The Public Health Institute at the Federal University of Rio de Janeiro has worked on HIV prevention since the late 1980s. Recently, when poor married women emerged as a group particularly vulnerable to the virus and its effects, the Institute undertook a pilot project in Rio's slums. The purpose of the project was to develop and evaluate a gender-based intervention model for training under-privileged urban women as community health agents to address HIV/AIDS in a broader context. The model focuses on strengthening the women's emotional autonomy and their sense of social responsibility. They documented the entire process of intervention development on video tape.

Most of the residents have little schooling, 3-4 years of primary school being the norm. Major health problems include malnutrition among children and infants, unwanted pregnancies and abortions, cervical cancer and HIV/AIDS. Partly due to their efforts to offer Vila's residents assistance through social projects, the evangelical churches have gained many members.

Using contacts established during 13 years' work in Vila do João, the staff of the Public Health Institute initially selected a small group of women for training. The women had to be able to read and write simple texts. As none of the women had full-time jobs, they had time to participate; the project paid them US$ 100/month, slightly less than the minimum wage of $120 that they could earn by working as domestic maids. Ultimately two adolescent girls (16 and 18 years) and 10 married women with children formed the trainee group.

Two perspectives guided the training: 1) women's vulnerability to HIV/AIDS is embedded in gender-based relations; 2) health education aimed at promoting safer sex should also promote individual emotional autonomy, self-esteem and a new regard and valuation of life.

Over four months, the group met three times weekly in sessions of at least three hours. Scientific university staff, NGO activists, officers of state and city health secretariats and professionals from other areas collaborated with the Institute's psychologists and anthropologist as trainers. They used group dynamics for workshops, formal academic classes supported by slides and pictures, testimonies by NGO activists working on AIDS, and videos for debate, etc. The training was divided into three modules:

• mutual introductions of the university research team and the health agents and a presentation on the project's objectives and schedule
• gender representation as reflected in Brazilian sexual culture, sexuality, human anatomy and physiology and reproductive health
• an introduction to epidemiology regarding HIV/STDs and drug use and HIV transmission; social and legal aspects of the epidemic; safer sex negotiation.

Parallel to the training process, the health agents learned to study their own community. This helped ensure that they would reach people outside their own social networks and helped them gain an overview of their community as a whole.

Applying simple questionnaires, they carried out two small surveys on contraceptive practices and knowledge and representations of the AIDS epidemic (risk perceptions, HIV prevention, etc.). The women analyzed the results with the research team. They debated the results extensively and the outcome of the debates guided the health agents' fieldwork.

Health learning materials

Towards the end of the training, the health agents were invited to participate in assessing and developing educational materials. They evaluated booklets, comics and videos on HIV/STD prevention aimed at women produced by Brazilian NGOs. The evaluation contemplated several aspects: format, language (simplicity and directness); quality and beauty of illustrations; information (quality and amount).

Based on their assessment, the women chose various booklets and videos for use in their work. The women themselves designed one poster, with a message regarding safer sex negotiation during intimate sexual encounters. They also produced badges and T-shirts with the group's logo.

The women received certificates designating them as community health agents at a special graduation party. Members of their entire community, including opinion leaders, were invited to the official ceremony.

The first meeting has as its main theme gender relations. Topics considered include: the meetings' objectives (what participants want); why gender relations affect HIV prevention; and the human body: reproductive organs, the menstrual cycle, contraceptive methods, decision-making on contraception (the current and ideal situations), and contraception and HIV transmission. They also suggested a series of questions for debate:

• Have the differences between men and women stayed the same throughout the history of the AIDS epidemic? What has caused changes?
• Is it better to be a man or a woman? Why?
• What would the ideal man be like? And the ideal woman?
• How is women's subordination related to HIV/STD transmission?

A second meeting on sexuality and HIV/STDs places prevention in a broader context. During a workshop on why people have sex, participants discuss sex as a source of pleasure, prejudices that constrain pleasure, sex for procreation and sex for fun. Information is given on STDs and their symptoms in women and men, highlighting their importance in relation to HIV transmission. Questions for debate during this session include:

• How do men and women learn about sex?
• Why are men allowed certain things that women are not?
• How can we have a happier sexual life?

A third meeting focuses on AIDS. Facts and issues are presented: the meaning of a syndrome and the difference between HIV and AIDS; transmission mechanisms; living with HIV and living with AIDS; HIV testing (how it is done, when and why to do it, principles of anonymity and confidentiality); HIV prevention and blood transfusions, drug use, sexual relations, and pregnancy and breastfeeding. A video on negotiating safer sex initiates debate on the following questions:

• Is it possible to talk with our partners about condom use? Why, or why not?
• Women's status: what are women's chances of prevention?
• How do we talk about HIV prevention with our partners?

The women organize these meetings for groups of people whom they have recruited door to door. The sessions are held in varied venues, ranging from private homes to rooms in public schools, the evangelical churches and health services. The health agents give community women special cards to simplify their acceptance at local health centres for family planning counselling and Pap smears. The Institute staff follow up with the health centres to ensure that they accommodate the women referred.

The women noted positive changes in their private lives: "the training was a gift," said one, while another stated: "I do not think I have changed too much, but my husband thinks I have changed for the better in everything, even in the way I relate to him."

Since most of the women felt more self-assured, they dared to take measures to ensure their participation in the fieldwork: "Now I am confident in what I am going to do, in what I am going to say"; "if the work is serious, if it is what I need...to improve, to help somebody else, then I will go out and do it; he [her husband] is not my owner." In the two adolescents' views, this increased sense of autonomy helped them find new directions for their daily lives and, consequently, their plans for the future. 

All of the trainees pointed out that their internal changes, new-found ability to understand others, and greater openness to people in general helped them become more responsible in both their personal and social domains:

• "I have learned to live better with other people; now I am more patient, I do not try to impose my opinions on the others."
• "After the training I feel more controlled, I am able to listen to people, I feel more self-confident...before it I just talked, talked, talked and nowadays I listen more to people."
• "First, we have to take care of ourselves and then we can go on sharing the information with others."
• "This training has brought me more resolution, more responsibility towards STDs, things I did not have."

Many health agents stated they previously knew few people in their community except for relatives. However, owing to the fieldwork, they had to leave their houses, go out into the streets and talk to people. Their expectations about the community's acceptance of their work raised questions about their public exposure. Some women saw it as a risk to be taken, others as a challenge to be overcome.

One of their difficult discussions was about the video production; some did not want to take part in it because they feared retaliation by drug dealers. The dealers generally prevent people from taking pictures or recording inside the community to prevent their houses and hideouts being identified.

The women who were willing to affirm their relative power in the community prevailed in the group. Their arguments convinced the others of the need to emphasize their presence in a place they are obliged to share with drug dealers. Also, they wanted to show that slums do not only comprise misery, illness and pollution. They are citizens conscious of their social role; they wanted to highlight that not only on the video but also by participating in television programmes and international scientific events (see box).

Today the women are recognized in the streets of Vila do João and are invited to participate in developing health prevention activities inside the community. Though the project has ended (and with it their monthly reimbursements), they are actively trying to influence community health policies by working with health services. On their own initiative, for example, they have started offering educational sessions to women who are waiting to be seen for gynaecological consultations.

One challenge to be overcome is ensuring replication at a lower cost since other communities and organizations may be unable to reimburse trainees as was done in the pilot project. The second is to expand the intervention to male health agents as adolescent and adult men have expressed their desire to participate as well.