According to the 2004 UNAIDS report on the global AIDS epidemic, it is estimated that 0.2% of Nicaraguans between 15-49 years of age are infected with HIV. This prevalence is much lower than figures for the region as a whole and neighbouring Honduras (0.5% and 1.8%, respectively). Despite having one of the lowest HIV-infection rates in Latin America and the Caribbean, social, political, demographic and cultural factors make prevention difficult and could lead to a rapid spread of HIV. Sexual activity begins at an early age and the effect of machismo on both men's and women's sexuality is significant. Unprotected sex is the most common form of transmission. This puts the future of the next adult generation at risk.

Cultural norms in Nicaragua encourage male sexual irresponsibility and efforts to prevent the spread of HIV/AIDS, through the promotion of condom use and the reduction of stigma, are hampered by custodians of tradition, especially the Catholic Church. In 2003, these sectors forced the government to withdraw a manual on comprehensive sex education for schools. In this context, mass media becomes a useful tool to fight HIV/AIDS, and using mass media in Nicaragua has at least two main advantages. Television and radio are by far the main forms of entertainment for Nicaraguans and almost all households have them. Furthermore, men and women seem to have equal access to them.

Mass media and social action

Between 2002 and 2005, SDSI has taken on HIV prevention. The programme aims to increase young people's perception and personalization of risk of infection; encourage them to develop or adopt more equitable gender norms and behaviours; and promote an environment where young people can engage in prevention actions, individually and collectively. SDSI combines two components that complement each other: mass media and social action.¹

Mass media – The strategy promotes favourable conditions at the level of public opinion and social support to facilitate prevention and non-discrimination. More than half a million young people between ages 13 and 24 in Nicaragua are targeted by the mass media component through the weekly drama TV series Sexto Sentido ("Sixth Sense") and Sexto Sentido Radio, both educational entertainment ("Edutainment") programmes. Sexto Sentido Radio is a call-in debate programme hosted by young presenters. Sexto Sentido Television weekly soap opera is about the daily lives of a group of youth, and is broadcast on the largest commercial TV station and re-broadcast on 11 local cable channels.

Social action – Through agreements with more than 80 local service providers, Puntos seeks to increase access to quality SRH services for young people, and together with some 200 collaborating organizations, it hopes to create a more favourable environment for young people to develop their own initiatives.

Challenging machismo to prevent HIV

Under the campaign slogan "We need to be able to talk", there is an argument that machismo is a risk factor that increases the chances of contracting HIV. The TV series approaches this issue from various angles. For example, one of the main characters becomes infected and confronts the prejudices – including his own – about forms of transmission and what kinds of people get HIV. A young woman living with HIV shows the difference in men's and women's experiences with HIV/AIDS. The show also demonstrates the accumulated effects of gender-based bias and stigma towards women, homosexuals and sex workers. The series conveys the message that with awareness, open communication and equitable decision-making processes between men and women, HIV can be prevented.

Monitoring and evaluation

The current focus on HIV/AIDS responds, to a large extent, to the needs expressed by young people in the previous period. The evaluation of the programme consists of a sequential approach of quantitative and qualitative research. For the 2002-2005 HIV/AIDS project, the effects are being measured in a cohort of 4,800 young people (13-24 years old) randomly selected in three cities in Nicaragua who will be interviewed three times: for baseline, for mid-term evaluation and several months after the project activities end. About 200 young people will be enrolled into the two qualitative measures, which comprise focus groups and individual interviews with young participants and non-participants of social action activities (workshop, camps, etc.). The evaluation is being conducted by a multi-agency team comprised by Horizons/Population Council, Program for Appropriate Technology (PATH), Centro de Investigación de Demografía y Salud (CIDS) and local consultants.

Lessons learned

The findings of the baseline survey were not surprising: while there is good knowledge about HIV/AIDS, AIDS-related stigma is prevalent, and safer sex is not practised very often. There is already some evidence to suggest that the strategy may play a helpful role to prevent HIV. Several factors can be seen as windows of opportunity for a sustainable strategy:

Questioning cultural norms – Challenging machismo is a long-term process. SDSI is contributing to young men and women beginning to question, among other things, the social norms that govern their interpersonal relations and sex lives, and which negatively affect their quality of life.

Integrated approach – The integration of different themes plays an important role in the sustainability of the SDSI strategy. HIV/AIDS and machismo are linked to a range of relevant themes: drug and alcohol abuse, physical, psychological, and sexual violence against women and girls, and early pregnancy, which are serious problems in Nicaragua.

Capitalizing on popularity – In the four years since Sexto Sentido began national broadcasts, the series has become a source of national pride, especially when relatives in the United States reported seeing the show on TV "up there".² The popularity of the TV programme and its cast has helped reduce opposition from some conservative sectors, especially at the Ministry of Education, since actors are allowed to go to local high schools and talk with students about topics and perspectives that are usually not allowed in the curriculum.

Collaboration – Working in an alliance provides another opportunity to sustain the programme. Collaborating organizations have already developed some ownership of approaches, themes and methods. In interviews with representatives from organizations, service providers and local media outlets with whom Puntos de Encuentro works, it was clear that SDSI is seen to have supported their own organizational work on these issues.

Challenges

The use of the media in SDSI has helped reach a wider public and provide information on prevention, existing services and the rights of people living with HIV/AIDS, including the right not to be discriminated against. Nevertheless, it is a challenge to demonstrate that changes in attitudes, norms and behaviours are taking place in the target population and to disentangle the attribution of those changes to SDSI and its components. While initial cost analysis shows that the programme is very inexpensive given its reach,³ additional analyses of costs in relation to impact are warranted.

The author would like to thank Amy Bank and Irela Solorzano of Puntos de Encuentro, Julie Pulerwitz of Horizons/Population Council, and Vanessa Kurz for their valuable contributions.

2. Sexto Sentido has recently begun broadcasting in the USA to Hispanic-Central American audiences via Centroamérica TV, a satellite cable station. It will also soon begin broadcasting on Honduran and Costa Rican TV stations.

3. Based on audience estimates, the national broadcast of Sexto Sentido costs US$0.04 per youth viewer per episode. The cost per viewer is less if adults and children are taken into account as well, and it is even less as the total audience increases as a result of broadcast in other countries and distribution of videos.