learning materials on knowing your body, AIDS and cervical cancer.
Rand 80.95 (book) and Rand 30 (workshop package) plus postage from Women's Health Project, PO Box 1038, Johannesburg 2000, South Africa.

Talking together is a handbook containing diagrams and activities to help parents talk with children aged 10-19 years about sexuality and family life. 
Available from Family Life Association of Swaziland, PO Box 1051, Manzini, Swaziland. (Contact FLAS for price.)

Where women have no doctor is a health book for women and girls, including information on sexual and reproductive health.
Available in English from TALC, PO Box 49, St Albans, Herts AL2 5TX, UK. For other languages contact Hesperian Foundation, 2796 Middlefield Road, Palo Alto 94305 CA, USA.

The universal childbirth picture book! flip-chart has drawings of the male and female sex organs, conception, pregnancy and birth.
Available in English, Arabic, French, Spanish and Somali for US$7 (book) and US$25 (flipchart) plus postage from Women's International Network (WIN), 187 Grant St, Lexington, MA 02173, USA Contact WIN for information on other language editions.


Videos

Silent epidemic
provides information on symptoms and transmission of STDs and suggests practical solutions for young people to reduce transmission risk.
£23 from Ace Communications, PO Box 15182, Nairobi, Kenya.


Newsletters

Network
is a quarterly newsletter on family planning. It contains research and project reports and lists publications. 
Free in English, French and Spanish from Family Health International, PO Box 13950, Research Triangle Park, NC 27709, USA.

Passages is a quarterly newsletter on sexual and reproductive health programmes for young people around the world. 
Free to organisations from developing countries or US$15 to orders from Advocates for Youth, 1025 Vermont Avenue NW Suite 200, Washington DC 20005, USA.

Planned Parenthood Challenges is a six-monthly newsletter on reproductive and sexual health programmes. Each issue covers a different theme with case studies, project reports and resources.
Free to those working in family planning and associated activities from Distribution Unit, IPPF (address above).

Reproductive Health Matters is a twice-yearly journal on reproductive health issues. It includes papers, current research and a listing of new publications. 
Available from Reproductive Health Matters, Farringdon Point, 29-35 Farringdon Road, London EC1M 3JB, UK (Contact RHM for price.) 

Child Health Dialogue 8 on safe mother-hood is due out in early 1998 from AHRTAG.

Making sex work safe is a hand-book for sex work projects.

NEW! Making sex work safe is a hand-book for sex work projects. It covers issues such as developing strategies, what is safe commercial sex, and working with mobile populations and drug users.
It is published by the NetWork of Sex Work Projects and AHRTAG.  Single copies free to developing countries, £12/US$24 elsewhere, from AHRTAG.

 

Managing editor Nel Druce
Commissioning editor
Sian Long
Executive editor
Celia Till
Design and production Ingrid Emsden
Editorial advisory group Kathy Attawell, Maggie Basngster, Marge Berer, Meena Cabrol, Jane Galvao, Patricia Nava, Dr Kevin O'Reilly, Dr Arletty Pinel, T K Sundari Ravindran, Dr Sununda Ray, Dr Geeta Sodhi, Anete Strom, Dr Michael Tan, Margaret Usher
 
Aids Action Publishing partners HAIN (the Philippines) SANASO Secretariat (Zimbabwe) ENDA (Senegal) ABIA (Brazil) Colectivo Sol (Mexico) Consultants based at University Eduardo Mondlane (Mozambique)
 
This Issue is funded by DANIDA, DflD, Kvinnefronten/NORAD
 
AHRTAG's AIDS programme is supported by CAFOD, Charity Projects, Christian Aid, DfkF/JFS, Finnish Government, HIVOS, ICCO, Memisa Medicus Mundi, Misereor, Norwegian Red Cross, Oxfam, Save the Children Fund, SIDA.

 

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AIDS Action
The International Newsletter on AIDS Prevention and Care


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