An Overview of the Academic Production on HIV/AIDS Prevention (2007-2011)

ISSN 1413-389X Temas em Psicologia – 2013, Vol. 21, nº 3, 837-858 DOI: 10.9788/TP2013.3-EE07EN

Condom Use in Brazil: An Overview of the Academic Production on HIV/AIDS Prevention (2007-2011)

Thiago Félix Pinheiro1 Medical School from the University of São Paulo, São Paulo, Brazil Gabriela Junqueira Calazans Centre for Reference and Training in HIV/AIDS from the Department of Health of the State of São Paulo, São Paulo, Brazil José Ricardo de Carvalho Mesquita Ayres Department of Preventive Medicine from the University of São Paulo, São Paulo, Brazil

Abstract Since the beginning of the AIDS epidemic, condoms have been the main preventive strategy of the Brazilian policies. This study presents a refl ective essay on the academic production on condom use as a method for HIV/AIDS prevention in Brazil, based on papers published in scientifi c journals between 2007 and 2011 and indexed in the Virtual Health Librar y. It outlines an overview of these studies and their results and conclusions. Despite the diversity of the production analyzed, it was found that the studies concentrated on young people, with great attention given to gender issues. From combined analysis on the goals and the theoretical and methodological frameworks of the articles, six areas of production of knowledge on the subject were identifi ed: epidemiological studies; studies on knowledge and behavior; studies on specifi c contexts; studies on senses and meanings; studies on activities; and review studies. The literature analyzed is presented in a diffuse manner so as it interlocks approaches and directions, which requires an epistemological and methodological maturity of the frameworks used. Keywords: Condom, AIDS prevention, safe sex, sexually transmitted infections.

Uso de Camisinha no Brasil: Um Olhar sobre a Produção Acadêmica Acerca da Prevenção de HIV/Aids (2007-2011)

Resumo Desde o início da epidemia de aids, a camisinha tem sido a principal estratégia de prevenção das políti- cas brasileiras. Este estudo apresenta um ensaio refl exivo sobre a produção acadêmica a respeito do uso da camisinha como método de prevenção de HIV/aids no Brasil, com base em artigos publicados em periódicos científi cos entre 2007 e 2011 e indexados na Biblioteca Virtual de Saúde. Delineia-se um panorama dos estudos realizados e dos resultados e conclusões encontrados. A despeito da diversidade da produção analisada, identifi ca-se concentração de estudos realizados com jovens e grande atenção dada às questões de gênero. A partir de uma análise conjunta dos objetivos e do aporte teórico-metodológico dos artigos, são identifi cadas seis vertentes de produção de conhecimento sobre o assunto: estudos epi- demiológicos; estudos de conhecimentos e comportamentos; estudos de contextos específi cos; estudos de signifi cados e sentidos; estudos de atividades; e estudos de revisão. A literatura analisada apresenta-

1 Mailing Address: Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, Av. Doutor Arnaldo, 455, 2o andar, sala 2213, Cerqueira César, São Paulo, SP, Brasil, 01246-903. E-mail: [email protected], [email protected] e [email protected] Support: This study received support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP). 838 Pinheiro, T. F., Calazans, G. J., Ayres, J. R. C. M.

-se de forma difusa, de modo a entrelaçar abordagens e direcionamentos, o que demanda um amadure- cimento epistemológico e metodológico dos referenciais utilizados. Palavras-chave: Preservativo/camisinha, prevenção de aids, sexo seguro, infecções sexualmente transmissíveis.

Uso de Preservativo en Brasil: Una Mirada a la Producción Académica sobre la Prevención de VIH/SIDA (2007-2011)

Resumen Desde el comienzo de la epidemia del sida, el preservativo ha sido la principal estrategia de prevención de las políticas brasileñas. Este estudio presenta un ensayo refl exivo sobre la producción académica respecto al uso del preservativo como método de prevención del VIH/sida en Brasil, basado en artículos publicados en revistas científi cas entre los años 2007 y 2011 e indexados en la Biblioteca Virtual em Salud. Se traza un panorama de los estudios realizados, de los resultados y conclusiones encontrados. A pesar de la diversidad en la producción analizada, se identifi ca una concentración de estudios realizados con jóvenes y una gran atención dada a los problemas de género. A partir de un análisis conjunto de los objetivos y del aporte teórico-metodológico de los artículos, se identifi caron seis vertientes de producción del conocimiento sobre el tema: estudios epidemiológicos, estudios de conocimientos y comportamientos, estudios de contextos específi cos, estudios de signifi cados y sentidos, estudios de actividades y estudios de revisión. La literatura analizada se presenta de forma difusa, de manera que se entrelazan enfoques y orientaciones, lo que requiere una madurez epistemológica y metodológica de las referencias utilizadas. Palabras clave: Preservativo/condón, prevención del sida, sexo seguro, infecciones de transmisión sexual.

Prevention of HIV/Aids cated the “sanitary isolation” of the population and Condom Use groups in which, according to epidemiological studies of that time, the chance to meet people The AIDS epidemic, due to the incurable with the disease was greater than in the so-called character of the disease, was presented as a major general population, the so-called at-risk groups. challenge for public health. In this scenario, harm In resistance to this concept and to the strategies reduction and prevention were highlighted as key of abstinence and isolation it was proposed the strategies to face the epidemic. In Brazil, since centrality of the concept of risk behavior, and, the beginning of policies on AIDS, condoms on this basis, the incorporation of condoms as a have been, and continue to be, the main bet in way to prevent HIV/AIDS that would allow the the fi eld of prevention (Paiva, Venturi, França, maintenance of sexual practices (Ayres, Cala- & Lopes, 2003).The promotion of condom use zans, Saletti, & França, 2006). was part of a non suppressive approach of pre- In this manner, promotion of condom use has vention, that characterized most successful natio- been linked, within the historiography of opera- nal responses to the HIV epidemic, unlike other tive concepts for AIDS prevention, to surpassing contexts, where preventive work persisted in the the idea of at-risk groups through a behavioral idea of sexual abstinence (Kalichman, 1993). conception of prevention, articulated in terms of The original proposal to adopt condom use at-risk behavior versus safe practices. This pro- as a strategy for HIV/AIDS prevention dates from cess has produced a tendency towards universal- the fi rst decade of the epidemic, in the 1980s, ization of the preoccupation with AIDS, such that from initiatives by the organized gay movement it has become possible to work more openly and in the United States. This group refused to adopt with greater legitimacy in relation to information the proposals from Public Health, who advo- and guidance on sexual practices that are safer or Condom Use in Brazil: An Overview of the Academic Production on HIV/AIDS Prevention 839 less safe, and to publicize and teach about how to strengthened as a possibility for these people’s use condoms. Marketing logic has become im- sex lives to continue, along with protection printed on prevention, such that condom adver- against (re)infection. tising has been emphasized in association with On the other hand, since the end of the practices and behavioral patterns that it is also 1990s and throughout the 2000s, complaints and desirable to “sell” (Paiva, 2000). comments regarding what is generally known as Subsequently, in an attempt to respond to “condom fatigue” or “prevention fatigue” have the perception that people’s exposure to HIV often been made, as can be observed in articles and to illnesses due to AIDS did not result purely in the media worldwide2 and within the scope of from a set of individual factors, the perspective introductions and explanations of some scientifi c of vulnerability was elaborated. In this, it was articles that have been based on this social phe- proposed that not only individual but also col- nomenon, in order to research AIDS prevention lective and contextual factors that lead to greater (Adam, Husbands, Murray, & Maxwell, 2005; susceptibility to infection and illness should be Ostrow et al., 2008). analyzed. Inseparably, the degree of availability In this regard, it does not seem to be acci- of resources of all orders for both individual and dental that, in entering the fourth decade of cop- collective protection would also need to be ana- ing with the epidemic, major investments in bio- lyzed (Ayres et al., 2006). According to Paiva medical forms of HIV prevention are being seen (2000), the perspective of vulnerability brought around the world. These methods include use of into view the limitations of campaigns for pub- microbicides, pre-exposure prophylaxis (PrEP), licizing condom use that were conducted out of post-exposure prophylaxis (PEP), test and treat, context and insuffi ciently explicitly or specifi c treatment as prevention and vaccines. However, for each group, with its own values, singular sex- even though such strategies have shown prom- ual preferences and different language for deal- ise, they have been regarded in many programs ing with sexuality. as tools that should be integrated into the strat- Adoption of the concept of vulnerability as egy of promoting condom use in HIV/AIDS pre- a guide for prevention and care policies within vention policies of great reach among the pop- the national context was linked to “incorpora- ulation. It is believed that only in this manner tion of the gender perspective and the guarantee will it be possible to make this fourth decade the of human rights . . . [as] fundamental conditions last of the AIDS epidemic (Joint United Nations for reducing vulnerabilities and for preventing Programme on HIV/AIDS [UNAIDS], 2012; sexually transmitted diseases and HIV/AIDS” United Nations Organization, 2011). (Ministério da Saúde [MS], 2009). In Brazil, the Taking the perspective of the centrality of idea of sex protected through condom use has condoms in coping with the AIDS epidemic, the been integrated as will be seen later on, with current nature of the debate and the diversity of the perspective of human rights. Through con- academic production in this regard, we present dom use, a possibility of connecting preventive here a refl ective essay on the academic produc- work with a positive concept of sexual rights has been identifi ed. This not only ensures protection (against violations and diseases) but also 2 With regard to “condom fatigue” or “prevention promotes the right to pleasure and to satisfactory fatigue”, refer to: (a) “Condom fatigue” may be behind STI rise: University of British Columbia. and safe sex life (Petchesky, 1999). Retrieved June 10, 2012, from http://www.ctv. With antiretroviral therapy freely and uni- ca/CTVNews/Health/20070913/bc_sex_070913/; versally available in Brazil since the mid-1990s, (b) “Condom Fatigue” Leading to More AIDS. and with the consequent increase in the popula- Retrieved June, 10, 2012, from http://www. tion living with HIV, the question of caring for goldtalk.com/forum/showthread.php?t=23956; (c) Condom Fatigue Or Prevention Fatigue?. individuals under such conditions, especially Retrieved June, 10, 2012, from http://ezinear- within the sphere of sexual health, has emerged. ticles.com/?Condom-Fatigue-Or-Prevention- Within this context, protected sex has become -Fatigue?&id=5196308 840 Pinheiro, T. F., Calazans, G. J., Ayres, J. R. C. M. tion relating to condom use as an HIV/AIDS mitation of the present study, given that it only prevention strategy in Brazil. The analysis was covers the most recent production on this topic. undertaken based on studies published in scienti- These articles received an initial analysis fi c periodicals over the last fi ve years. We started with a view to outlining a panorama of the aca- from the assumption that refl ection on and com- demic production on condom use as an HIV/ prehension of these studies, their theoretical re- AIDS prevention strategy, starting from charac- ference points and their methodological designs teristics such as source and year of publication, might contribute towards understanding the cur- participants and region in which the study was rent challenges within the fi eld of prevention and conducted. Following this, we conducted a more directing new studies with a commitment towar- detailed analysis regarding the objectives, the- ds transforming the context of vulnerability to oretical-methodological basis and results of the HIV that is faced in this country. studies. The analytical process then consisted of exploratory, selective and analytical readings of Methodological Path the articles.

The academic production on the topic of this investigation was gathered through a biblio- Panorama of the Literature: graphic search conducted in March 2012, throu- Contexts of Knowledge Production gh the Virtual Health Library (BVS)3. This and Dissemination portal brings together the main databases in the fi eld of healthcare (LILACS, MEDLINE, CO- The articles analyzed (Table 1) were pu- CHRANE and SciELO), thus forming a wide- blished over the course of the fi ve-year period -ranging and practical option for investigating investigated, with nonlinear distribution, such articles that are available through online access that we were unable to discern any increase or open to the public. decrease in the numbers of published papers on We selected studies that presented the Por- condom use as a strategy for prevention of HIV/ tuguese-language descriptors camisinha, pre- AIDS over this period. We found that there were servativo, sexo seguro or prevenção de aids in few studies of national coverage and that the gre- their titles, or the same descriptors in English at majority had been produced in specifi c locali- (condom, safe sex or AIDS prevention), with ties in Brazil. There were studies from all regions addition of the term Brazil. Among the studies of the country, but the numbers were smallest in found, we only kept the articles that were avai- the Central-Western and Northern regions. lable as complete texts that had been published According to the classifi cation of the scien- during the last fi ve years (from 2007 to 2011). tifi c periodicals present in the BVS, the articles Studies conducted in other countries were ex- analyzed were concentrated in periodicals concluded, as were those that did not cover condom nected with public health and nursing, which use as a method for preventing HIV/AIDS or shows that there was some funneling of the dis- sexually transmitted infections (STIs) in a ge- cussion on this matter into these fi elds. Following neral manner, and those with online addresses this, in smaller proportions, we found articles in that were not active and could not be accessed periodicals relating to medicine and other fi elds through the link provided by BVS or through of healthcare, particularly the fi eld of STIs. It was other platforms (such as Google). In the end, a noticeable that there was only a single article pu- total of 38 articles were selected to comprise the blished in a psychology periodical. analysis material. Most of the articles concentrated on stu- The time cutoff was necessary given the dying male condoms, but some included or ex- large number of articles found in the fi rst steps clusively studied female condoms. Here, we did of the search. Nevertheless, this represents a li- not make any separation according to this crite- rion, since we were considering condom use in a general manner. In some articles, condom as a 3 http://brasil.bvs.br Condom Use in Brazil: An Overview of the Academic Production on HIV/AIDS Prevention 841

Table 1 Characterization of the Articles Reviewed

Year of N°* Authors Study participants** Study Field of know- publi- location ledge of the cation periodical****

2007 1 Leite et al. University students*** PI Nursing 2 Carvalho, Bezerra, Leitão, Joca and Pinheiro Young people*** CE Nursing 3 Maliska, Souza and Silva Women with HIV SC Nursing 4 Benzaken, Galbán Garcia, Sardinha, Pedrosa - AM Public health and Paiva 5 Viana, Faúndes, Mello and Sousa Students*** MG Public health

2008 6 S. M. Barbosa, Costa and Vieira Parents of adolescents*** CE Nursing 7 Alves and Lopes University students*** SP Nursing 8 Marta, Francisco, Martins and Clos University students*** RJ Nursing 9 Madureira and Trentini (a) Heterosexual couples - Nursing 10 Saldanha et al. Students*** PB STI 11 Lima, Silva, Godoi and Merchán-Hamann Men who have sex with men DF Medicine 12 Berquó, Barbosa, Lima and Grupo de General urban population Brazil Public health Estudos em População, Sexualidade e Aids 13 Paiva, Calazans, Venturi, Dias and Grupo de Adolescents*** Brazil Public health Estudos em População, Sexualidade e Aids 14 Oliveira, Moura, Guedes and Almeida Health professionals (STI/AIDS) CE Public health 15 M. C. P. Sousa, Espírito Santo and Motta Women PI Public health 16 Madureira and Trentini (b) Heterosexual men SC Public health

2009 17 R. K. Reis and Gir Serodiscordant couples SP Nursing 18 Kalckmann, Farias and Carvalheiro Women SP Epidemiology 19 Matos, Veiga and Reis Students*** MG Gynecology/ Obstetrics 20 Moura, Lima, Farias, Feitoza and Barroso Women prostitutes CE STI 21 Brisighelli, Araújo, Doher and Haddad - - Medicine 22 Costa, Rosa and Battisti University students*** SC Public health 23 Ferraz and Nemes - SP Public health 24 Maksud Serodiscordant couples - Public health 25 A. A. Sousa, Lucareski, Brizolara, Bortoletto - SP Public health and Pinto

2010 26 Nicolau and Pinheiro Female inmates CE Nursing 27 Sampaio, Paixão, Andrade and Torres Adolescents*** PE and BA Psychology 28 Riscado, Oliveira and Brito Women in remnant communities AL Public health of former slaves 29 Cruzeiro et al. Adolescents*** RS Public health

2011 30 Maschio, Balbino, Souza and Kalinke Elderly people*** PR Nursing 31 Laroque et al. Elderly people*** RS Nursing 32 Gomes, Fonseca, Jundi and Severo Heterosexual couples RS Nursing 33 Ribeiro, Silva and Saldanha Young people*** PB STI 34 Albuquerque and Villela Women CE Care provision 35 Rebello, Gomes and Souza Men - Public health 36 Sampaio, Santos, Callou and Souza Adolescents*** PE and BA Public health 37 C. B. Reis and Bernardes Inmates*** MS Public health 38 Borba Transvestites working as Southern Public health Transvestites prostitutes Brazil Note. *Identifi cation number for the article, used to organize our analysis. **According to the descriptions given in the articles. ***Participants of both sexes. ****According to the BVS classifi cation. 842 Pinheiro, T. F., Calazans, G. J., Ayres, J. R. C. M. method for HIV/AIDS prevention was the cen- account all the elements that characterized the tral theme. In others, this subject appears as part studies, which could have led to other ways of of the broader theme of STI prevention. There analyzing them. were also articles in which this topic was linked Starting from these strands, which expres- to other discussions, such as in relation to sexual sed different forms of logic in constructing kno- initiation, contraception, violence, racism, use of wledge within the fi eld investigated, we move on healthcare services, etc. to presenting the studies and their results. In the literature analyzed, the terms camisinha, preservative and condom were found and Epidemiological Studies were used in the searches of the bibliographic Among the studies on the prevalence of databases. In the present description, however, condom use, we can highlight those of natio- we used the term condom uniformly, even when nal coverage. In this regard, two of the articles the original text made use of other expressions. analyzed presented data from the survey “Sexual In the Portuguese version, we adopted the term behavior and perceptions of the Brazilian popu- camisinha as this term seems to us to be more lation regarding HIV/AIDS” [Comportamento associated with approaches that place value on sexual da população brasileira e percepções do the sociocultural aspects of sexual practices and HIV/AIDS], which were gathered in 1998 and the perspective of prevention guided by the the- 2005, from representative samples of the urban oretical framework of vulnerability and human population of this country. rights, as opposed to terms that tend to form part Berquó et al. (2008) presented data on con- of discourse that takes a more strictly biomedical dom use among people aged 16 to 65 years over line regarding infection, centered on preventive the 12 months prior to the survey and showed 4 strategies for specifi c protection . that there had been a substantial increase between 1998 and 2005. This increase was seen among Knowledge Produced: people who only had casual partnerships (from Systematization of the Studies 63.5% to 78.6%), those who only had a steady and Presentation of the Results partnership (from 19.1% to 33.1%) and those with both types (from 24.5% to 46.3%). The pre- The articles presented signifi cant diversity valence of use in the fi rst group was higher than in relation to what they proposed to investigate in the other groups. Overall, in 2005, 21% of the and their study designs. Thus, they differed re- people said that they had made consistent use of garding the type of knowledge produced. Hence, condoms, i.e. in all sexual intercourse over the in order to assess and discuss the studies found, 12 months investigated. Young people (16 to 24 along with their results, it seemed to us to be use- years of age) were highlighted as the segment ful to group them through combined analysis of that best protects itself. the objectives and the theoretical-methodologi- Paiva et al. (2008) concentrated specifi cally cal basis. In this manner, we identifi ed six stran- on the young participants of this survey (seg- ds of study on condom use as a strategy for HIV/ ment from 16 to 19 years of age) and particular- AIDS prevention (Table 2). ly investigated condom use in sexual initiation. This systematization fulfi lled the purpose Towards similar results to the previous study, of discussing what types of knowledge had been they found an increase both in the case of the produced in the fi eld in question and on what it fi rst sexual experience took place in a steady re- had been based. However, this did not take into lationship (from 48.5% to 67.7%), as in the case of a casual partnership (from 47.2% to 62.6%). This increase did not occur for some young peo- 4 For a comparison between the fundamentals and ple in relation to religion (Protestants and no re- methods of the main conceptual frameworks of ligion), family income and having had their fi rst prevention, refer to: Ayres, Paiva and França (2011). sexual intercourse before age 14. Condom Use in Brazil: An Overview of the Academic Production on HIV/AIDS Prevention 843

Table 2 Characterization of the Strands of Research in the Studies on Condom Use as an HIV/AIDS Pre- vention Strategy

Research Characterization Articles strand identiﬁ ed according to category

Epidemiolo- These studies identiﬁ ed the prevalence of condom use or occurrence related in 5, 11, 12, 13, gical studies certain group or population segment and/or investigated factors associated with 18, 22, 29, 30, use of condoms. These studies had adopted quantitative methodology. 33

Studies on These studies sought to identify the level of information that a certain group had 1, 2, 6, 7, 8, knowledge in relation to STI/AIDS and preventive methods, along with sexual practices 10, 14, 19, 26, and behavior and behavior relating to condom use. They were based on behavioral concepts 31 of HIV/AIDS prevention (at-risk behavior versus safe practices). There is variation and combination of quantitative and qualitative methodologies.

Studies on These studies were circumscribed to a particular context of research, in seeking 15, 20, 28, 37 speciﬁ c to understand the possibilities for and challenges of prevention of HIV/AIDS in contexts speciﬁ c situations or groups. They prioritized the study of sociocultural aspects and had adopted qualitative methodology.

Studies These studies were focused on the senses and meanings attributed by people 3, 9, 16, 17, on senses or groups to condom use or unprotected sex, in seeking to comprehend how 24, 27, 32, 36 and meanings symbolic constructs regarding these practices might hinder or facilitate prevention. These studies had adopted qualitative methodology.

Studies on These were case studies on activities that promoted condom use as a preventive 4, 23, 25, 34, activities measure for HIV/AIDS or studies that involved such activities as part of the 38 research, and they analyzed the possibilities and challenges of the situation examined. These studies were justiﬁ ed in terms of publicizing experiences that could be taken as examples or deserved to be debated. They also encompassed participatory research. They had adopted predominantly qualitative methodology.

Studies of These studies provided review of scientiﬁ c literature produced in relation to 21, 35 literature condom use as a prevention strategy for HIV/AIDS. They were summarized review and/or analyzed within a certain theoretical framework or thematic focus. In reviewing the literature, a diversity of styles and ways of working were encompassed.

The other articles in this strand of resear- ber of sexual partners in the last 12 months and ch presented studies that had been conducted condom use in the last three sexual intercourses. among certain population groups and in speciﬁ c Regarding the second indicative, the use of con- localities in the country. Most of these studies doms was constant for 56.3% of the participants. aimed to investigate condom use among young For girls, the risk of using condoms only occa- people, like the study by Cruzeiro et al. (2010), sionally increases by 21%, compared with boys. who presented a household survey with a repre- The authors observed a linear trend with respect sentative sample of the segment 15-18 years li- to maternal education, as the occasional use sho- ving in the urban zone of Pelotas, RS. In this stu- wn greater the lower the years of schooling of dy, it was investigated the occurrence of “risky the mother. sexual behavior”, deﬁ ned in terms of the num- Costa et al. (2009), Ribeiro et al. (2011) and 844 Pinheiro, T. F., Calazans, G. J., Ayres, J. R. C. M.

Viana et al. (2007) also investigated condom use a student at elementary school level) and being among the young population, in this case, howe- older were associated negatively with consistent ver, only with young people within the educatio- condom use with casual and steady partners, res- nal system. The fi rst two of these studies compa- pectively. red condom use between the fi rst and the most Condom use among other groups was also recent sexual intercourse. investigated in the studies along this research Costa et al. (2009) identifi ed, among college strand. For example, the elderly population was students with a mean age of 23.6 years, the pre- the focus of the study by Maschio et al. (2011), valence of 71.4% in fi rst and 61.4% in the last who investigated measures to prevent STI/AIDS sexual intercourse. Regarding the associated fac- by patrons of an institution that develops progra- tors, this research shows that having candidiasis ms to improve the quality of life in old age. In this is a protective factor for condom use in the fi rst study, the majority of the participants (87.7%) and last sexual intercourse. Moreover, having a expressed the need to use preventive measures, non-stable marital relationship and having a par- among which condom use was prominent as the tner who was doing a health-related course were best-known method (mentioned by 70% of the positively associated with condom use during participants). However, only 42.8% reported ha- the last sexual intercourse. Among the subjects ving used a preventive measure, among which themselves, doing a health-related course was 64.2% made reference to condom use. not signifi cantly associated with condom use. The study by Kalckmann et al. (2009) fo- Ribeiro et al. (2011), in turn, observed cused specifi cally on use of female condoms. among public school students (12-20 years) the In monitoring the use of these condoms in pu- absence of condoms decreased among males blic healthcare services (which participated in a (from 35% in the fi rst intercourse to 21% in the project to implement their use), the researchers last) and increased among females (from 39% to found that only 14.4% of the women investiga- 43%). Referring to all sexual intercourse, the di- ted had made continuous use over a 12-month fference according to sex was also signifi cant in period. The women with higher frequency of this study. The majority of the boys (53%) said sexual intercourse per month used the female that they always used a condom, while the ma- condom for longer times, as did those who used jority of the girls (54%) said that they used them the healthcare services of community projects, sometimes. According to the researchers, this in comparison with those who used primary he- difference might be related to the fact that the althcare units and specialized services. Using a majority of the steady relationships (68%) were contraceptive practice and the method chosen reported by women, while a proportion of the were not shown to be associated with continuity men (38%) said that they had had four or more of use. sexual relationships. However, no other data re- The study by Lima et al. (2008) focused on lating to the type and quantity of relationships men who have sex with men (MSM) and, among were presented in the article. other aspects, investigated their use of healthca- Other factors associated with condom use re services (specialized in STIs), to obtain con- among young people were found by Viana et al. doms. In this regard, the researchers found that, (2007). These researchers found among sexually among the participants, the younger men were active students at public schools, aged between buying condoms with noticeable frequency, al- 10 and 19 years that being male and having he- though less frequently than the older men. In althcare professionals involved in teaching were relation to socioeconomic status, men with lo- positively associated with all the safe sex indica- wer income have less access to condoms, espe- tors investigated. Furthermore, having a mother cially at “gay meeting points”. From a table in with more than eight years of schooling was po- this study that presented the forms of access to sitively associated with condom use with either a condoms, it can be seen that in a general manner, steady or a casual partner, while being a student condoms were being bought or were being ac- at high school level (in comparison with being quired at “gay meeting points” and events more Condom Use in Brazil: An Overview of the Academic Production on HIV/AIDS Prevention 845 often than they were being acquired through he- The study by Marta et al. (2008) aimed to althcare services or non-governmental organiza- delineate the profi le of undergraduate nursing tions. students with regard to AIDS. In this study, the majority of the participants presented correct in- Studies on Knowledge and Behavior formation about the forms of HIV transmission. Studies on knowledge and behavior tend to Condoms were prominent as the preventive me- make use of theoretical-methodological models thod most often mentioned (91.7%). Among based on behavioral and socio-cognitive studies, the sexually active participants, 58.8% said that such as studies on Knowledge, Attitudes and they had used a condom in their fi rst sexual in- Practices (Alves & Lopes, 2008; Marta et al., tercourse. However, this measure was dismissed 2008; Nicolau & Pinheiro, 2010); Theory of Sta- by 48.5% after a month of dating, when the rela- ges of Change (S. M. Barbosa et al., 2008); The- tionship was considered to be steady and without ory of Planned Behavior (Matos et al., 2009); risks. and The Behavioral Risk Factor Surveillance Other studies have concentrated more speci- System (Saldanha et al., 2008). fi cally on behavior relating to condom use as an Furthermore, most of the studies along this STI/AIDS preventive strategy. Among these, the strand of research focused on investigating con- article by Saldanha et al. (2008) described the dom use among young people. However, each sexual behavior and “AIDS vulnerability pro- study presented particular features due to the fi le” among students aged 13 to 18. According segment investigated and the research design. to the researchers, early sexual initiation with The studies by Alves and Lopes (2008) and an older partner and having several partnerships Marta et al. (2008) put forward analyses that co- were factors that increased vulnerability and vered knowledge, attitudes and practices among were worsened through non-systematic condom young people. Alves and Lopes (2008) conduc- use. In this regard, 54% seemed to state that they 5 ted a study among university students aged 18 always used condoms . The study investigated to 19 years in relation to contraceptive pills and the young people’s knowledge only in relation condoms. They found that the participants had to contraceptive methods: 56% of them said that high levels of knowledge and positive attitudes they used contraception, and condoms were ci- in relation to this topic, but that from the par- ted most frequently (64%). ticipants’ reports on their practices, these were Likewise, Carvalho et al. (2007) conducted 6 incorrect and included condom application only a study among young adults aged 18 to 50 years at the time of penetration, whereas according to frequenting night clubs. In this context, the rese- these authors, “the most appropriate procedure archers investigated not only safe sex practices would be to use it throughout the sexual inter- but also whether the participants were carrying course, starting from before any genital contact” condoms with them at the time of the survey, and (p. 15). Although this study focused on contra- how they were packed. They found that 58.8% ception, it also covered STI/AIDS use with re- of the interviewees said that they always used gard to condom use. In this respect, practically condoms and 38.4% were carrying condoms all the participants stated that it was necessary to use condoms during all sexual intercourse: 5 a signifi cant number of them (65.1%) said that In the article by Saldanha et al. (2008), there is a mismatch in some information relating to the fre- they would not have sexual intercourse if the quency of condom use, between what is presented partner did not want to use a condom, although in a table and in the abstract. some of them (17.6%) said that they would have 6 Although it is uncommon to use the term “young intercourse without protection if they knew the people” for a group of this age range, it seems that partner well. In addition, 46.1% of the university the researchers used this term based on the fact that more than half of the participants were be- students considered that condoms did not inter- tween 18 and 23 years of age, such that the mean fere with sexual intercourse and 23.1% stated age was 22.56, the mode was 18 years and the me- that they caused diminished sexual pleasure. dian was 21 years. 846 Pinheiro, T. F., Calazans, G. J., Ayres, J. R. C. M. with them at the time of the survey. Among the sults indicated that there was a knowledge defi - latter, 40.7% were carrying them in their wal- cit in relation to the basic characteristics of fe- lets. It was observed that there was a relationship male condoms and how to put them on among between the packing and packaging conditions, the professionals in both categories. However, such that all the condoms that were crushed were knowledge about the steps involved in putting found in wallets. Prominent among the reasons condoms on was shown to be associated with fe- for not using condoms were use of hormonal males. Furthermore, it was seen that there was contraception (43.2%) and complaints that con- little promotion of the use of female condoms, doms diminished the pleasure (29.6%). and this was justifi ed by these professionals on Matos et al. (2009) also concerned themsel- the basis of the high price, lack of availability ves with behavior, but focusing on factors that at healthcare units, lack of knowledge and lack motivated safe sex practices among young adult of adherence among women, unlike the greater students aged 18 to 19 years. Thus, they sought access to male condoms. to identify the antecedents of the intention to use The study by S. M. Barbosa et al. (2008) co- condoms among the participants and concluded vered the parents of adolescent students at public that formation of the intention was dependent schools. These researchers investigated behavio- not so much on attitudes but, rather, on social ral change stages in relation to communication norms and on perceptions of behavioral con- with their children regarding sexuality and me- trol, i.e. personal belief regarding the degree of asures for preventing STI/AIDS. The results in- ease in adopting this behavior. In this regard, the dicated that most of the parents talked to their moral obligation to use condoms was expressed children about this, or were interested in doing more by the men than by the women. However, so. However, some of them expressed diffi culty the women were seen to be less susceptible to in this, especially regarding the need for greater the temptation to have sex without a condom and clarifi cation regarding measures for preventing manifested less diffi culty in preventing that sex STI/AIDS or unwanted pregnancy. happens in this conditions. In relation to social The behavior of elderly people in relation to pressure, doctors and mothers were highlighted STI/AIDS prevention was studied by Laroque et as the most signifi cant infl uences on the intention al. (2011), who identifi ed a variety of factors that to use condoms, especially among the women. contribute towards the low adherence to condom Leite et al. (2007), in turn, emphasized the use among this segment of the population, espe- process of choosing the method for contracep- cially during the post-reproductive period. These tion and prevention of STI/AIDS among univer- factors included embarrassment in talking about sity students within the fi eld of healthcare. They sexuality and proposing condom use; resistance found that these individuals almost unanimous- to and prejudice against condoms, given that this ly chose condoms as the contraceptive method. segment of the population started their sexual Among the boys, this choice was explained es- lives prior to the AIDS epidemic; and the fact pecially by practicality and low cost; and among that sexual practice at this stage of life imply cer- the girls, by the absence of side effects. However, tain limitations, which is added using condoms. in a general manner, such a choice did not appear Moreover, according to the authors, prevention to be linked to STI/AIDS prevention, which dra- aimed towards this population comes up against ws the attention of the authors because it is the the diffi culty that healthcare professionals have prospect of future healthcare professionals. in dealing with the sexuality of elderly people. Healthcare professionals were also inves- Lastly, among the texts analyzed, there was tigated by Oliveira et al. (2008), who ascertai- the preliminary note by Nicolau and Pinhei- ned the level of knowledge regarding female ro (2010), who communicated about a study to condoms and the dynamics of promotion this be conducted among female convicts regarding method, among doctors and nurses at public their knowledge, attitudes and practices relating reference institutions for STI treatment. The re- to male and female condoms. Condom Use in Brazil: An Overview of the Academic Production on HIV/AIDS Prevention 847

Studies on Specifi c Contexts high degree of vulnerability of these women to Among the studies along this strand, which STI/AIDS was linked to their context, marked were characterized by covering specifi c contexts by precarious living conditions, high levels of with reference to sociocultural factors, the atten- occurrence of domestic violence and racism tion given to women and to gender relations wi- (experienced in different contexts of social and thin the contexts investigated can be highlighted. institutional relationships), diffi culties in access- Different data-gathering techniques were used: ing healthcare services, lack of any effective Riscado, Oliveira and Brito (2010) and Reis and healthcare policy and lack of educational work Bernardes (2011) used the technique of focus in such communities. groups; Moura, Lima, Farias, Feitosa and Barro- The study by Moura et al. (2009) also fo- so (2009) conducted interviews and participant cused on women, within a scenario of prostitu- observation; and Sousa, Espírito Santo and Mot- tion and poverty in the interior of the state of ta (2008) put these techniques together in their Ceará, in which there were a variety of obstacles investigation. hindering prevention. The researchers noticed M. C. P. Sousa et al. (2008) circumscribed that the prostitutes investigated faced diffi cul- the context of adult women in steady conjugal ties in acquiring condoms, such that their use be- relationships who were living in a low-income came the client’s responsibility. In general, con- region on the periphery of Teresina, state of doms ended up being used only in intercourse Piauí. To identify these women’s vulnerability with unknown and recent clients, and were dis- to HIV, the researchers looked into whether they pensed with in intercourse with old and known were using condoms, the gender relationships clients, and also with steady partners (sometimes that they experienced with their partners and the married or in relationships with other women). actions implemented within the Family Health Moreover, the context of a prostitute’s submis- Program (FHP) [Programa de Saúde da Famí- sion to a client gives legitimacy to demands by lia] in this context. The researchers perceived clients for sexual intercourse without a condom, that the majority of the women did not make which may even place the sex worker’s health in continuous use of condoms, especially because jeopardy if she does not consent to this practice. of diffi culties relating to negotiation of this prac- On the other hand, C. B. Reis and Bernardes tice with their partners; condom use was more (2011) looked into the context of penitentiaries, early included in sexual practice when envisaged to investigate strategies adopted for preventing as contraceptive. In relation to the assistance infection and the spread of STI/AIDS. They no- provided by the FHP to these women, the re- ticed that the male and female participants, in- searchers emphasized that this was restricted to mates from public jails in cities in the state of health education on women’s health, centered on Mato Grosso do Sul (who interacted with the prenatal follow-up and on measures for reduc- community through family members, visitors, tion of gynecological cancer. Thus, the health- prison offi cers and in their different experiences care teams did not incorporate discussion about of recidivism), recognized the importance of sexuality and gender relations, which worsened prevention and were able to indicate the main these women’s vulnerability in this context. preventive methods, among which they high- In the same direction, Riscado et al. (2010) lighted consistent use of condoms as the most conducted a study among women in remnant effi cient method. However, they tend to use communities of former slaves, known as Quilom- them only sporadically, due to diffi culty in its bos, in the state of Alagoas, and found that these acquisition, lack of counseling from the local women had a signifi cant lack of knowledge of healthcare team on this topic and lack of inter- the importance of condom use, along with resis- est among the inmates themselves, which they tance to the adoption of this practice and diffi cul- explained through their involvement with steady ties related to the need for their partner’s permis- partners. The researchers drew attention to the sion to do so. According to these researchers, the precarious healthcare provided for the male and 848 Pinheiro, T. F., Calazans, G. J., Ayres, J. R. C. M. female inmates, which was correlated with soci- or the use of condoms and “blame” on girls due ety’s prejudice and discrimination. to cases of STI or unplanned pregnancy. The study by Madureira and Trentini Studies on Senses and Meanings (2008b) used the notion of attitude and looked In this research strand, the articles rely on at the perspectives of heterosexual men in rela- different concepts and theoretical perspectives tion to condom use. The results indicated that in for understanding the senses and meanings at- STI/AIDS prevention, “issues relating to beliefs, tributed to the use of condoms as a prevention myths, health stereotypes and the characteristics strategy for STI/AIDS. Here too, the resource of relationships between men and women were to gender issues was recurrent, for understan- tangled together” (p. 1807). Among the justi- ding aspects related to the use of condoms, es- fi cations for the recognized male resistance to pecially within the scope of emotional-sexual condom use, the researchers identifi ed the no- relationships. tions that condoms are bothersome, imply inter- Sampaio et al. (2010) and Sampaio et al. ruption of sexual foreplay, reduce pleasure and (2011) made use of the theoretical-methodologi- cause fear of losing erection or of poor sexual cal model of discursive practices and investiga- performance. In addition, they highlighted that ted STI/AIDS prevention within the context of the central motive for not using condoms was the care provided for adolescents at Family Health association that had been established between Units. The fi rst study (Sampaio et al., 2010) dis- preventive practice and mistrust or infi delity. cussed the production of meanings by adoles- From these fi ndings, these authors produced cents and healthcare teams regarding gender and an essay (Madureira & Trentini, 2008a) in which sexuality and their implications for STI/AIDS they correlated STI/AIDS prevention with the prevention. The researchers identifi ed macho confi guration of affective-sexual relationships concepts among the adolescents, along with lack within a heterosexual conjugal context. In this of knowledge in relation to the forms of STI/ regard, they drew up three models of relation- AIDS prevention. More specifi cally, they have ships, in which are articulated in different ways highlighted production of meanings in relation the elements of love, desire, pleasure and fi delity. to romantic love, fi delity and monogamy among Each model was tied to a particular construction young people and adults, both men and women, of masculinity and had different repercussions which were correlated with a supposition of pro- with regard to adoption of safer sexual practices. tection that would make it unnecessary to use Although this formulation presented closed-off condoms in relationships conformed from these models that categorized individuals’ participa- elements. Among the health professionals, they tion in relationships, it produced fi ndings that noticed a “signifi cant diffi culty in working on were the same as in other studies, such as the sexuality during adolescence, such that it was notions that condoms as a preventive method are fundamental to rethink bio reductionist discour- considered to be unnecessary in steady relation- se and banking education as strategies for coping ships in which fi delity is presumed, and that they with STI/AIDS” (p. 173). are used especially in casual intercourse, i.e. ex- On the other hand, the article by Sampaio tramarital sex in this case. et al. (2011) focused on the vulnerability of In turn, Maksud (2009) investigated the so- young women to STI/AIDS and especially, the cial representations of serodiscordant couples meanings attributed to gender relationships in in relation to sexual practices and condom use. confi guring the diffi culties that adolescents face This author took the view that such representa- in negotiating condom use with their partners. tions conformed logics that generally was not Among these senses, the researchers highlighted accompanied by the offi cial discourse regarding that the initiative of proposing condom use was prevention. From an attempt to “understand the identifi ed as the man’s prerogative; the estrange- meanings of sexual behavior and the social sens- ment towards girls proposing sexual intercourse es of desire” (p. 355), this author identifi ed con- Condom Use in Brazil: An Overview of the Academic Production on HIV/AIDS Prevention 849 structs such as the relativization of disease and Lastly, Gomes et al. (2011) proposed to of the risk of seroconversion and the diffi culties identify the perceptions of young heterosexual relating specifi cally to the situation of conjugal- couples aged 20 to 27 years comprising students ity, such as the unpredictability of sexual prac- in an undergraduate nursing course and their tices and the rationale, expressed by men, that male or female partners, regarding their use of they did not like to use condoms because they female condoms and associated factors that fa- want “to feel the skin”. In this regard, it seems to vor or hamper the adoption of this practice rou- occur a process of routinization of intimacy and tinely. The researchers concluded that the parti- a suspension of safer sex. cipants know the effi ciency of this method, but In the same direction, R. K. Reis and Gir emphasized the diffi culty for women to negotia- (2009) conducted a study among individuals with te its use, the little dissemination about female HIV/AIDS who were living with serodiscordant condoms and its high cost. In relation to its use, partners and who were attended at a public out- the participants said that they were practical, re- patient referral service for HIV/AIDS patients. liable and gave pleasure but on the other hand, Among the meanings identifi ed in the partici- there was pain, discomfort and a grotesque appe- pants’ statements, an idea of naturalization of arance. Lack of familiarity and lack of knowled- HIV/AIDS infection as a disease manage able by ge seemed to be the main triggering factors for medications was outlined, along with a belief that diffi culties. antiretroviral therapy and, particularly, undetect- able viral load prevent the risk of virus transmis- Studies on Activities sion, and a feeling of invincibility that arose with Firstly, we present studies that looked into increasing length of time that the couple had been activities relating to HIV/AIDS prevention as together. These constructs appear as factors in- the subject of the investigation or report. Then terfering in the maintenance of condom use, and we describe a study that used condom promotion therefore increased the vulne-rability of the sero- activities as part of a specifi c investigation. negative sexual partner to HIV infection. Among the fi rst group is a description of Like in the above two studies, the article a community-based intervention for control of by Maliska et al. (2007) discussed prevention STI/AIDS in the Amazon region, presented by regarding relationships in serodiscordant cou- Benzaken et al. (2007). This intervention pro- ples. However, in this study, the discussion was gram was developed within the scope of the Bra- undertaken from the perspective of feminization zilian National Health System [Sistema Único de of the AIDS epidemic and the “vulnerability of Saúde (SUS)], with the participation of resear- women”. The results indicated that the parti- chers, government offi cials, health professionals cipants, who were users of a healthcare facili- and the community. Its actions ranged from local ty specialized in STI/AIDS, believed that they data collection (dynamics of prostitution, sale of were protected in steady relationships and that, condoms and behavioral characteristics) to STI even after becoming infected, faced diffi culty prevention and care actions within the public in negotiating condom use with their partners. healthcare system and capacitation provided for Going against the healthcare team’s prescription sex workers, along with assessments of the ac- advice to use condoms, resistance to this preven- tions and the process. A variety of positive results tive method emerged among the men, sustained from the experience were reported. Regarding by the belief that they would not transmit to their condoms, it was seen that there were general in- seropositive female partners any infection that creases in sales and in use among sex workers, was more serious than what the partners alrea- along with reduction of the incidence of bacterial dy had, through the “myth” that women do not STIs and stabilization of the occurrences of HIV/ transmit HIV to men and through possible trans- AIDS and congenital syphilis infection. gressive motivation to the regulation imposed by Also in this regard, the article by Ferraz prevention. and Nemes (2009) presented an assessment of 850 Pinheiro, T. F., Calazans, G. J., Ayres, J. R. C. M. the implementation of STI/AIDS prevention ac- although they expressed diffi culties in relation to tivities in a Family Health Unit. According to handling and introduction, due to excessive lu- the authors, the technological profi le of the unit brication. Although the focus of the study was investigated resembled that of the traditional pri- on contraception, STI prevention came up as an mary care services in Brazil, with limited poten- important motive for choosing this method. In tial to establishment of the principle of compre- a general manner, however, use of female con- hensiveness. Along these lines, the prevention doms was hindered by diffi culties in negotiating activities implemented (including dispensing of this with partners. condoms) were seen to be fragmented and “emp- tied of important technological directions, such Studies of Literature Review as dialogue and attention to users’ singularities” Among the articles analyzed, only two of (p. S249). them fi tted into this category. The article by Bri- The study by Borba (2011) refers to the anal- sighelli et al. (2009) presented, in abbreviated ysis of interventions, in which activists from a form, a review on the effi cacy of condoms as a non-governmental organization distributed con- method for STI prevention. From the studies sur- doms among transvestite who prostitutes. With veyed, the authors emphasized that condoms do emphasis on the relationship between language not provide a completely effective barrier, given and interactional construction of social identi- that their material is permeable to small viruses, ties, the researcher examined the discursive dy- that they do not cover the entire perineal region namics that emerged in interactions between the and that transportation and storage may alter people providing the intervention and the trans- their quality. In addition, lack of knowledge of vestites and argued in favor of the importance and familiarity with correct use of this method is and usefulness of comprehending these elements an important factor in diminishing their effi cacy. in prevention work among marginalized groups In another direction, the review produced and fi ghting the spread of STI/AIDS. by Rebello et al. (2011) emphasized the rela- A. A. Sousa et al. (2009) presented a short tionship between men and AIDS prevention. report on a project that they were conduct- From the studies found, the authors point out, ing every three months in Suzano, state of São among other things, the centrality of condoms in Paulo/SP. It is a themed soiree aimed at artists, prevention. However, this element appears in the teachers and community members in general, in literature especially from the questioning of the which artistic and musical activities are linked acceptance of its use by men. In this regard, the to the provision of condoms and informational authors emphasized the consensus that the rea- materials that foster discussions about sexuality sons for not using condoms are structured from in the light of safer sexual practices. This event models of beliefs present in the social imagina- encouraged reading and erotic art, along with ry. Over the course of their review, the authors dissemination and expansion of access to health identifi ed different constructs that are characte- services. ristic of these models: power relations between In turn, the study by Albuquerque and Vil- men and women; the association of condoms lela (2011), among women at a Family Health with illicit sex, and therefore with infi delity; the Unit on female condoms, presented an interven- idea that condom does not fi t with marriage; that tion as part of the study. In this, the data-collec- condoms may be waived in relationships invol- tion itself is combined with educational activi- ving effective commitment and the belief that ties, experimentation with the female condom at condom use can harm to men, because it retains a nursing consultation offi ce and use at home. something that should be released, and for the The results showed that after the initial perplexi- women because it prevents the uterus from being ty regarding female condoms, most of the users moistened by the semen; the belief that women reported that they gained a positive impression, cannot transmit HIV; the refusal to use a condom Condom Use in Brazil: An Overview of the Academic Production on HIV/AIDS Prevention 851 as a demonstration that the risk is not feared; and cipants and delineating the studies, such as race/ the association between satisfaction in anal sex ethnicity (investigations on black or indigenous and the identity of men who have sex with men. populations, etc, are scarce or nonexistent). Lastly, these authors argue that this discussion On the other hand, the second highlight is progresses as it articulates the role of such pre- thematic and relates to gender relations that have ventive measure itself with the meanings asso- set up certain challenges to the adoption of con- ciated with condoms. dom use, given the relational nature of sexual practices, the dimension of power that articu- By Way of Discussion: Highlights lates gender relations and cultural values asso- from the Literature and Considera- ciated the constructions of masculinity and fe- tions about the Strands of Research mininity. This highlight appears more clearly in investigations of qualitative design: both in stu- Despite the diversity of studies on condom dies that directly discuss the relationships betwe- use as a strategy for HIV/AIDS prevention, we en couples and in studies conducted specifi cally can identify certain highlights, notably the atten- among men or among women. In an incipient tion given to young people and to gender issues. manner, gender relationships have been linked Studies along these lines can be comprehended to other relevant social issues, such that they can in the light of the emphasis given to young seg- be found in studies on serodiscordant couples, ments of the population in relation to prevention women from remnant hinterland communities of policies (Paiva et al., 2008) and in the light of the former slaves, poor women, young women and centrality of discussions regarding “negotiation” female prostitutes. on condom use between the partners (Madureira Gender relations emerged as an important & Trentini, 2008a, 2008b). Nonetheless, these determinant of the HIV/AIDS epidemic at the are two highlights of different natures. time when the trend towards feminization of the The fi rst of these is directed towards a po- epidemic was identifi ed at the beginning of the pulation segment and predominates among the 1990s, with the growth in the numbers of AIDS more quantitative studies. It can be noted that the cases in Brazil and around the world (MS, 2009). group named young people (or adolescents) was Within this sphere, it is important to be attentive defi ned in different ways in these studies, with towards the complexity of such social confi gu- different age limits and covering participants rations, because of the risk of reproducing cli- who were both within and outside of the educa- chés that are often seen in discussions on gender, tional system. which make it diffi cult to refl ect on nuances and Regarding the other groups present in the circular arguments regarding the relationship literature examined, we emphasize that there between gender and sexuality, and more specifi - was a scarcity of studies discussing condom use cally, regarding condom use. In this manner, we among men who have sex with men, injectable recall the criticism and relativization of the idea drug users and sex workers, which are the groups of negotiation of condom use within the sphere in which the HIV and AIDS epidemic in Brazil of unequal gender relations, made in the 1990s has remained concentrated since its beginnings by R. M. Barbosa, Villela and Uziel (1995). The- (Malta et al., 2010). In this regard, we can hi- se authors questioned the simplifi cation of the ghlight that, among young men, homosexuals complex equation established between the ideas have been shown to be the segment most affec- of negotiation and the adoption or not of safer ted by HIV over the last few years (MS, 2011). sexual practices. Likewise, only a few studies have encompassed In relation to other topics that were covered the context of prostitution and male commercial less notably or were absent among the set of stu- sex workers have not been included. Moreover, dies examined, the list of issues that could be and there has been little or no consideration of other deserve to be considered within the scope of this social markers of difference in defi ning the parti- subject is endless. Among these, we can highli- 852 Pinheiro, T. F., Calazans, G. J., Ayres, J. R. C. M. ght the lack of refl ection within Brazilian acade- specifi c type of knowledge. From a panoramic mic production on the topic of “condom fatigue” viewpoint, we can emphasize that these diffe- and the need for more in-depth discussions on rent approaches are complementary, given that the role of health services in this context, the all the studies add information to the literature. relevance of which is marked by recognition of Nonetheless, it is fundamental to be attentive to the programmatic dimension of vulnerability to the limits that exist in relation to these forms HIV/AIDS and, in this regard, the support avai- of producing knowledge and to the care needed lable for prevention. Furthermore, especially in in conducting studies with certain designs, with studies on senses and meanings, it would be use- regard to reading and using the conclusions pre- ful to deepen the refl ections on medicalization sented. of condom use and of the discourse of preven- In this regard, it is worth indicating that epi- tion7, along with investigation of the possibility demiological studies have recognized relevance of bringing this discourse closer to the dimen- in terms of the coverage of the data produced (for sion of erotica, which was suggested by Parker example, these are the studies that make it pos- (1994), for example. sible to estimate condom use in the population) With regard to the six research strands of and contribute towards indicating the priorities these studies, we emphasize that the categori- in drawing up preventive actions and policies. zation thus produced does not exhaust the pos- However, the construction of such knowledge sibilities for joint analysis on the texts used. In entails successive processes of conceptual abs- addition, the characterization of these strands traction, which ensure formal and mathematical was not totally homogenous, considering that handling of great precision, at the cost of moving although some articles fi tted better into one type away from fundamental aspects of the reality to of study, they could present some characteris- think prevention (Ayres, 2002). The history of tics of another strand. So it is with the article by the production of knowledge in the fi eld of AIDS Cruzeiro et al. (2010), which was placed in the has shown the danger of making this separation, group of epidemiological studies, but operates, especially with regard to using a probabilistic however, a typical logic of studies on knowledge association [for example, the indication in the and behavior. This intersection seemed to occur study by Berquó et al. (2008) that people in the most clearly in relation to the debate on senses Pentecostal religion use condoms less frequen- and meanings, which was present secondarily tly that do those without religion or those who in the articles by Ribeiro et al. (2011), among follow other religions] to generalize a given cha- the epidemiological studies; M. C. P. Sousa et racteristic, thereby producing identities and la- al. (2008), among the studies on specifi c con- beling people and hence guiding the design and texts; and Matos et al. (2009) and Saldanha et implementation of preventive actions (Ayres et al. (2008), among the studies on knowledge and al., 2006). behavior. On the other hand, studies on knowledge and Although all the studies analyzed had in behavior represent an attempt to identify and/or common the purpose of producing knowledge structure information and practices that are use- that would be useful for coping with HIV/AIDS ful for HIV/AIDS prevention. These seem to within the fi eld of prevention, and specifi cally take techniques of relevance for preventive work by means of condom use, each strand of rese- as their baseline: for example, they seek to iden- arch presented its own logic regarding the man- tify which information is less well-known and ner of looking into the question and produced a needs to be better disseminated, or which guidance is more effective in educational activities. However, this way of producing knowledge may 7 “Medicalization of condom use and preventive incur in adopting naturalized or normative crite- discourse” is understood here in the sense used in ria over sexual practices, in taking, as a param- discussions on “social medicalization”; refer to: Tesser (2006). eter, knowledge and behavior considered correct Condom Use in Brazil: An Overview of the Academic Production on HIV/AIDS Prevention 853 regardless the contexts of intersubjectivity in place and the social constructs in which they op- which personal identities, values and practices erate. In this regard, going beyond condom use are concretely and dynamically constituted. and (re)cognition of its importance, these stud- As pointed out by Paiva (2000), the be- ies enable advances in knowledge and refl ection havioral conception of prevention, although it regarding the implications of this practice for the represented an overture towards working with subjects involved, and what this represents and information and counseling regarding sexual gives rise to in certain situations. practices (more or less) safe, especially in rela- Nevertheless, consideration of the specif- tion to condom use, this tends to disregard the ic contexts and the construction of senses and social context. In this, behavioral change is tak- meanings, by themselves, do not ensure produc- en to be an individual responsibility and an in- tion of a useful comprehensive totality on the tentional process among subjects who have been diffi culties and possibilities relating to condom “convinced” by experts of their needs. use as an HIV/AIDS prevention method. Along In a particular manner, studies following these strands, there is a danger of being caught in this research strand that have identifi ed that most the fallacy of dealing with these matters simply young people have knowledge about AIDS and as instruments for “convincing” people better about the ways of preventing it, especially con- regarding condom use, without actually seeking dom use (Alves & Lopes, 2008; Leite et al., 2007; to merge horizons8 with such contexts and con- Marta et al., 2008), lead us to conclusions that structs. favor dissemination of information and guidance Also in relation to studies on specifi c con- on prevention, and to the working on education texts, it should be borne in mind that these gener- for sexuality. However, this situation is contra- ally operated with a logic in which the subjects dicted by studies such as the one by Sampaio are comprehended as collective subjects, as a et al. (2010), which is categorized as a study on function of the conditions of their surroundings. senses and meanings, and which found that ado- In this case, attention is needed in order not to lescent girls and boys frequently did not know lose the perspective of subjectivity and the sin- about STIs and prevention, whereas healthcare gular manner in which individuals relate to such professionals believed that these young people conditions. It is particularly important in the pro- possessed such knowledge but, despite this, did cess of understanding, to be able to observe the not maintain preventive behavior through irre- way in which different intersubjective contexts sponsibility, thereby making preventive work shape identities and practical horizons that are impossible among this population group. In this central to the establishment of dialogues that can regard, we can point out that there is a need to effectively promote changes in relationships and distinguish between access to information and reduction of vulnerabilities. the real possibility of communication among the The relevance of studies on activities is subjects involved in preventive practice, with a demarcated by registering experiences and the view to transforming the contexts of intersub- possibility of articulating studies with interven- jectivity that shape vulnerability to HIV/AIDS tions. This is especially important in a fi eld such (Ayres, França, Calazans, & Saletti, 2003). as prevention of STI/AIDS, which remains close Studies on specifi c contexts and studies on to practice and whose actions, especially actions senses and meanings, which are governed by the to promote condom use, are under construction, logic of understanding about the use of condoms, given that signifi cant challenges still exist and seem to respond to the perception that acquisi- that what has been accumulated comprises some tion of knowledge regarding STI/AIDS and con- lessons, as shown by Ayres (2002) and Paiva dom use is not enough for practicing protected (2000). sex (which was mentioned by Alves & Lopes, 2008, for example), since such practices are not 8 For a discussion on the concept of merging of ho- detached from the contexts in which they take rizons, refer to: Ayres (2008). 854 Pinheiro, T. F., Calazans, G. J., Ayres, J. R. C. M.

Among all the studies examined, we need in selecting the articles and the criteria that could to highlight that few of them had focused on the not be incorporated in the analysis, such as cha- far from insignifi cant challenge of how to pro- racterization of the authors and the institutional mote condom use. Taking into consideration, affi liation of possible groups of researchers. In- among the studies on activities, only the reports vestigating of these matters could, for example, and analyses on experiences, it can be seen that make it possible to pose the question of what se- there were few initiatives dedicated to descri- emed to us to be a concentration of published bing and/or evaluating technological proposals papers on this topic within certain areas, notably regarding how to promote condom use in given public health and nursing, thus highlighting the contexts. It seems to us that this is a fi eld that scarcity of articles in journals of psychology. The needs to be better explored, based on descrip- concentration of such published papers within a tions of technological innovations relating to restricted area of the fi eld of health sciences di- practices and articulating with in-depth refl ec- verges from the understanding that the actions tion on the theoretical basis and the diffi culties for reducing vulnerability to STI/AIDS should and potentials identifi ed in different contexts not be restricted to the institutional sphere of and with different population groups. In this re- health and should be expanded in their scope of gard, considering the centrality of condom use action in an interdisciplinary and intersectoral within policies on prevention of STI/AIDS in manner, with a view to transforming the contexts the Brazilian context, this is a fundamental type of vulnerability (Ayres et al., 2003).With regard of knowledge production with regard to the fi eld to psychology, it can also be considered, in par- of health practices. ticular, that, among the authors of the articles In a general manner, studies of literature analyzed, there were researchers and professio- review are opportunities for gathering, synthe- nals with training in psychology and that some sizing and evaluating knowledge that has been of the articles were anchored in theoretical re- produced regarding a given topic. In relation to ference frameworks originating from psycholo- condom use as a strategy for STI/AIDS preven- gy9. In the absence of systematic analysis in this tion, such studies have been scarce over the last respect, we can only ask why the psychologists fi ve years. Considering that the two studies that who investigated prevention of STI/AIDS have we identifi ed within this strand of research are sought or found more space in journals within related to specifi c themes (effi cacy of condoms other fi elds. and prevention among men), we note that there Furthermore, lack of expansion of the sco- is a lack of broader work of systematization of pe of this research by the use of other databa- studies on condom use as a preventive method, ses constitutes a limitation because of the res- which is a topic central to the policies for coping trictions found in the portal that was used for with STI/AIDS in Brazil. searching for articles, especially with regard to Directed toward overcoming this gap, this the mechanisms for searching for and retrieving essay represents an attempt to provide a critical articles through the links that are made available overview of studies on this topic, which may in the portal. contribute towards comprehending how condom Lastly, it should be borne in mind that be- use and HIV/AIDS prevention have been thou- cause of the large quantity of studies produced ght and how research and practices within this about themes related to the condom use, we cho- fi eld have been put into operation theoretically se to direct the focus of the present work towards and methodologically. In this regard, our inten- HIV/AIDS prevention, and did not include some tion was that this study should make it possible specifi c issues of importance to discussions re- to conduct new analyses and undertake new approaches relating to this topic. 9 It is clear that this study presents some im- For example, the studies on behaviors or behavioral change and on discursive practices, which portant limitations, such as the time cutoff used are presented in the Results section. Condom Use in Brazil: An Overview of the Academic Production on HIV/AIDS Prevention 855 garding contraception and prevention of other nology of the theoretical framework of vulnera- STIs. bility and, in a certain way, its legitimacy has a broad reach [which, as seen earlier, has even Final Remarks been recognized by the national public policies (MS, 2009)]. On the other hand, we noted that The analysis undertaken in this article has a large number of different directions have been allowed us to come to some conclusions regar- taken in the production of knowledge on this ding the academic production on the use of con- subject, which indicates that there is a need for doms as a strategy for HIV/AIDS prevention. greater debate and epistemological and metho- Firstly, the literature on this topic can be des- dological maturation in relation to the theoreti- cribed as concentrating on investigating some cal framework of vulnerability, as well as with groups of participants and on discussing some regard to the theoretical and methodological fra- topics in particular, while leaving out some sub- meworks used in studies on condom use as an jects, contexts and issues that have been shown HIV/AIDS prevention strategy. to be important in coping with the AIDS epide- We see this maturation process as a task that mic and in the adoption of preventive practices. cannot be delayed and as a historical commit- This diverges from the impression that the lite- ment that is necessary for coping with the AIDS rature is wide-ranging and diverse, which might epidemic, in the following senses: (a) recogni- be supposed when looking at the amount of stu- zing the population groups that are most affec- dies published that address this subject. In this ted; (b) seeking to comprehend their complex regard, it is opportune to develop new studies susceptibilities socially confi gured; and (c) de- that analyze and create panoramas regarding this signing vigorous, creative and potent approaches production, so as to delineate the paths that need that are capable of involving individuals and to be traced out or strengthened, in investigating groups so that they can appropriate and mobilize the fi eld of prevention of HIV/AIDS. in an authentic manner in order to fi nd practical Another characteristic observed was that alternatives that make it possible to overcome the literature studied was of diffuse nature in re- the conditions that shape their vulnerabilities. gard to the logic of the production of knowledge. Despite the inherent value of a production that References comprises different theoretical-methodological bases, we found an interweaving of approaches Adam, B. D., Husbands, W., Murray, J., & Maxwell, and directions, which at some moments seemed J. (2005). AIDS optimism, condom fatigue, or self-esteem? Explaining unsafe sex among gay confusing. We saw this in identifying the perma- and bisexual men. The Journal of Sex Research, nence of studies based on behavioral approaches 42(3), 238-248. towards prevention, which linked this to condi- Albuquerque, G. A., & Villela, W. V. (2011). Uso do tions of vulnerability that, in the history of opera- preservativo feminino como método contracep- tional concepts of investigations within the fi eld tivo: Experiências de mulheres em uma Unidade of AIDS, mark criticism and surpassing of the Básica de Saúde no município de Juazeiro do individualistic perspective of this fi rst approach. Norte - CE. Revista de APS - Atenção Primária We found a variety of references to vulnera- à Saúde, 14(2), 185-196. bility to HIV among the set of studies analyzed, Alves, A. S., & Lopes, M. H. B. M. (2008). Conheci- ranging from a more superfi cial usage of the spe- mento, atitude e prática do uso de pílula e preser- cifi c terms of this framework to a more substan- vativo entre adolescentes universitários. Revista tial appropriation of this referential framework, Brasileira de Enfermagem, 61(1), 11-17. including intermediate positions of linkage be- Ayres, J. R. C. M. (2002). Práticas educativas e pre- tween this and the notion of risk, or between venção de HIV/Aids: Lições aprendidas e de- this and a behavioral approach. We assume, on safi os atuais. Interface – Comunicação, Saúde, the one hand, that the formulations and termi- Educação, 6(11), 11-24. 856 Pinheiro, T. F., Calazans, G. J., Ayres, J. R. C. M.

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