AIDS has become a global pandemic. Hundreds of studies, programs, and conferences have alerted the world to the prevalence and dangers of AIDS in North America, the Caribbean, Europe, sub-Saharan Africa, and parts of Asia. AIDS appears to have taken hold in South America somewhat later, and the incidence remains relatively low. However, socioeconomic and cultural conditions in the region indicate that AIDS could soon become a very serious problem--that is, at the level of sub-Saharan Africa. In this paper, we are particularly concerned with Brazil, the largest and most populous country in South America, with by far the largest number of HIV seropositive persons (Sipan & Hovell, 1996). Further, Brazil is a young country demographically: one-third of the population is under 16. Thus, in order to be effective, AIDS and sexually transmitted disease (STD) prevention programs will have to reach adolescents and impact their sexual and condom use behavior. Our paper reports interview findings from Brazilian teenagers about the nature of their sexual relationships and their experiences using condoms, and makes recommendations for HIV prevention and intervention programs.
A UNAIDS/WHO Epidemiological Fact Sheet reports 120,409 AIDS cases in Brazil (as of 1997) out of a population of 163,132,000 (UN-AIDS, 1998). When sources of transmission were identified, heterosexual contacts accounted for 21% of the cases, while homosexual and bisexual contacts accounted for 33%. Project Hope, a Brazilian nongovernmental organization (NGO) program, states that "about half of the cases to date have been found among homosexual and bisexual men. At the same time, the male to female ratio of AIDS cases has fallen from 9:1 in 1987 to the current 3:1 [in 1997]" (UNAIDS, 1998). According to Csillag (1999), "about 60,000 children in Brazil have a mother with AIDS; 16,000 have lost mothers to AIDS; and about 140,000 have a mother who is HIV-positive." Notably, Inciardi, Surratt, and Telles (2000) place the number of AIDS cases at 163,355 in 1999, an increase of over 35% in just two years.
AIDS awareness campaigns were launched in the late 1980s and early 1990s by Brazilian and non-Brazilian organizations but have been considered to be largely ineffective in impacting behavior because they did not place enough emphasis on the sociocultural context in which heterosexual relations take place (Araujo & Diniz, 1995). Many of the AIDS prevention and education programs were designed for homosexual men, commercial sex workers, and intravenous drug users (Goldstein, 1994). Yet women are particularly at risk for contracting HIV in Brazil due to the cultural context of sexual relationships, and the ongoing increase in infection of women due to heterosexual contact underscores this point. It is common practice for married and unmarried men to engage in homosexual relations (although they are not considered such in Brazil; specifically, to practice nonreceptive "dominant" anal sex), and to not tell their wives or lovers (Inciardi, Surratt, & Telles, 2000; Parker, 1987). The nature of sexual interactions is also very gender-hierarchical, with women being punished, hurt, or rejected for refusing sex, asking for condom use, or asking the man about his sexual history (Araujo & Diniz, 1995; Parker, 1991). Thus, there is an urgent need in Brazil to develop AIDS prevention programs that address the social construction and dynamics of sexual relationships between men and women (Araujo & Diniz, 1995; Brasilia, 1999; Goldstein, 1994; Sipan & Hovell, 1996).
Another factor that should be considered in any comprehensive condom use intervention in Brazil is that men are generally not circumcised, except in the case of phimosis (a condition in which a tight foreskin prevents the baring of the glans of the penis) or some other unusual condition. It has recently been found that AIDS is far more prevalent in areas of Africa where men are generally not circumcised than in areas where they are, either near birth or as part of male initiation ceremonies (Halperin, 1998; Halperin & Bailey, 1999; Pennink, 2001). …