Nicaragua Diary:
Reaching the High Risk to Keep HIV Low

MANAGUA, Nicaragua — It is late afternoon in a porno theater in the Zona Rosa, an entertainment district of Managua. In the first row of seats, straight men are taking it all in. But in the darkened back of the theater, men are hooking up with other men. Outside at the concession stand, Maynor Yanil Gòmez Osorio, promotor de Comunicación para el Cambio de Comportamiento of PASMO, PSI’s affiliate organization in Central America, is working — chatting up theater management, talking to patrons about safer sexual behavior and trying to keep Nicaragua’s HIV prevalence the lowest in Central America. Maynor, who has been a PASMO promotor for five years, has a disarming smile and a pleasant manner, and it is easy to see why people trust him for advice on how to protect themselves.

Playing Games with Sex Workers
A couple of kilometers away, Nelson Anibal Gonzalez Moreno, another PASMO promotor, is leading a game of “1-2-3 Saludable” (1-2-3 Healthy), originally developed by PASMO/Guatemala, with a group of five female commercial sex workers (CSWs) just off a street in a lower/middle class area of Managua. The card game consists of a series of questions and answers pertaining to safer sexual behavior, including how to use a condom and what kind of lubricant to use and to not use, and was specifically developed for high risk groups. Although Nelson has been a promotor for only a few months, he has the same good humor and trustworthy demeanor as the much more experienced Maynor. He has the women’s rapt attention and laughs easily with them. Two of the women are university students and are doing this to make ends meet. An infant is bouncing around the room in a walker; I assume he belongs to one of the women playing the game with Nelson. But eventually another woman and man emerge from a back room together. The man leaves, and the woman goes to pick up the baby. And then I understand: The CSWs playing the card game were looking after the baby while the infant’s mother was in the back, taking care of business.

Epidemic Driven by MSMs
These are just two of the many activities conducted every day by the behavior change communication promotores of PASMO, the Pan American Social Marketing Organization that came to Nicaragua in 1998. HIV epidemics in Central America are related mainly to HIV transmission during unprotected sex between men and unsafe paid sex, according to UNAIDS’s 2007 Latin American AIDS Epidemic Update Regional Summary.

In Nicaragua, 2002 HIV infection levels among men who have sex with men (MSM) were 38 times higher compared with HIV prevalence in the adult general population (this is a much greater difference than Honduras, Guatemala, Panama and El Salvador)1. One half of men harbored misconceptions about HIV transmission. More than half of men said they had not consistently used condoms with non-regular male partners and almost half of CSWs said they had not consistently used condoms with new and regular clients. However, not all was gloomy: Only 8% of MSM tested positive for HIV, the lowest of the five Central American countries tested Nicaragua (9.3% based on more current data from 2003-2005). And HIV prevalence among female sex workers was only 0.3% based on the more current data. The people I talk to believe that condom use among these people engaging in high-risk behavior has increased since 2002.

Waiting for Health Care to Improve
JINOCUAO, DEPARTAMENTO DE CHINANDEGA — It is 10 o’clock at the Centro de Salud of Jiñocuao, a remote village in the northwestern corner of Nicaragua, 10 kilometers from Honduras and far from the streets of Managua. It is already hot and humid. A dozen people are sitting on the benches in front, waiting for the doctor who has been called away to deliver a baby (Nicaragua is one of only three countries in the world where abortion is illegal with no exceptions). Residents say that under Daniel Ortega, the Sandinista leader who returned to power in 2006 elections with 38% of the vote, health center fees have been eliminated and medicines have become more available. Of course, that doesn’t mean they are always there or are affordable at the pharmacy. People in Jiñocuao are very pro-Sandinista; many of them fought a guerilla war against the Contras in the 1980s. Even though things are far from perfect in the new Ortega administration, people in Jiñocuao are sympathetic towards Ortega. One of them, a leader of the village, tells me: “Previous governments left the country in such bad conditions that, for all his efforts, Daniel has a hard time improving things. Every time he patches a pothole, another one pops up.” A natural medicine center (where the most expensive product is 30 cordobas, about US $1.50) provides products made with local plants, and is a popular — and always more affordable — alternative to modern medicine. But it has no traditional methods of contraception, for which there is growing demand.

PSI Meets PASMO in Chinandega
CHINANDEGA — I am driving back to Managua from a private trip, unrelated to PSI. But when we stop in Chinandega to refuel, I spot a PASMO vehicle garishly painted with VIVE condom brands. Inside the mini-mart I introduce myself to Adan Hernández Sandoval, a PASMO sales promoter, who is restocking the 13 VIVE brands in this sales outlet. He is surprised to run into someone from PSI/Washington out here, in the far west of Nicaragua. He is one of four PASMO salesmen and behavior change communication promoters assigned to the region of León. He says sales are good in his region.

Club Connects with Youth
CIUDAD DE SANDINO — I visit one of two PASMO youth centers in Nicaragua, called Club en Conexión, this one in a very poor area of Ciudad de Sandino, about 20 kilometers from Managua. PSI Board Member Ashley Judd visited this center in 2006. Young people between the ages of 20 and 29 are particularly vulnerable to HIV/AIDS, according to the Ministry of Health: The majority of people with HIV and AIDS from 1987 to March 2008 are in that age range. These centers provide a conducive place for adolescents to get together to surf the Internet, watch movies, listen to music and dance, but also to learn about how to manage their reproductive health and protect themselves from sexually transmitted infections (STIs), including HIV. Martha Karolina Ramirez, the coordinator of Comunicación para el Cambio de Comportamiento, says that the centers strongly promote abstinence and delayed sexual debut as the first line of defense but also provide information about condoms for those already sexually active. These youth centers also exist in Guatemala, El Salvador and Honduras. The objectives are to reduce the incidence of STIs and HIV and to improve the sexual and reproductive health of low-income youth. PASMO reports that in 2006, in all four countries:

• More than 1,200 youth were trained as peer educators;
• More than 970 of the educators replicated activities with their peers;
• More than 6,700 activities were held directed at low-income youth;
• More than 98,400 youth were reached through these activities.

PASMO does not know the real health impact of all this activity and, if, for example, the age of first sexual relations has gone down. That should be revealed in the next Demographic and Health Survey.

Keeping HIV Low
MANAGUA — The next day at lunch time, Maynor drops me off at the airport. Always smiling, he will immediately head for the Zona Rosa and more encounters with the high-risk individuals, work that could determine whether or not Nicaragua’s HIV prevalence remains one of the lowest in Central America.

— David J. Olson

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Three Nicaraguan youth stop by the PASMO youth center in Ciudad de Sandino on their way home from school.