http://www.pepfar.gov/ Working in partnership with host nations, over ten years PEPFAR plans to support treatment for at least 3 million people; prevention of 12 million new infections; and care for 12 million people, including 5 million orphans and vulnerable children. To meet these goals, PEPFAR will support training of at least 140,000 new health care workers in HIV/AIDS prevention, treatment and care. In the fiscal year 2009, $897,000 was given through PEPFAR to three organizations to work in HIV/AIDS prevention in Nicaragua. Peace Corps was one of those organizations - the others were the Centers for Disease Control and USAID.
In Nicaragua, the second-year Community Health Peace Corps Volunteers (PCVs) are allotted PEPFAR funding according to their regional area to carry out workshops with a population of their choice. I am living in the northern region of Nicaragua, and together with the seven other health PCVs that also live here, we decided to focus our HIV/AIDS workshop on adult men. In Nicaragua, approximately 97% of all HIV transmission occurs through sexual contact – the majority between heterosexuals. There often exists the belief in Nicaragua that AIDS is only something that affects homosexuals or prostitutes, but the group most affected by the epidemic right now is actually housewives. Their husbands leave the home, town, department, or even country to work cutting coffee or in other agricultural labor such as beans or maize, and are away from home for days, months, or even years at a time. On their journeys, they inevitably have sex with women who are not their wives without using condoms. It is not uncommon for one man to have several girlfriends, or to frequently use the services of sex workers. When he returns home, he will refuse to use a condom with his wife – “What, do you not trust me?!” – and transfer any STD he has acquired to her. The wife will most likely do the test for HIV the next time she gets pregnant (it is common procedure during a pregnancy to avoid transmitting it to the baby), and will find out that she is HIV positive.
Besides the fact that they are often a mobile population and often have multiple partners, men are a vulnerable group for HIV infection in Nicaragua also because of machismo, that Latin phenomenon which most men here embody. Machismo creates a man-focused society – marginalizing women’s contributions, shunning feminine attitudes, and above all being non-feminine and very macho. This usually manifests itself in high domestic abuse rates, men having multiple sexual partners, a strong discrimination against homosexuals, strong gender role differentiation, and the marginalization of women in public life. Women are often in a vulnerable position, powerless to request that their husband or boyfriend use a condom. It is the man who usually makes these decisions, and he is often not willing to oblige.
Every PCV invited three to four adult men from their communities to participate in our two-day PEPFAR workshop. In addition to second-year community health PVCs, we also included four other PCVs from different sectors (Agriculture and Small Business Development). From my community I invited a policeman, a nursing student who was doing his practicum in my health center, and a community health volunteer. Other PCVs invited students, migrant workers, youth leaders, businessmen, transsexuals, and gay men. As you can see, there was quite a variety. There were participants who came from urban areas as well as the most rural and isolated communities. Many of them knew nothing about HIV; although some were well-versed in the epidemic and were already working in preventative health. Every invitee was chosen by the PCV in their community because they were leaders and worked in some capacity with the PCV, and would possibly be interested in future HIV/AIDS educational activities. Below: a couple of my invitees and me.
Our workshop started out with reviewing/learning the basics of HIV and AIDS: how it affects your body and immune system, how it is transmitted, and how to prevent it. We also did a condom demonstration relay race, dividing the men up into teams and having them all put a condom onto a cucumber using the seven correct steps we had taught them. (Cucumbers were used in lieu of wooden penises since most PCVs forgot to bring theirs - they are usually common at health centers and standard issue for PCVs for use in condom demonstrations). Below: the relay race.
The Laboratory Technician from my health center – Xiomara - came to facilitate the session on the test for HIV. She is a very dynamic person and did a great job explaining the test – which with the new fast technology, takes only about 20 minutes to see results. A male PCV volunteered to go through the steps of the test in front of everyone; even having the blood taken from his finger using a lancet to show how easy it was.
On day two we had guest speakers discuss sexual diversity and sexual and reproductive rights. You could tell many of the men were uncomfortable discussing these topics, and there were quite a few snickers and sideways glances. However a few men voiced their opinions that these topics were “very important” and “should be discussed more, especially starting in the home.” The transsexual and gay members of the group appreciated this session I think and felt validated by the facilitator leading the session.
The next session was given by a Nicaraguan organization called “Men Against Violence,” and they discussed machismo and violence towards women and how they affect the current AIDS epidemic. The participants became very animated and everyone had something to say. Most of these men probably grew up in households where they saw violence towards, or at least mistreatment of women, and they probably had never thought about its impact on HIV/AIDS before. While all the men agreed that violence against women and female subordination was the norm in Nicaragua – they also agreed that this was hindering the fight on HIV/AIDS and they could each start with individual change by being positive examples in their own lives and in their own families.
Next, I co-facilitated a session with another PCV regarding behavior change, focusing on men and their adoption of healthy sexual practices such as condom use, limiting their number of sexual partners, and doing the HIV test. We reviewed the five steps of change: pre-consciousness, consciousness, preparation and intention, action, and maintenance. We also discussed what influences our behavior changes: role models, culture, learned behaviors, habits, rewards, consequences, and social norms. The men were all very participative in the session; thinking about men in their own communities and if they are or are not practicing healthy sexual behaviors, why, and how to overcome these obstacles to behavior change.
To culminate day two, we hosted an evening billiards tournament at a nearby pool hall. This was no regular pool tournament however; it was an HIV/AIDS educational tournament. We divided the men up into groups and each group was responsible for giving a short talk between the rounds of pool on various HIV-related themes: how HIV and AIDS work, how it is transmitted, how to prevent it, the HIV test, and correct condom use. The men themselves would play in the tournament as well as facilitate the educational talks in-between the rounds. In the last billiards round, the two final players had to answer correctly a question about HIV/AIDS; otherwise the ball would be taken out of the pocket and placed back on the table – losing their points. So, in order to win the tournament, the players not only had to be good at pool, but they also had to know their HIV/AIDS information. The men really enjoyed it – pool is a popular pastime for men in Nicaragua and billiards tournaments are an effective way to educate men about HIV/AIDS and condom use while having fun.
On the last day of the workshop, we had a testimonial from a man who is HIV positive. He came from a Nicaraguan organization of people living with HIV/AIDS. He has had the virus for 15 years, and has still not acquired AIDS. He had been participating in the workshop for the previous two days, and none of the other participants had any idea he was HIV positive; I think it shocked a few men to hear his story. He explained how he had never been educated on sexual and reproductive health as a child and his younger sister had had to explain sexual intercourse to him since he didn´t receive the information from his parents or teachers. He only found out he had HIV when he decided to do the test on a whim while in the Health Center testing for an STD. Although he said it still hurts deep inside and he struggles daily to cope; he finds hope in the fact that he is working for an organization which strives to educate Nicaraguans about HIV/AIDS and how to prevent it, and for those who are infected – how to live a long, healthy life and ensure their human rights are respected. At the end of his session, the man formed a ribbon on the ground with candles (to represent the red HIV/AIDS ribbon which represents solidarity with HIV positive persons), and he sat in the middle. We all encircled the ribbon of candles, listening to his story and taking in the moment. A few tears were shed. Many of the men had gotten to know this HIV positive man throughout the past two days of the workshop and were shocked and saddened to find out his tragic story.
At the beginning of the workshop, the participants had been asked to write down on a piece of paper the first word that came to mind when they thought of HIV/AIDS. Their answers ranged from “fear,” and “danger,” to “remorse,” “pity,” and “sadness.” At the end of the workshop, however, their answers were quite different. Now many of them wrote “solidarity,” “compassion,” “collaboration,” and “unity.” Each of the men who attended the workshop was changed. They left fired-up to work in HIV/AIDS education along with the PCV in their community. They had learned so much and felt empowered and able to educate other men in their community. The men from my community who attended the workshop with me planned a few activities to carry-out back here in-site. We are planning to do HIV/AIDS workshops with local migrant workers, male sports team members, and male health volunteers. They also pledged to support my HIV/AIDs volleyball tournament which is coming up on December 1 for World AIDS Day, and we’re planning an HIV/AIDS billiards tournament of our own. I was happy to be a part of such an excellent workshop and a great Presidential initiative. Thanks PEPFAR!