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

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.


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 syndemic 19 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 plagues 22 is gradually being recognized in health promotion literature, it is rare that an action plan is defi ned 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 offi ce, 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,* through a local needs assessment conducted by local authorities.** 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,"** 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 fi rst 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, refl ecting the demographic profi le 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 fi eld diaries. The residents were identifi ed with fi ctional 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 fi eld diaries, recorded, and later transcribed. The data was coded and inserted into databases using the program "Atlas ti".* 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.

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%).* 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.* 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,** you cannot go to Andarilho** you cannot go to Três Lagoas** you cannot go to any place because when they [drug traffi ckers] 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%),*** while many others are connected to drug traffi cking, 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 infl uence 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: 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." 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.* Those interviewed recognize the Center as a community place for discussions regarding the possibility of safer sex practices. 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 fi nd 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.
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 traffi cking 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 traffi cking), 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 specifi cally 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 refl ections 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   Nonetheless, there are limits in terms of the supplies and reach of prevention actions. The number of condoms available for distribution is insuffi cient 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. 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

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 traffi cking for decades. The lack of privacy pro-duced 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 stigma 18 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 traffi cking, 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,* and as shown in the current study, AIDS was perceived to be a potential problem among the residents of Vila Consolação. Grimberg's 11 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 syndemic 19 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 specifi c 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.