AIDS action Issue 45 Page 1 2
Issue 45 July - September 1999
Talking about safer sex
Laverne knew when she had got HIV. 'Did you know about HIV?' she was asked. 'Yes,' she said. 'Did you know about condoms? ' 'Yes,' she said. 'I asked him to use them and he said he would. It was only after that I realised he had not.'
Giving people information about HIV and the risks of unsafe sex is important. But even when we know the risks of unsafe sex and want to practise safer sex, it can often be difficult. Some barriers that stop people practising safer sex come from the wider environment. For example, social and economic inequalities between sexual partners can make it difficult for people to be in control of how they have sex. These social and economic inequalities also lead to lack of access to sexual health information and services, including condoms.
Negative cultural or religious ideas about sex and sexuality, and laws that stop some people from getting the information and services they need, can make safer sex difficult. Attitudes about gender also affect people's ability to be in control of sex. AIDS Action 29 gave an overview of some of these wider barriers and examples of projects that have helped overcome them.
This issue of AIDS Action looks at some practical approaches and activities that can help people practise safer sex. These include building people's knowledge and skills, so that they feel more confident to discuss safer sex, and addressing local and community barriers that make it difficult for people to have safer sex.
Most people are sexually active, including many old people and adolescents, people with physical and mental disabilities and people with HIV. Different groups might have different sexual health needs and need quite different approaches. For example, people who are attracted to people of the same sex, couples where one partner has HIV, people who are sterilised and people who want to get pregnant.
Since many people are interested in new HIV prevention technologies that women can use, pages 6 and 7 give an update on the female condom and microbicides.
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In this Issue
Steps to safer sex
Having safer sex
Safer sex is not easy for anyone, but it can be made easier by taking the time to think about it, alone or with other people.
HIV and other serious infections can be transmitted sexually. If someone with HIV has sex, the virus can pass from their blood, semen or vaginal fluids into the other person's blood stream through the mucous membranes lining the inside of the vagina, penis, rectum or mouth. This is why some HIV prevention messages include 'abstain from sex' or 'delay the start of sexual relations'. As most people find it very difficult not to have sex at all, another crucial HIV prevention message is 'practise safer sex'.
Agreeing to have safer sex – an example
Maria wants Juan to use a condom when they have sex. He refuses. Maria may try different ways to get Juan to use a condom. She may beg him or confront him, even threaten him. Or she may offer him something he wants if he agrees to use a condom. She may, for instance, agree to have sex with the light on, give him a massage, or practise oral sex. Perhaps she has not done these things before but she will agree to do them if he also agrees to use a condom. If they reach an agreement, they are agreeing to have (negotiating) safer sex.
From: Women, vulnerability and HIV/AIDS produced by the Latin American and Caribbean Women's Health Network.
Safer sex means:
non-penetrative sexual activity, such as masturbation, thigh sex (where the penis does not enter the vagina or rectum), stroking, massage or kissing
using a barrier, such as a male or female condom, during vaginal or anal sex to stop HIV entering the blood. This is known as protected sex.
only having unprotected sex when both partners know that they have no sexually transmitted infections (STIs) (and are not at risk of infection through infected blood, from injecting drug use or unsafe blood transfusion). Even when we do practise safer sex it can be very difficult to practise it for every single sexual act. It is still important to try. It can help if we:
Know more about our bodies Our sexuality and sexual behaviour is influenced by how much we know about how our bodies work and what we feel about our bodies. Exploring sex and sexuality in safe discussion groups can give people more information about their bodies and their sexual and reproductive health (see page 5). It can also help people explore the joys of non-penetrative sex.
Listen to our emotions Our emotions affect our sexual behaviour. In Puerto Rico, the group 'Our Voices against HIV/AIDS' works with young heterosexual women to address emotions that are barriers to safer sex, such as fear and anxiety, and emotions that make it easier to negotiate safer sex, such as trust and confidence.
Look honestly at our sexual behaviour Outside influences, such as family, community, culture, religion and friends, give us strong messages about how we should behave sexually. What we find ourselves doing sexually is often different from what we think we should do. This can make it difficult for people to be honest with themselves and other people about their real sexual behaviour, such as sex outside marriage. When people deny their risky sexual behaviour, they are less likely to protect themselves and their sexual partners from STIs. Exercises that help people see how they might be vulnerable to getting HIV/STIs or might be a risk to others can help (for example, the 'Wildfire' exercise in AIDS Action 27).
Steps to safer sex
Having safer sex
Each time we have sex it is different. The context in which we have sex can make it harder or easier to make sure it is safer sex. For example, do I have privacy? Is my partner violent? How well do I know my partner? Do I trust him or her? Am I financially or emotionally dependent on him or her? Do I have access to condoms and STI treatment? Is it acceptable for me to use condoms? Can women talk about sex in this community? Even when a person knows and trusts their sexual partner, it can still be difficult to agree to have safer sex. It is important to pick a safe time.
Sex after HIV
'The relationship I have now with Richard, who is also living with HIV, has shown me sex is not the most important component in love. Understanding, support, caring and the desire to live meaningful and respectful lives are even more important.'
Activities that can help include:
Practising skills in private or in safe groups In Senegal, members of two traditional women's associations were trained to recognise STIs and use condoms. Later, one woman said 'My husband returned from a trip and during the erotic play I had learned from the other women, I looked at his penis. I saw a small pimple on it. I did not say anything to him and I continued to excite him until he came without penetrating me. After that I led him into a discussion of his extramarital affairs, STIs, the need for him to seek care, and told him that in the meantime he needed to use a condom.'
Sex after HIV
Improving communication skills and assertiveness can help us feel more comfortable talking to our partner about sex, and what safer sex practices we would enjoy. This can mean practising using clear statements of feelings, such as 'I do not like it when you want me to…' or using role play to practise saying no. One way to start talking about safer sex might be to suggest five safe sex activities you would like to do and five you would not like to do, ask your partner to do the same and then share these with each other.
Increasing self-esteem and confidence can help us to negotiate safer sex. In Chile, many women do not see themselves as independent sexual beings and they see their male partners as responsible for their own sexual behaviour. The Chilean AIDS Prevention Council runs safer sex workshops for university women, which encourage the women to see that they are in control of their sexual behaviour. The workshops also provide practical tools to help the women discuss and practise safer sex.
Addressing social barriers
Group work can highlight social barriers that make it difficult for people to discuss safer sex, such as sexual violence (see box). It can also be used to address these issues:
Improving access to STI treatment and condoms In South Asia, Naz Foundation is developing projects for kothis (one group of men who have sex with men) in order to reach them and other men who have sex with men. The projects provide sexual health information and social services, improve access to condoms and lubricants, ensure safe spaces for men who have sex with men to socialise, as well as increase access to sympathetic STI treatment.
Improving opportunities for income generation for people who have little access to money and who have to have sex in return for goods or services when they do not want to.
Addressing religious barriers Some Christian organisations that have not wanted to promote condoms for religious reasons are starting to acknowledge the reality of people's sexual behaviour. As one organisation in Zimbabwe puts it, 'The Ten Commandments are God's plan A. But we need to have a plan B too!'
With thanks to Cheikh I Niang, Cheikh Anta Diop University, Senegal; Tim Frasca, Chilean AIDS Prevention Council, Chile; Latin American Carribean Women's Health Network, Chile; Linnea Renton, ActionAid, UK; Rachel Jewkes, Medical Research Council, South Africa and Shivananda Khan, NAZ Foundation, UK.
Sexual violence or fear of violence stops many people, especially women, practising safer sex. Research in South Africa has shown that adolescent sexual relationships are often violent. In one study over half the teenage girls had been hit, beaten with objects or stabbed to force them to have sex. Men and boys use violence, including rape, to force girls to have sex with them, to make girls go out with them, and to stop their girlfriends ending the relationship or going out with other people. The participatory training programme Stepping Stones is being used to help young people and their communities to raise issues, such as gender relations and gender violence, by encouraging men and women and boys and girls to talk together about violence (see Resources, page 8).
Let's talk about sex!
Projects designed to help young people avoid HIV need to take into account their knowledge, attitudes and beliefs. They should also be fun!
In Zambia, the Kara Counselling and Training Trust, Choma District, recently ran a project on how to prevent HIV infections among young people. We ran AIDS clubs with sporting and other recreational activities.
Members were encouraged to talk about sex and HIV. Their views were not all the same as our own or each others, but over time they became more comfortable talking about the issues. We discussed facts about HIV and group members gradually decided upon a prevention strategy that they felt was appropriate for them. It included HIV testing, counselling and staying faithful to one partner. Over time many participants also began to support condom use.
The group wrote drama sketches, poetry and rap music to spread its prevention messages and attract new members. The group created a play about young girls going out with sugar daddies (wealthy older men). Despite the serious message, the play was fun and one young man wrote a rap song for the ending. We took the play to schools and other venues to reach as large an audience as possible. Performing the play helped the group to explore the different roles that people take in sexual encounters and to practise different ways of agreeing to have safer sex or refusing sex. This helped them to build their self-esteem and confidence.
Youth AIDS groups should regularly look at their views on HIV issues and look at how their clubs are doing. Strategy meetings can be part of the fun.
Here are a few points to remember:
Make the whole thing fun!
Encourage everybody to have a say.
Have the relevant facts at hand.
Use music, props or costumes to make activities more interesting.
Reward good work to motivate people to participate fully.
Have a 'plan B' if one activity fails.
Make sure that audiences understand the topic of the group's plays or music.
Forget the views of the quieter members, especially girls.
Forget that the young people are volunteers.
Use too many rewards or people may forget the real purpose of the group.
Expect too much from the group.
Let groups get too big (more than 15-20). Make new groups instead.
Tom Scalway, PO Box 630461, Choma, Zambia.
In Uganda, Straight Talk, a popular monthly newspaper for young people aims to raise the average age of first sexual intercourse, reduce HIV and other sexually transmitted infections (STIs) in sexually active youth and reduce teenage pregnancies. AIDS Action asked Straight Talk's technical adviser Catharine Watson about the newspaper.
Q Why did you opt for the 'delay sex' message?
A We were influenced by a 1994 World Health Organization study of 35 sex education programmes. It showed that 'no sex' or 'abstinence based' sexuality programmes have little impact. The programmes which succeeded in raising the age at first sex were the ones which told young people to 'delay sex'.
Q You want to reduce HIV infection but you don't write very much about AIDS. Why?
A First, AIDS is frightening. And fear-based messages don't work. Second, when we started, kids said 'We've had AIDS dramas, lectures, seminars, poems, songs, quizzes. Please no more! ' In fact, all that AIDS education was great. It is why AIDS awareness is so high in Uganda. But we wanted to take a further step and look at sexuality, which had been neglected, and the skills to put knowledge into practice.
Q What about the material in Straight Talk?
A Sexuality education has to address three areas: facts and information, feelings and values, and skills and behaviour. We include information on a range of sensitive topics such as masturbation, vaginal fluids and wet dreams. We want adolescents to be safe.
With thanks to Catherine Watson, Straight Talk Foundation Limited, PO Box 22366, Kampala, Uganda.
Communities working together
Talking in small groups can help people develop the skills and confidence to discuss safer sex.
Cambodia has a rapidly growing HIV epidemic. Part of the Khmer HIV/AIDS NGO Alliance (Khana) programme is to work with local NGOs and community groups to look at the barriers to HIV prevention and how to overcome these. A local NGO, the Association for Farmers Development (AFD), works near the border with Vietnam. Some of its main concerns are:
women are not supposed to know about sex, so they are not involved in decisions that affect their sexual health
it is acceptable for single and married men to have many sexual partners
in many areas, abortion is the main form of contraception
where people know about condoms, they associate them with commercial sex
people do not know very much about sexually transmitted infections (STIs) and others do not believe that HIV and AIDS exist.
AFD works with small groups of young married women. Members are invited to join during house visits and by informal invitations. AFD arranges the first meeting. After this, groups decide when and where they want to meet, making sure that they have some privacy. AFD makes a special effort to include women who are poor or marginalised, such as informal sex workers. When these women are not comfortable working in groups, staff work with them individually.
The women talk together to under-stand how their bodies work, communicate comfortably about sex, learn about STIs including HIV and help each other find ways to negotiate condom use with their partners. Body mapping (where people draw pictures of how they think the body works) is used to discuss sexual health and sexuality. Role plays are used to practise communication and negotiation skills. Resource mapping (where people draw maps of their community) are used to see where STIs can be treated and condoms distributed, where influential people live and work, and so on.
AFD found it was important to give plenty of time for activities so the women could build their confidence.
The HIV wheel (see activity box) is used to explore barriers to HIV/STI prevention. If the women feel comfortable, they also discuss more sensitive issues, such as masturbation. Because women are often too embarrassed or do not have the money to seek treatment, AFD nurses treat them syndromically. They also provide practical support, such as care during childbirth.
AFD also works directly with men to encourage them to have safer sex and seek treatment for STIs. Involving men has made it easier for men and women to negotiate condom use. After the first year, AFD found that many more married couples reported using condoms. The incidence of domestic violence in the villages has decreased and there are also fewer abortions.
Kov Pisey, AFD and Tilley Sellers, adviser to Khana, c/o Khana, P O Box 2311, Phnom Penh 3, Cambodia. E-mail: [email protected]
Exploring barriers to HIV/STI prevention
AIM To identify barriers to safer sex and identify practical solutions
PARTICIPANTS A few people with similar concerns e.g. married women
One member of the group draws a circle on the floor and divides it into segments. The group labels each segment by writing or drawing one thing that they feel would help protect them from HIV/STIs, such as:
being able to discuss sex with their partners
using condoms for birth spacing and not just disease prevention.
After discussing each option, the group shades it. The more shading, the easier the group feels it is for them to achieve.
The group then explores why some options are more difficult to achieve, such as:
women's reluctance to go to hospital for STI treatment
sex workers' difficulty in persuading clients and partners to use condoms.
Then the group explores possible solutions, such as:
offering childcare so women can attend hospital for treatment
promoting condom use to soldiers and policemen.
The group then draws up an action plan. AFD helps each group carry out its action plan, find resources and, where necessary, get help to influence other sections of the community.
The female condom
In some countries the female condom is becoming more available. It offers a new choice for people who want protected sex.
The rate of HIV infection in women is increasing. The female condom is a method that women can use that protects against both sexually transmitted infections (STIs) and unwanted pregnancies.
What is the female condom?
The female condom is like a large male condom. It is a thin plastic sheath with a small (inner) ring at one end and a large (outer) ring at the other end. It can be used with water-based or oil-based lubricants.
The inner ring is pushed high up into the vagina where it fits over the cervix (the firm, rounded bump at the top of the vagina, which connects it to the uterus). Some people find the inner ring uncomfortable and it can be removed. The outer ring fits over the lips of the vagina. The sheath lines the walls of the vagina.
During sexual intercourse the man puts his penis through the outer ring of the condom and into the vagina. The female condom can be used for anal sex. It can be inserted into the anus (rectum or back passage) or put on the penis first.
Female condoms in Zimbabwe
HIV has hit Zimbabwe hard, especially Zimbabwean women. Six times more women than men are infected. Women's groups in Zimbabwe led a demand for the female condom because they knew many women found it difficult to ask their partners to use condoms.
As a result the Women and AIDS Support Network (WASN) ran an acceptability study on female condoms. Rural and urban women, including sex workers, were given male and female condoms and trained in how to use them. Workshops in communication and technical skills also showed them how to introduce the female condom to a partner. This showed that many women preferred the female condom to the male condom because:
they did not feel able to negotiate male condom use with their partners and the female condom offered a measure of control they had not experienced before
they felt better protected with female condoms because of the condom's strength and resistance to breaking.
Men liked the female condom because:
it could be inserted before sex, with no interruption of intimacy
they did not have to have a full erection before intercourse
the device did not constrict the base of the penis, like male condoms
they did not have to withdraw from the vagina immediately after ejaculation.
Promoting the female condom
Zimbabwe's National AIDS Coordinating Programme (NACP) and the Zimbabwe National Family Planning Council (ZNFPC) invited Population Services International (PSI) to launch a social marketing programme to promote the female condom. The male condom is associated in Zimbabwe with promiscuity so the female condom was named the 'Care contraceptive sheath'. Donor subsidies made it possible to reduce the price, and the female condom was also distributed free through government family planning clinics. Health professionals and distributors were trained in how to use and promote it.
A Consumer Use Profile Study conducted in 1998 showed that 18 per cent of women who were using the product had not used the male condom in the past. They had been having unprotected sex. The female condom was most popular with single urban women aged 24– 29 and married urban men aged 27– 34. Unlike the male condom, which is mostly used in casual relationships, female condom users were mainly in regular relationships. Women were more likely to initiate use of the sheath and buy it. However, a large number of women have problems with using female condoms and need training on how to use it and follow-up counselling.
In two years, about 350,000 'Care contraceptive sheaths' have been sold making this social marketing programme one of the most successful interventions to increase female condom use.
Social marketing is now targeting women in banks, insurance companies and colleges. As well as promotion, targeted education and awareness campaigns will concentrate on individual education, training and feedback to encourage users to use the sheath every time they have sex and to help them use it comfortably.
Sanjay Chaganti, PSI Zimbabwe, PO Box 3355, Harare, Zimbabwe.
E-mail: [email protected]
Researchers are trying to find new, safe products that can be used by men and women to prevent HIV transmission.
What is a microbicide?
A microbicide is a chemical substance that can be used in the vagina or rectum to reduce transmission of sexually transmitted infections (STIs), including HIV. Microbicides could be produced in many forms, including gels, creams, suppositories and films, or in the form of a sponge or a vaginal ring that slowly releases the active ingredient over time.
Are such products available?
Not yet. Scientists are currently testing existing spermicides and other substances to see whether they help prevent the spread of HIV and other STIs. Researchers are working on 30 possible microbicides, including at least 15 that have worked in animals and are now being tested in people. Researchers hope that one will be available within five years.
How would microbicides work?
Scientists are looking at substances that:
kill the pathogen (bacteria or virus that causes the STI) or stop it from working
block infection by creating a barrier between the pathogen and the vagina or rectum so that it cannot enter the body
prevent infection from taking hold after the pathogen has entered the body.
Since STIs are caused by different pathogens (some viral, some bacterial) a microbicide that works against one STI pathogen would not necessarily protect against another. But scientists are trying to develop a product that would be effective against a wide range of pathogens, including HIV.
How could microbicides be used?
When used consistently and correctly, condoms are likely to provide better protection against HIV and STIs than microbicides, so they will still be the preferred option.
People could use microbicides:
on their own if they are unable to use condoms
as a mouth rinse, to offer protection during oral sex
as a vaginal wash to reduce mother-to-child HIV transmission during delivery.
Microbicides will be especially useful:
to protect women from STIs while trying to get pregnant
to reduce the risk of infection after forced sex or condom failure.
Microbicides could be good news for men as well as women, because if a woman used a vaginal microbicide it would probably also prevent transmission of HIV and other STIs to her male sexual partner.
It might also be possible to use microbicides in the rectum to prevent transmission during anal sex. However, the safety and effective-ness of microbicides for rectal use will need more research. Rectal safety studies of some potential microbicides are just beginning.
What if a woman wants to get pregnant?
Some of the microbicides currently being investigated prevent pregnancy (by killing sperm with spermicide) while others do not. It will be important to develop a microbicide that does not kill sperm in addition to one that does, so that women and couples can protect themselves against HIV yet still get pregnant. This is not possible with condoms.
Adapted with permission from Action Kit: Global Campaign for STI/HIV prevention alternatives for women. Available free from: CHANGE, 6930 Carroll Ave, Suite 910, Takoma Park, MD 20912, USA.
E-mail: [email protected]
News / Letter / Resources
1999: Year of the elderly
Many older people are still sexually active and at risk of HIV. The United Nations Year of the Elderly has highlighted the need to provide safer sex initiatives to older people. Issues that affect older people include problems using male condoms as many older men have difficulty maintaining an erection.
'My belief is that to bring about real behaviour change we need to help men and women redefine (or actually define for the first time) what it means to be a sexual being. We need to substitute current sexual practices with practices that are of equal or greater value. Maintaining current sexual practices, with just the addition of barriers such as condoms, even vaginal creams, isn't enough. We need a deeper and more fulfilling sexuality to take the place of what is currently available to most. We also need to be willing to really look at ourselves as sexual beings and talk about it. Providing a new sense (or rather a return to ancient practices and teachings) of our sexuality may be the biggest gift and greatest legacy of this epidemic.'
Margo Caulfield (in an e-mail to the gender-aids forum), Twin State Women's Network, PO Box 3, Cavendish, VT 05142-0003, USA.
To join the gender-aids forum send an e-mail to [email protected] or go to http://www.hivnet.ch:8000/gender-aids
A positive woman's survival kit has been produced by and for HIV-positive women. It includes information on relationships, sex and sexuality.
Available free in English, French and Spanish from the International Community of Women Living with HIV/AIDS, 2c Leroy House, 436 Essex Road, London N1 3QP, UK. E-mail: [email protected]
AIDS and men: taking risks or taking responsibility? looks at how men's risky behaviour makes them and their sexual partners vulnerable to HIV.
A limited number of copies are available free to NGOs in developing countries from AIDS Programme, Panos Institute, 9 White Lion Street, London N1 9PD, UK. E-mail: [email protected]
Much more than information: AIDS Action 29 looks at barriers to behaviour change and provides examples of successful projects that have helped people adopt safer sexual behaviour.
A limited number of free copies are available from Healthlink Worldwide.
Starting the discussion: steps to making sex safer is a guide to training activities on HIV prevention and safer sex.
Available free to readers in developing countries from Healthlink Worldwide.
Reproductive health: new perspectives on men's participation, Population Reports, 26 (2), October 1996 looks at approaches to involve men in reproductive health.
Available free to developing countries in English, French, Portuguese and Spanish from the Population Information Programme, Center for Communication Programs, The Johns Hopkins University School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202-4012, USA.
Stepping stones is a training package designed to help facilitators run work-shops with communities on HIV/AIDS, communication and relationship skills.
Available for £16.50 in English, French, Luganda and Swahili from Teaching aids At Low Cost (TALC), PO Box 49, St Albans, Herts, AL1 4AX, UK. E-mail: [email protected]
Treasuring the gift: how to handle God's gift of sex includes activities for Christian and Islamic youth groups.
Available from Project Concern International, Box 32320, Lusaka, Zambia. E-mail: [email protected]
Violence against women: a priority health issue suggests what health workers can do, and what World Health Organization (WHO) and NGOs are doing on violence against women.
Available from WHO, CH-1211 Geneva 27, Switzerland or directly from their website: www.who.ch
Dossier on female condoms and microbicides A limited number of free copies are available from Healthlink Worldwide.
New from Healthlink Worldwide
HIV testing: a practical approach contains practical information on HIV testing and counselling services for use in developing countries. It is aimed at health workers who provide counselling, testing or laboratory services and NGOs that offer counselling and support programmes. It is a revised version of Practical issues in HIV testing, published by Healthlink Worldwide in 1994.
Available free to readers in developing countries; £7.50/US$15 elsewhere.
Commissioning editor Siân Long
Editor Christine Kalume
Copy editor Celia Till
Design and production Ingrid Emsden
Editorial advisory group Calle Almedal, Dr Sandra Anderson, Kathy Attawell, Dr Rachel Baggaley, Dr Nina Castilio-Caradang, Nancy Fee, Susie Foster, Peter Gordon, Dr Sam Kalibala, Dr Elly Katabira, Dr Ute Küpper, Philippa Lawson, Dr Simon Mphuka, Dr Arletty Pinel, Dr Eric van Praag
Aids Action Publishing partners HAIN (the Philippines) KANKO (Kenya) SANASO Secretariat (Zimbabwe) ENDA (Senegal) ABIA (Brazil) Colectivo Sol (Mexico) Consultants based at University Eduardo Mondlane (Mozambique)
AHRTAG's AIDS programme is supported by CAFOD, Christian Aid, DfkF/JFS, HIVOS, ICCO, Irish Aid, Misereor, Norwegian Red Cross, SIDA.
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