HIV vulnerability in a shantytown: the impact of a territorial intervention, Rio de Janeiro, Brazil

Abstracts

OBJETIVO: Analisar o impacto da implementação de um programa participativo de promoção da saúde sexual em uma comunidade empobrecida, e descrever como o uso dos espaços públicos e privados para práticas sexuais constitui-se um fator que exacerba a vulnerabilidade ao HIV/Aids. MÉTODOS: Estudo etnográfico conduzido em 2002, em favela localizada no município do Rio de Janeiro. Os 6.000 moradores viviam em condições de vida deficitárias em que se verificou a ausência de políticas públicas, postos de saúde, lazer, oportunidades de emprego e segurança, o que consolida o poder de grupos criminosos. Foram abordadas as condições referentes à saúde sexual e à implantação do programa participativo de promoção da saúde sexual pelo Núcleo Comunitário de Prevenção, criado por uma organização não-governamental. Após dois meses de observação participante, foram realizadas 35 entrevistas semi-estruturadas em profundidade com moradores com idade entre 17 e 65 anos. Foram analisadas 11 histórias de vida de líderes comunitários e agentes comunitários de prevenção e sete grupos focais formados a partir dos grupos pré-existentes na comunidade. O material foi categorizado e analisado qualitativamente. RESULTADOS: A precariedade das moradias favorecia maior exposição às práticas sexuais, acentuando o estigma de ser morador de favela vivenciado pela comunidade. Com a implantação do programa do Núcleo, crianças, jovens e adultos se familiarizaram e passaram a ter conhecimento sobre prevenção do HIV/Aids; e jovens e adultos passaram a ter acesso a preservativos. CONCLUSÕES: Os resultados decorrentes da intervenção mostraram que embora a vulnerabilidade permaneça, a prevenção pode ser inserida na cultura local. A prevenção da Aids pode ser fomentada por meio de uma abordagem territorial com base na participação dos moradores e no fortalecimento da organização coletiva.

Síndrome de imunodeficiência adquirida; Sexualidade; Promoção da saúde; Educação em saúde; Vulnerabilidade em saúde; Áreas de pobreza; Centros comunitários de saúde; Serviços de saúde comunitária Pesquisa qualitativa; Brasil

ORIGINAL ARTICLES

HIV vulnerability in a shantytown: the impact of a territorial intervention, Rio de Janeiro, Brazil

Kátia Edmundo^I; Cecília de Mello e Souza^II; Maria Luiza de Carvalho^III; Vera Paiva^IV

^ICentro de Promoção da Saúde. Rio de Janeiro, RJ, Brasil

^IIPrograma de Estudos Interdisciplinares de Comunidades e Ecologia Social. Instituto de Psicologia. Universidade Federal do Rio de Janeiro. Rio de Janeiro, RJ, Brasil

^IIIMaternidade-Escola. Universidade Federal do Rio de Janeiro. Rio de Janeiro, RJ, Brasil

^IVDepartamento de Psicologia Social e do Trabalho. Instituto de Psicologia. Universidade de São Paulo. São Paulo, SP, Brasil

^{Correspondence}

ABSTRACT

OBJECTIVE: To analyze the impact of a participatory sexual health promotion program implemented in a poor community and describe how the use of public and private spaces for sex is a factor that exacerbates vulnerability to HIV/Aids.

METHODS: This ethnographic study was conducted in a Rio de Janeiro shantytown in 2002. Six thousand people live in precarious living conditions in which the lack of public policies, health posts, recreational activities, employment opportunities, and security consolidates power in criminal groups. Issues related to sexual health were addressed in addition to a participatory sexual health program implemented by a Community HIV Prevention Center established by a non-governmental organization. After two months of participatory observation, 35 semi-structured in-depth interviews were conducted with community members between the ages of 17 and 65. Eleven life histories of community leaders and HIV prevention promoters and seven focus groups formed from pre-existent community groups were analyzed. The material was categorized and analyzed qualitatively.

RESULTS: The precarious nature of living conditions contributes to increased exposure to sexual practices while also enhancing the stigma experienced by the community for living in a shantytown. Through the implementation of the program by the Community HIV Prevention Center, children, teenagers and adults have become familiar with and knowledgeable of HIV/AIDS prevention; and teenagers and adults gained access to condoms.

CONCLUSIONS: Although vulnerability to HIV was not affected, research results reveal that HIV prevention can become part of the local culture. HIV/AIDS prevention can be fomented by a local approach based on community participation and strengthening collective organizing.

Key words: Acquired immunodeficiency syndrome, prevention & control. Sexuality. Health promotion. Health education. Health vulnerability. Poverty areas. Community health centers. Community health services. Qualitative research. Brazil.

INTRODUCTION

An empirical relationship between AIDS and poverty has been found all over the world.^13,17 The AIDS epidemic is characterized by an epidemiological synergy or syndemic¹⁹ in which different factors and/or co-occurrence of epidemics converge to form an unfavorable social environment which creates vulnerability to HIV.^1,17 In this context, substance abuse, violence, gender inequality, poverty, mental health problems, in addition to HIV/AIDS can also be observed.^13,17,21 While the synergism of plagues²² is gradually being recognized in health promotion literature, it is rare that an action plan is defined that includes co-existent epidemics which lead to HIV/AIDS vulnerability and other problems.^14,16 All social problems and co-existent epidemics related to HIV/AIDS do not need to be solved to obtain positive results through local prevention actions. Relatively few community leaders and public policy makers and have shared their experiences and knowledge obtained through innovative approaches implemented in impoverished communities.^2,7,20

In the Brazilian urban regions, the poorest populations reside in shantytowns, one of the typical places where a synergism of plagues can be found. The shantytowns in general have high rates of infectious and non-infectious diseases, domestic and structural violence, alcohol and drug abuse, child abuse, depression, stigma, discrimination, human rights violations, and in the recent decades, HIV/AIDS infection.

In this context, the Non-Governmental Organization Health Promotion Center (CEDAPS) created, in 1996, the Community Prevention Center, whose objective is to promote the prevention of sexually transmitted infections and AIDS in various lower class communities in Rio de Janeiro. Each Center organizes an educational space in their office, generally located in a community center and has prevention activities planned and developed by community prevention agents, who are represented by local leaders.⁸ The objective of CEDAPS is to promote a social response created for and by the communities which seeks to expand prevention restricted to HIV/AIDS to a health promotion perspective.^4,24

In 2001, the implementation of the community prevention centers began in the shantytown Vila Consolação,¹ through a local needs assessment conducted by local authorities.² HIV/AIDS was considered by the population to be a top priority for public policy, and prevention was understood to be an entry point for confronting the synergism of plagues.

The current article seeks to verify the impact of the implementation of a participatory sexual health promotion program in an impoverished community. The analysis is based on the use of public and private space for sexual practices, as a factor which exacerbates vulnerability to HIV/AIDS.

METHODOLOGICAL PROCEDURES

Between July and December of 2002, an ethnographic study was conducted in the shantytown, "Vila Consolação,"² located in Rio de Janeiro. The study focused on the local conditions related to sexual health and the response of the community to the safe sex program implemented by the Community HIV Prevention Center.

"Vila Consolação" is a community with close to 6,000 inhabitants, located in the western region of Rio de Janeiro, more than 70 kilometers from the center of economic activity. The community has various rural characteristics and is isolated from other neighborhoods. Three sub-areas, marked by the type of housing, divide the community. The lower part of the shantytown is made up of blocks called "carriages" because of they appear similar to train carriages. Each carriage has eight dwellings, divided by thin and fragile walls, at times made of clothing or cardboard by the people who live in them. The majority of the dwellings have only one room. The "carriages" were constructed as temporary living spaces by the government 30 years ago, when the first families were taken from the center of the city and relocated to this area. The higher part of the community is made up of row houses with two rooms in each one. The third part is made up by habitat units spread over clandestine lots built during recent decades.

After two months of participant observation and informal interviews regarding life in the community and the Center activities, 35 semi-structured in-depth interviews were conducted with residents, of which 12 were men and 23 women, predominantly black and unemployed, reflecting the demographic profile of the community. Their ages varied between 17 and 65 with an average of 5 years of formal education. In addition to this, 11 life histories of community leaders and prevention community health agents were analyzed. Seven focus groups were formed from pre-existent groups in the community, linked by institutional (day care, school, church) and/or neighborhood relationships.

The following people were selected for the interviews and focus groups: community leaders, prevention community health agents, people who frequent the Center, residents who had not heard of the Center, religious leaders, school and daycare professionals, and groups of teenagers. Interviews conducted in the residences and/or in spaces located in the community yielded close to 70 hours of recordings and 172 hours of participant observation recorded in field diaries. The residents were identified with fictional names.

The interviews and focus groups included themes like: HIV/Aids, sexually transmitted infections (STIs), sexuality, contraceptive and reproductive methods, health, family, leisure, work, quality of life in the community, individual and collective projects, dreams and life perspectives, and the response of the community towards the Center's activities. The interviews, life histories, and focus groups were registered in field diaries, recorded, and later transcribed. The data was coded and inserted into databases using the program "Atlas ti".³ A content analysis was conducted of the categories referring to socialization context, sexuality, and perception of the Center and its services.

The project was approved by the Institutional Review Board of the Federal University of Rio de Janeiro's Research.

ANALYSIS OF RESULTS

Social aspects of the shantytown studied

The rooms are small with an inhabitant density of more than two people per room in nearly half of the dwellings (48.5%), a rate much higher than the national average (14,9%).³ The living conditions, according to the residents, are marked by permanent degradations. In the very words of the residents, the houses are characterized by "rotting wood," "old screens," "destroyed house", "sewer leakages", "lack of electrical installations", "there are rats", "there are creeks very nearby", "exposed to shots and stray bullets".

The shantytown only has one public school, an unemployment rate of 78% and did not have health posts.³ There was no public transportation nor leisure options. The closest health post is in a neighboring community and it inaccessible due to a war between drug gangs. The lack of public policies that promote the human and citizenship rights leads to power being consolidated in narcotics gangs.

" here is the kind of place that you cannot go to Romarão,⁴ you cannot go to Andarilho⁴ you cannot go to Três Lagoas⁴ you cannot go to any place because when they [drug traffickers] say that you cannot go from here to there [limits between gangs], nothing happens." (João, community agent, 17, interview)

A diversity of values and behaviors exists in this territory. Many families participate in different religious groups (53.1%),⁵ while many others are connected to drug trafficking, groups formed in bars and the streets of the shantytown, or those which are restricted to family groups.

Sexual settings and exposure

According to the residents, the living conditions and physical characteristics of the residences directly influence their sexual lifestyle. The precarious division between the houses limits sexual privacy and permits the neighbors to be exposed to the sounds and scenes of adjacent units. The residents perceive the exposure of the sexual life of their family and neighbors as something that introduces children to sex early:

" ( ) here the houses are all small, each house has, I think five or six children ( ), there is no way for the men to sleep, understand? And the guy drinks, or maybe the mother drinks, and 'go for it' [have sex]. The children, right, see everything, awake ( )" (Marcilia, 25, interview)

"There are parents who do things and the children grow up seeing it, there is no respect for the child, their doing it in front of the child, the child sees it, grows up wanting to do it to ( ) there in front, everyone was sitting on the bad watching television and mother and father in back doing that." (Valeriana, 23, resident-educator, focus group)

The lack of privacy is perceived as a limitation to sex life, causing unhappiness, in addition to the embarrassment related to the place where they live.

"Yesterday, the day before last, I woke up in a bad mood, very sad and that made me sick, my neighbor having sex with his wife, from my house I could hear everything, it was terrible girl, I was just minding my business, and I think right away, if I had my own house, just for me, I wouldn't have to hear this, my child is growing up asking, 'mom, what is this?" (Eliete, 26, interview)

Some of the abandoned houses in the communities were used as places to have sex, available for couples or serving as houses of prostitution, where sexual activities were publicly exposed.

Young people have limited access to leisure options and sexual activity normally occurs in the "forest."

"Pequeno": "But there is no pretty place to take your girlfriend the other day I went to make out with my girlfriend and I stayed in front of the creek."

Reginaldo: "You have to go all the way to the middle of the forest, full of mosquitoes .that is why there are a bunch of young girls pregnant." (Conversation between young people, participant observation)

Those interviewed also saw poverty and proximity to narcotics trafficking as factors that aggravates the vulnerability of children to violence and sexual exploitation.

"These girls, sell their body for a hamburger ten cents is just to touch. For 50, they'll take off their clothes. One real gets full service". (Mariano, 24, interview)

The sexual act is commonly marked by danger and transgression. Empty houses are used as motels. The forest also serves so that João (17, community agent, participant observation) called "mating in the moonlight." Fátima, (31, community agent, participant observation) agreed:

"I am tired of passing by and seeing people in the alleys it is there where I think they don't use condoms there are 12, 13 year old girls pregnant."

These perceptions aggravate the stigma associated with the shantytown residents. Those interviewed described the sexuality present in the shantytown as exacerbated. Sexual practices are talked about publicly. Members of the "movement" (drug trafficking), for example, frequently make their violent sexual conquests public.

"There is one, he raped a 1 year old girl They [gang members] grab the children and rape them they grab us and tell us to suck their thing and if we don't do it they say they'll hit us " (9 year old girl, participant observation)

The exhibitionism of violent sex is associated with power and virility, thereby increasing vulnerability even more. It should be considered in prevention strategies designed specifically for the cultural and social context.

The Center and its intervention in the sexual culture

In this setting of social vulnerability, the Center mobilized the community around a discussion about safe sex practices through the close relationship established with the community prevention health agent. Using local language and codes, the community health prevention agent inserts information and reflections regarding the importance of adopting preventive practices into the local population. Since the beginning of its activities, such as the organization of the physical space of the Center and the direct educational approach with residents, the number of residents enrolled to receive condoms monthly has continuously grown (Figure).

The regular distribution of condoms requires that enrolled residents spontaneously seeking them and reaches an average of 2,880 requests per month.⁶

Those interviewed recognize the Center as a community place for discussions regarding the possibility of safer sex practices.

"( ) when the very people saw the Center's work, us giving talks, the educational stands here in the community, they started to wake up, what is this, what is it that is happening? ( ) The Center entered, arrived here, because the people couldn't go outside to search, so today we have the Center here, that functions so that people come freely, get condoms, use them " (Renata, 28, prevention agent, interview)

"( ) the Center is important because there are people who do not totally know, do not know how to protect themselves. There are people who think it is a waste, 'use condoms for what? Avoid what, not going to get anything anyway, if you avoid it, you get it, if you don't avoid it, you get it too,' so that is why I think this is very important." (Betânia, 21, resident, interview).

The Center opened up the discussion regarding the incorporation condoms into sexual settings. Young people interviewed responded positively to the Center and the prevention agents, becoming regular visitors and actively participating in the proposed activities.

In the same way that children are exposed to the sexual activity of adults, they also learn about condoms, which they find used in the streets where they play. They showed the Center to a teacher during an educational activity, and described it as a place where teenagers and adults have access to condoms.

Researcher: Have you been to the Prevention center?

No. I've heard of it. The children talk about, they also talk about condoms. And talk about it in a way, as if they know what it is, as if they used it. Sometimes we walk around the community with the children, around vacation time, and the children point it out, its there that they have them, right (Valeriana, 23, resident-educator, focus group)

Nonetheless, there are limits in terms of the supplies and reach of prevention actions. The number of condoms available for distribution is insufficient for the local demand. In addition to this, the prevention program does not reach all of the social groups in the community, especially women who suffer violence, church members, and men who reject experimenting and using condoms.

The new sources of information and access to condoms provided by the Center stimulated recognition of the need to use condoms.

Reginaldo: I use condoms. If not, she's be pregnant by now.

Researcher: Do you always use them?

Reginaldo: Every time we go (swings his hips, interpreting sexual movements).

Researcher: Where do you get condoms?

Reginaldo: At the Center. Have to use them to not get a child, and there are the diseases

Researcher: Is it good to use them?

Reginaldo: I mean, I don't think it is good, to make out, but you have to use them

Ivonete, who worked at the Center: "This here was my regular client." (Conversation in the Center, Reginaldo, 18, resident, participant observation)

Various residents interviewed described how they decided to use condoms, influenced by posters and conversations with community agents.

"( ) Then I went there and asked for a condom. Then I said, ' Oh my God, how do I put this on?' And my husband also had never had sex with a condom. And by the data, when I met him, he had only been with one woman, right? ( ) So he had his woman there and hadn't been with anyone else, understand? He said: "No Luciana, I am a man like that, of just one woman, understand? And I don't talk about these things, not even with the woman there,' he says. Oh my God where I was, safe (laughter). And then I – hold onto the tip, hold onto the tip. Because there in the Center there are a bunch of posters, talk about it a lot, and then I say, "Hold onto the tip, roll it down, keep rolling it down. So it was the first time we had sex with a condom and he liked it." (Luciana, 26, resident, interview)

The same environment which leads to sexual activity being public also facilitates the dissemination of information and safer sex techniques.

"Come here, let's talk, sit down there. The girls arranged themselves in the room as if we were going to gossip. One of them said: 'Come quickly, for the meeting of the telephones' and others came. They start to talk and laugh at the same time, as I start asking if they use condoms or not as the conversation starts." (Ivonete, 27, prevention agent, interview)

The condoms are distributed in a way that facilitates their access. One clear example of this is a community prevention agent who distributes condoms at nighttime through the window of his own home. The community recognizes the importance of access to information and condoms.

The shantytown residents face various stigmas that reinforce their personal devaluation. The incentive behind their prevention attitudes toward diseases like HIV/Aids appears to be profoundly related to how they value themselves as people:¹⁸

"( ) if you are discriminated against: 'stupid, stupid, ignorant, ignorant', one day you are going to be stupid even if they give you that title. From the moment that history is modified, that they give you an opportunity, to say that you are capable, that you are a professional, that you are a professor, that you are a furniture maker, that you are someone, that's when you are going to want to be someone." (Fabíola, 39, interview)

Knowledge regarding prevention is considered as wisdom to be conquered, associated with the right to health and the ability to protect oneself, as explained by Paulo (40) in a focus group:

"The only thing that no one can take away from you is your wisdom and your knowledge, your intelligence, your capacity, your wholeness, no one can take that. Because you can be poor, but you have to be whole. For you to be loved, you have to know, your wisdom. But if things continue in the same way, without something like that, that respect for your body, for yourself, things end up in what they end up, right, disease for sure."

FINAL CONSIDERATIONS

The ethnographic observations of the sexual settings in Vila Consolação show how urban planning can promote social exclusion and structural violence. This process started with the segregation of the community by the municipal authorities to areas far from public resources, including education and health, permitting that they became imprisoned to drug trafficking for decades. The lack of privacy produced by these living conditions transmits practices between generations, through the direct observation of sexual scenes by young people or by the sexual abuse that they suffer, aggravating their vulnerability to HIV/AIDS and other STIs.⁵

Stigma is also an obstacle to health promotion. The perception of this stigma¹⁸ makes collective exposure and lack of protection be perceived as a natural part of the destiny of the community. Without public policies to lessen poverty and promote access to safety and health, a sense of fatality is stimulated, which can be challenged when residents are considered citizens with rights, for example, to free and universal access to health care. Even in a shantytown entrenched in narcotics trafficking, the challenge can begin with simple initiatives such as condom distribution and the creation of safe spaces for dialogue.

The Center is recognized by those interviewed as the closest source of reliable information and access to condoms, a fundamental supply to concretize a community prevention approach. In this way, the Center establishes itself as a bridge between the population and the prevention agent. The community's spontaneous request for condoms can be considered as an indicator that the residents are more sensitized and informed regarding the importance of inserting condoms into their sexual practices. The sexual context began to include protection among its elements, having a fundamental role in sexual socialization.

The perception and priority given to AIDS varies within the shantytowns of Rio de Janeiro. In another shantytown, in 1997, problems such as violence and hunger were considered to be higher priorities.¹² In 2001,⁴ and as shown in the current study, AIDS was perceived to be a potential problem among the residents of Vila Consolação. Grimberg's¹¹ study about young women in Argentina, among other things, suggests the need to for prevention policies to be based on multi-strategy programs. The strategies should be based on the sexual context, livelihoods, and participating population's interpretation and needs. Various authors^5,6,20,23 report that community based interventions lead to greater interest of the community in prevention actions and are capable of strengthening social networks and implementing changes on a local level, thereby promoting improvements in living conditions.^8,19

An HIV/AIDS prevention strategy that stems from the multiple social relations in popular territories, as adopted by CEDAPS, has promoted a synergy in responses from community members on many other fronts.^1,3,8,9 The challenge is to maintain this effort and expand its impact, given that it is related to local actions, volunteers, and still not integrated into the public health system.

The spatial aspect of the syndemic described in the present study evidences the challenges of developing prevention programs based on the concept of vulnerability.¹ The implementation of the program requires an interdisciplinary approach, community participation, and the promotion of human rights.¹⁰ The structural dimension of HIV vulnerability has a direct negative effect on the family and community life, along with an impact on individual vulnerability.¹⁸ Projects such as the one described here offer an opportunity to challenge syndemics. Drug abuse and poverty in a shantytown will likely not be completely resolved, but participatory programs can promote community actions with realistic and cost-effective interventions that are adequate in terms of the prevention public policies.

A better understanding of the social problems that increase vulnerability to AIDS can be used to strengthen individual and community mobilization within a context that promotes human rights. Considering AIDS as one of the elements of a syndemic¹⁹ substantiates the need to develop initiatives that transcend controlling the epidemic through a prescriptive logic produced by external specialists.¹⁶ Participants in prevention programs should be seen not as consumers of behaviors to be adopted, but as collaborators in social and individual innovation.¹⁴ The promotion of sexual health should consider sexual activity inserted in its social and cultural context (its sexual setting) and not just specific sexual behaviors.¹⁵

In conclusion, it is possible to deal with situations of social vulnerability to HIV/AIDS in the community itself, even if the main structural problems have not been resolved. The lack of privacy that contributes to accentuating vulnerability may also favor the dissemination of information regarding safe sex. The factors which produce vulnerability remain, but condom use may become part of the sexual routine of the residents.

ACKNOWLEDGEMENTS

To the residents of the shantytown studied; to the Non-Governmental Community Health Promotion Center; to the team that collected data in the communities: Vanessa Fonseca, Irene Lowenstein, Jonatas Magalhães, Rosane Marques de Souza, Lina Rojas e Márcio Villard; and the contributions and criticism of Ron Stall and Claire Brindis.

REFERENCES

Received: 8/8/2006

Reviewed: 2/13/2007

Approved: 2/15/2007

Supported by Brazilian Ministry of Health (Project 914BRA3014/UNESCO.)

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1

Fictitious name

2

Prefeitura Municipal do Rio de Janeiro, Diagonal Consultoria. Diagnóstico Social de V P. Rio de Janeiro, RJ; 001

3

Atlas ti. The Knowledge Worksbench. Visual qualitative data analysis management and theory. Building version: WIN 4.2 (Buid 058) Scientific Software Development [software na Internet]. Berlim; 2004.

4

Bonatto D, Becker D, Edmundo K, Nunes NR, Souza R. Diagnóstico comunitário participativo de VP. Rio de Janeiro: Centro de Promoção da Saúde; 2003.

5

Shantytowns near the location studied.

6

CEDAPS/EICOS-UFRJ. Projeto Núcleos Comunitários de Prevenção das DST/Aids. Termo de Cooperação nº 819/03 Relatório de progresso semestral; 2004.

Publication Dates

• Publication in this collection
  12 Dec 2007
• Date of issue
  Dec 2007

History

• Accepted
  15 Feb 2007
• Reviewed
  13 Feb 2007
• Received
  08 Aug 2006