106

Chapter 5

Start where people are at. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

ACTIVITY: Secret questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Learn how STIs spread to help prevent them . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

Preventing STIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
How sexual networks spread infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
ACTIVITY: Handshake game. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

Facts about STIs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

Testing and treatment are essential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

Women’s equality prevents STIs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

Gender roles and STIs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

ACTIVITY: An STI drama. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
ACTIVITY: An STI board game. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Men share responsibility for STI prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126

Men as peer educators and role models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Community education where men gather. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Opposing gender-based violence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

Safer sex requires good communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130

Comfort with condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
ACTIVITY: Playing with condoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Change — it’s a process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

Community strategies for STI prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134

ACTIVITY: A treasure hunt to find resources for community STI prevention. . . . . . . . . . . 135

Help adolescents protect themselves from STIs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

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 107

Preventing Sexually
Transmitted Infections (STIs)
I am embarrassed, but I will tell
you. Esteban returned from the
Please tell me what’s city 2 weeks ago, and I was so
wrong, Clara. glad to see him. But now having
I can see you’re not sex is painful and it even hurts
feeling well. when I pee. I almost want him
to go away again! I don’t know
what to do.

Sexually transmitted infections, or STIs, are illnesses that pass from one person to
another during sex. All STIs can be prevented, but prevention is difficult for many
people, especially women.
To prevent STIs, it is important that people become comfortable thinking about
and talking about STIs without embarrassment or shame. Discussing STIs in a group
can help people talk about these infections as easily as they talk about health problems
that are not related to sex, such as diarrhea or the flu. Group discussions can also help
people understand how an STI never harms just one person. Learning about STIs with a
group can help spread prevention throughout the whole community!

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108 Preventing Sexually Transmitted Infections (STIs)

Start where people are at

When you are starting a conversation about STIs, it is almost always helpful to begin
by asking people what their concerns are and what they already know. Many people
today know something about HIV (Human Immunodeficiency Virus), because it is the
STI that causes AIDS (Acquired Immunodeficiency Syndrome). Millions of people all
over the world have died from AIDS, and millions more are infected with HIV now.
Because AIDS has been so deadly in the past but is now survivable, most countries have
programs to teach people about preventing and treating HIV.

Since so many people have heard

of HIV, I often ask what they have
learned about how to prevent it.

Yes, what they know

about HIV applies
to most other
STIs, so it’s a good
starting place.

Women are especially vulnerable to STIs and STIs are especially harmful to women
if they are not treated. Some STIs can cause severe illness, infertility, problems with
pregnancy, and even death. STIs can also cause serious health problems and lifelong
disabilities in babies born to women with untreated infections. Supporting women to
develop their ability to express their needs is key to helping them prevent STIs. “Gender
boxes” on page 44 and “Communication is powerful” on page 58 can help you work
with women learning to speak up. Also, you can adapt most activities in this chapter to
focus on STIs in general or only on HIV.

When I gave my first STI talk, I talked mostly about the risks
of unprotected anal or vaginal sex. I noticed people were only
half listening, and they were whispering among themselves.
Afterwards, some women came up to me. They took all the free
condoms I was handing out, but that wasn’t their main interest.
The thing that was on their minds was a man they had seen
with sores on his lips. I wish I had asked them at the beginning
of the meeting what their concerns were! I would have talked
more about signs of STIs that you can see.

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Activity Secret questions

Sometimes people feel uncomfortable asking questions about STIs in a group. This
activity can make it easier for people to ask about things they are concerned about,
or do not want to admit they do not know.

This activity works best when everyone in the group knows how to write. It can work
with a group of both women and men, as well as with only women or only men.

➊ Ask everyone to write down at least one question about STIs on a small piece of
paper. Collect the papers and put them in a bag or hat. No one will know who asked
which question, and you can also add questions you think people would like to ask
but are too shy to ask even privately.

I ask people to send a text message or call me

before the meeting and leave their questions on
my voicemail. They trust me not to reveal who
asked what.

➋ Review the questions and choose some to answer. You can do this at the beginning
or end of a meeting, or you can make it the focus of the whole meeting. You can also
save some questions for another meeting. But explain what you are doing so no one
feels her questions were ignored.

➌ Depending on the question, you might simply answer it, invite someone else to
answer it, or use it to start a discussion. You can invite a health worker to join you to
help answer questions.

Keep a box where people can put questions they do

not want to ask aloud. Take questions from the box
to read and discuss at each meeting.

I always remind the group that there is no such thing as

a stupid question, and that if one person has a question,
chances are many others have the same concern.

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110 Preventing Sexually Transmitted Infections (STIs)

Learn how STIs spread to help prevent them

Sexually transmitted infections are caused by different kinds of germs that live in a
person’s blood, semen, or vaginal fluids. These germs are too small to see. STIs are
passed from person to person only when an infected person’s blood, semen, or vaginal
fluids get inside another person’s body through contact between the vagina, penis,
or anus, or through cuts or sores in the skin. You cannot get any STI from touching a
person in other ways, from sharing food or toilets, or from insect bites.

Unprotected sex. All STIs can pass from an infected person

to another person if the couple has intercourse (man’s penis
in a woman’s vagina) or anal sex (man’s penis in a woman’s
or a man’s anus) without using a condom.

Oral sex. STIs can also pass from an infected person to another person
if the couple has oral sex (putting the mouth on another person’s penis,
vagina, or anus) without using a condom or a latex barrier between one
person’s mouth and the other person’s genitals. HIV is rarely passed from
person to person with oral sex, but other STIs such as gonorrhea, herpes,
and HPV (human papilloma virus) can be passed easily this way.
All STIs can be passed during sex, but some can also be passed in other ways.

Mother-to-child. A woman can pass most STIs to a baby during pregnancy

or childbirth. HIV is the only STI that can also be passed from a woman to a
baby through breastfeeding.

Blood transfusions. A person can become infected with

HIV, syphilis, or hepatitis B or C through a transfusion of blood
that has not been tested to prove it does not contain the germs
that cause these infections.

Injections, skin piercings, or tattoos using unsterilized needles

or sharp tools. A needle or sharp tool used to inject medicine or
drugs, pierce the skin, shave, or tattoo a person with hepatitis B
or HIV can pass those infections if it is used on another person. A new sterilized needle
or tool should be used each time for injecting, piercing, shaving, or tatooing.

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A person can have more than one STI at the same time. Having one STI often
increases the risk of getting another one, because the infection weakens the body’s
resistance to other STI germs. Discharge from the penis or vagina, or sores on the skin,
make it easier for germs to get inside the body.

STIs pass more easily from a man to a woman

There are 3 main reasons why women’s bodies are more vulnerable to STIs than men’s
bodies.
1. The semen of a man with an STI contains more germs than the vaginal fluids of
a woman with an STI, so a woman receives more germs when a man ejaculates or
climaxes inside her than a man receives from putting his penis inside the woman’s
vagina, anus, or mouth.
2. When a man with an STI has unprotected sex with a woman and he climaxes
inside her, his semen stays inside her body long afterward, so the STI germs
have more time and favorable conditions for causing an infection in the woman.
Rinsing the inside of the vagina after sex will not remove all of the semen.
3. The skin of both the vagina and the anus is thin and easily cut or torn during sex,
while the skin on the penis is thicker, so STI germs pass more easily through the
skin inside a woman’s body than through the outside skin on the man’s penis.

Men are more vulnerable to STIs when they have

sex with other men, especially the man who is
being penetrated. Unprotected sex in the anus is
the most dangerous type of sex for spreading HIV
and other STIs. Always use a condom!

Preventing STIs
Safer sex means ways of having sex that prevent or lessen the likelihood of STIs passing
between partners. It means having as little contact as possible with the skin of your
partner’s genitals and not letting fluids from your partner’s penis or vagina touch your
genitals or mouth (see pages 90 and 130 to 133 for more information). Safer sex is more
likely to happen when a woman is able to talk about sex with her partner (see pages 99
to 103) and when communities promote conditions that empower girls and women,
including through access to education and health services for the testing and treatment
of STIs.

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How sexual networks spread infections

Understanding how certain patterns of sexual relationships spread STIs can help people
understand the importance of preventing STIs in every relationship. Many women
want to believe that they can protect themselves by being faithful to their husband
or partner. But this works only when both partners are faithful and do not have any
infection when they first start to have sex together.
This activity can help people see how an infection can spread through a whole
community, even if only some people have more than one sexual partner.

Activity Handshake game

This activity uses HIV as an example, but all STIs can spread the same way.

To prepare, gather a small piece of paper for each person. Draw a circle on 3 papers.
Draw an X on 1 paper. Leave the others blank. Fold the papers to hide the markings.

➊ Mix the papers up and give one to each Hello. Let me

I’d like to
shake your
person. Ask everyone to look at her own paper shake your hand, too!
but not at anyone else’s. hand.

➋ Ask the participants to

walk around and shake
hands with 3 people and
then sit down.

➌ Ask the person with the X

on her paper to stand up.
Ask everyone who shook
hands with that person to
also stand up. Ask anyone
seated who shook hands
with anyone standing to
stand up too. Repeat this
until everyone is standing.

Explain that for this activity, the X represents HIV and shaking hands with the
person holding the X meant having unprotected sex. This means that all the people
standing might now have HIV.

➍ Ask those with a circle on their papers to raise their hands. Explain that the circle is a
condom, so the people using condoms were protected from HIV and can sit down.

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 Learn how STIs spread to help prevent them 113

Activity Handshake game (continued)

➎ Discuss the activity. You might ask questions like these:

• How did the person with the X feel to find out this meant having HIV?
• How did everyone feel when they had to stand? How is this like a person
finding out he or she had sex with someone who has HIV?
• When you learned the circle represented a condom, did you feel relief? Did it
make you glad you had used a condom?

➏ Collect all the papers and pass them out again. Do the activity again, but this time
give some choices anyone can use for preventing the spread of the infection.

• No sex at all ― the person does not shake hands.

• Use a condom ― have some plastic bags or socks people can use to cover their
hands.
• Have only one partner who has no infection and has sex only with you ― shake
hands after looking at each other’s papers and stay together without shaking
anyone else’s hand.
• Be sexual in ways that do not share body fluids, such as giving pleasure by
using hands ― touch fingertips or elbows instead of shaking hands.

➐ After the activity, ask the person with the X to stand up again. Then ask people to
stand up if they shook hands with that person without covering their hands.

➑ Ask anyone who did not stand to say what action they took to protect themselves.

➒ You might also ask whether it was difficult or uncomfortable for anyone to “use
protection” while shaking hands. Why? Would it become more comfortable with
time? Or if they had a single, faithful relationship, was that difficult? Why?

➓ Discuss what makes it easier or more difficult to talk about STIs with a partner.

• How would you feel if someone you had sex with told you that he or she had
an STI? Is it better to know or not know? Why?
• If you think it is better to know, how can you make telling someone easier?
• What can you know for certain about a sexual partner? What can you not know
for sure?

You can end this activity by reminding everyone that no casual contact such as
shaking hands or hugging can pass HIV or any other STI from one person to another.

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Facts about STIs

Discussing the health problems caused by STIs that go untreated can help everyone
understand the importance of seeking treatment and of preventing the spread of STIs in
the first place. Here is some general information about different STIs. You can find out
more in Where Women Have No Doctor or by speaking with a health worker.

Gonorrhea and chlamydia are easy to cure if treated early. If not, they can cause
serious infection and infertility in both women and men, and serious problems
for a baby during both pregnancy and childbirth.
Signs in a woman: she may have no signs at all, or they may not appear for several
weeks after sex with an infected person. There will be discharge from the vagina,
lower belly or pelvic pain, fever, and pain when passing urine. Oral sex with a
man who has gonorrhea can cause a sore throat with pus or swollen neck glands.
Signs in a man: often no signs, or signs may appear 2 to 5 days after sex with an
infected person. There will be discharge from the penis, pain when passing urine.
These infections can also affect a pregnancy by causing early labor, low-weight
babies, baby dying in the womb (stillbirth), or early infant death. In a newborn
baby they can also cause pneumonia and eye infections leading to blindness. A
woman can also get a womb infection (pelvic inflammatory disease), or a baby
can grow outside the womb (ectopic pregnancy), which can lead to infertility and
even death.

Syphilis is an STI that has effects throughout the body and can last for many
years. It can be cured with medicine if treated early, but will lead to serious illness
and death if not treated.
Signs in a woman and man: a soft painless sore (chancre) on the genitals that may
look like a blister or an open sore.
Syphilis does not affect fertility, but it can cause early labor, low-weight babies,
baby dying in the womb (stillbirth), or early infant death. Also, the baby may be
born with syphilis, leading to severe illness and death.

Trichomoniasis (trich) is a very uncomfortable and itchy STI that can be cured if
treated. Women and men often do not have any signs.
Signs in a woman: unusual bad-smelling discharge from the vagina, with red and
itchy genitals, and pain or burning when passing urine.
Fertility in both women and men can be affected, and a baby girl can be born
with a vaginal infection. Rarely, a baby may develop problems when passing
urine, and have trouble breathing.

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Chancroid causes painful sores on the genitals or anus that bleed easily and
swollen glands (buboes) in the groin. It is easily confused with syphilis. It can be
cured with medicine.

Herpes (HSV, genital herpes) is caused by a virus. There is no cure for herpes but
there is treatment to make a person feel better.
Signs in a woman or man: none, or during the first infection, may feel severe
burning and itching in the genitals followed by small painful blisters like drops
of water on the genitals that burst open and form painful open sores, along with
feeling ill, like having the flu. After the first infection, a sore will appear in the
same place over and over, but may be milder.
If a woman is pregnant and it is a first infection, herpes may cause a baby to
die in the womb (stillbirth), a severe infection in the baby, or problems in the
development of the baby’s brain and nervous system.

Hepatitis B (hep B) cannot be easily cured because the medicine is expensive and
often not available, but it can be prevented with a vaccine.
Signs in a woman or man: none, or fever, fatigue, yellow eye or skin (jaundice),
dark urine, and whitish stools.
Hep B can affect fertility and pregnancy if there is serious damage to the liver, and
can cause liver disease and cancer. A baby born to a woman with hep B may also
get the disease.

Human Papilloma Virus (HPV, warts) are small, painless bumps that have a rough
surface and can be removed, but not cured.
Signs in a woman: the bumps appear on the outside (vulva) and inside of the
vagina, and around the anus. Warts may grow larger and bleed during childbirth,
and a c-section may be required. Rarely, warts can pass to a baby during childbirth.
Signs in a man: the bumps appear on or inside the penis and around the anus.
Some types of HPV that can cause cancer of the cervix or penis can be prevented
with a vaccine. Regular cervical cancer tests for women can help find early signs.

Human Immunodeficiency Virus (HIV) has no cure, but treatment can help people
with HIV live longer and in better health.
Signs in a woman or man: none, or 2 to 4 weeks after contact a person may feel ill,
like having bad flu, diarrhea, fever, swollen lymph nodes, and weight loss.
HIV does not affect fertility, but it may cause early labor and can be passed to a
baby during pregnancy, birth, or breastfeeding, so testing is important.

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116 Preventing Sexually Transmitted Infections (STIs)

Testing and treatment are essential

Most STIs can be in a person’s body without showing any signs. This means that
a person can have an STI and pass the infection to others without knowing it. It
also means that many women have serious womb infections, ectopic pregnancies,
miscarriages, and other health problems caused by STIs that went untreated, because
the women didn’t know they had an infection.

One way to stop STIs from Why should

spreading is for women and I go to the
men to get treated as soon as clinic?
they have any signs and make
sure their partners get treated
at the same time. STIs can be treated with
medicines, but a person can get infected again
after treatment if she has unprotected sex with
a partner who has an STI. We can’t cure
Women and men should also get tested the infection
unless we treat it
every 6 to 12 months if they have unprotected
together.
sex with more than one partner, if they think
their partner may have sex with other people,
or if they or their partner injects drugs such as heroin. Some tests use a blood sample;
others use a sample of fluid from a woman’s vagina or a man’s penis, or a sample from a
person’s mouth.

Routine testing helps lessen the stigma of STIs

Health centers can help lessen the stigma of having an STI by providing testing and
treatment as a routine part of health care for both women and men. For people to be
comfortable getting tested for an STI, they need to trust that they will be treated with
respect and privacy.
Some health centers do provide STI testing and treatment as part of family
planning services and regular pregnancy check-ups. When men accompany women on
these visits, health workers can encourage them to get checked and treated for STIs. This
means the woman does not have the extra burden of telling her partner and making
sure he gets treated.

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 Learn how STIs spread to help prevent them 117

“Wellness check-ups” take the stigma

out of STI testing and treatment
Most people in Papua New Guinea live in rural areas far from health centers.
STIs are very common in these communities, because many people do not know
about prevention and cannot easily get tested and treated for infections. Many
women suffer from pelvic inflammatory disease (PID), a serious infection of
the womb that is often caused by untreated STIs. PID often causes infertility, so
a woman who has had it may never be able to get pregnant and have children.
Infertility can be very sad for any woman, but infertile women in Papua New
Guinea may be isolated from the community and beaten by their partners.
Marie Stopes International provides STI counseling, diagnosis, and treatment
to rural communities through mobile outreach teams. These teams of 2 or 3 heath
workers travel to remote parts of the country carrying the equipment they need in
small vans. By helping people understand how infertility can be caused by STIs,
these teams help motivate people to practice safer sex and get tested for STIs.
This program is successful in part because it brings information and services
directly to people in their communities. But it is especially successful because STI
services are included in “Wellness check-ups” for men, women, and youth. This
makes it easier for young people and unmarried women to have access to family
planning and STI services as part of general health check-ups.
The outreach
teams are also
well received,
because they
provide services
without judging
people’s customs
or relationships. In
the highland region,
where polygamy is
common, clients are
provided with treatment
for all sexual partners in
the marriage, if they choose.

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Women’s equality prevents STIs

The larger problems of injustice and inequality make women more likely to become
infected with STIs. For example, being poor does not spread STIs, but being poor can
mean a woman may trade unprotected sex for money or other needs. Many situations
can make it either easier or more difficult for women to protect themselves from STIs.
A woman may be LESS ABLE to prevent STIs if:

Most men in her community

have many partners.

She was married as a girl and is expected

to obey her husband without question.

She is a sex worker. Some men will not

pay if she asks them to use a condom,
or they react with violence.

She cannot read, or she

has never heard of STIs.

The government does

not support affordable
health services for women.

She does not give importance to her own

health problems and feels ashamed
to talk about her private parts.

Her partner is abusive and

often forces her to have sex,
especially when he drinks.

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 Women’s equality prevents STIs 119

A woman will be MORE ABLE to prevent STIs if:

She finishes high school and can

get a job to earn her own money.

She inherits property after her

parents or her husband die.

She and her partner know how to

give each other pleasure and use condoms
each time they have intercourse.

Her schooling included

sex education.

She gets free or low-cost health care at a clinic

near her home, including STI testing
as part of regular health and pregnancy care.

She believes that her own sexual health is important,

and she is not ashamed of her body or her sexuality.

She can decide when, how, and with whom

to have a sexual relationship.

It’s so easy to blame an individual woman or man for getting an STI

and failing to protect themselves. I like to use the “But why?” game
to help people see the ways that inequality makes it harder for
women to protect themselves. Then we do a yarn toss to brainstorm
things to do at a community level to make things better.

Chapter 3: Gender and Health and Chapter 4: Sexuality and Sexual Health suggest
many ways to improve conditions and help women prevent STIs.

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Puppet theater raises awareness

about domestic violence and HIV
In Lucknow, India, a group of adolescent girls uses giant puppets to speak out
against domestic violence and to provide information about HIV. They perform
short plays in public places and afterward speak with the audience about the rights
of abused women, and what community resources are available for preventing
both violence and HIV.
Puppet theater always draws a large audience, including people who would
not usually stop to listen to someone giving a talk in a public place. So puppets
provide important community education for people who might not have any
other access to the information. Just as important, working on this project has
transformed the girl puppeteers themselves. Many of them were not accustomed
to speaking out in public. Now, they say they feel self-confident and committed
to working for change. Their families, especially their mothers, also feel they are
doing good work.

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Gender roles and STIs

One of the reasons STIs spread so easily is that unhealthy gender roles prevent women
from being able to protect themselves.
Gender roles include expectations about what women and men do in sexual
relationships. When men are expected to control how and when they and their partners
have sex, they may not consider how women feel, and women often believe that their
feelings about sex do not matter. But to prevent STIs, women and men need to be able
to talk honestly with their partners about safer sex and to agree to make safer sex part
of their relationship.
For more information and discussion about gender roles, sexuality, and health, see
Chapter 3: Gender and Health and chapter 4: Sexuality and Sexual Health.

My partner and I
tried using condoms, but
sex didn’t feel the same,
so we stopped.
Jorge would
accuse me
of having
another
man…

Let sex workers use

condoms. I only have one
partner, so I don’t have to
worry about STIs.

Use drama to discuss gender roles and STIs

Creating a drama and acting it out with a group is a good way to look at the way gender
roles create barriers to preventing STIs. People enjoy radio and television dramas
because the characters are always getting into trouble and the stories include many
surprises. A drama can show characters doing things no one talks about, such as a man
paying a sex worker or having a sexual relationship with another man. You can use
a drama to discuss changes that would help more women and men take care of their
sexual health. You can also use a drama to have a deeper discussion about how gender
roles influence people’s sexual relationships.
The sample drama on the next page shows how to combine a drama with
discussion. You can also adapt the sample drama using characters and situations that fit
your community.

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122 Preventing Sexually Transmitted Infections (STIs)

These are some ways to make the drama interesting and useful for discussion:
• Give characters realistic emotions, and understandable reasons for their actions.
• Show characters making mistakes and also making healthy choices.
• Think about ways to include problems with consenting to have sex, power differences
between characters, and how people of different ages make sexual choices.

A sample STI drama

Characters:

Nina: 18 years old, religious, married to Rajiv with 3 children

Rajiv: t ruck driver, married to Nina, often drives to the city, has a girlfriend
named Roopa in another village
Roopa: Rajiv’s girlfriend, mother of Rajiv’s baby
Mohan: married and faithful to Maya, has HIV but does not know it
Maya: village health worker, married to Mohan
Gita: sex worker in the city
Roopa takes her sick baby to see Maya, the health worker. Maya treats the
baby and then talks to Roopa about HIV. Asked if her boyfriend uses condoms,
Roopa says no. (You can stop here to discuss STI prevention in Roopa’s situation.)
Maya tells Roopa that although her husband Mohan is faithful, they always
use condoms because they had sex with others in the past. At first Mohan did not
want to use them but now he is used to them. (Another place to stop and discuss.)
Meanwhile, Rajiv is driving his truck to the city. That night, he arranges to
have sex with Gita, a sex worker. (Stop and discuss again.)
To Rajiv’s surprise, Gita insists on using condoms! Her sex workers’ union
taught about HIV, and they agreed to demand that all their customers use
condoms. Rajiv has had sex with many women, but Gita is the first to make him
use protection. He objects at first, but she makes using a condom so sexy that he
does not mind. (Stop and discuss again.)
In the morning, Rajiv returns to Nina. He rememberss what Gita said about
HIV. Rajiv considers talking to his wife about condoms but decides she would
suspect he is unfaithful. That evening, Rajiv and Nina have sex without a condom.
(The story could continue with more scenes, but this is a good place to stop.
Discuss what has happened and what people think will happen next. See the
questions in step 4 of the activity on the next page.)

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Activity An STI drama

Before this activity, create a drama. It should have several situations that connect
different characters to each other through sexual relationships.

➊ To begin the activity, make sure the participants understand how STIs spread. See
page 110. If the group has not done the Handshake game on pages 112 to 113, it may
be a good idea to do that first.

➋ When the group is ready, ask different people to be characters in the drama you
have created. Tell them the story and give them a few minutes to work out how they
will act out the scenes.

➌ As the actors perform the drama, stop it at certain points to ask how their actions
help spread or help prevent STIs. You might also ask at each point what a character
could do differently to protect her own or her partner’s health.

What do you think I think Roopa could

the characters in decide to ask Rajiv
the drama should to use a condom.
do now? After all, she knows
he has sex with
other women.

I want to know
what Gita does
with the condom to
make Rajiv like it.

➍ At the end of the drama, ask the actors to leave their roles and join the group
to discuss how the characters’ gender roles influenced their ability to protect
themselves or their partners from STIs.

You might ask people to consider the ways each character fits gender expectations
about being a man or woman. How does gender inequality make it more difficult for
the women in the drama to protect themselves from STIs?

What would happen if the characters were more honest with each other about their
sexual relationships and how they can give each other pleasure? What makes this
difficult?

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124 Preventing Sexually Transmitted Infections (STIs)

Activity An STI board game

You can adapt the board game on pages 197 to 199 to discuss the facts about STIs
and how to prevent STIs from spreading. The discussion during the STI board game
will help your group:

• test what they know about different STIs.

• explore the reasons why women may have difficulty preventing STIs.
• practice explaining why preventing STIs is important for women’s health.
• find out what they want to learn more about.

For more instructions about how to make the board game and how to play, see
pages 197 to 199.

To prepare: Make STI health fact questions. The chart

on pages 114 to 115 has information about STIs that
you can use to make health fact questions such as
the ones on this page. (The answers are included for
you here, but do not put them on the cards. Make a
separate answer sheet instead.)

ss
Kissing will NOT pass
that can pa
HIV from one person to 3 STIs a b y
Name to her b
another. True or False? woman or bir t h .
from a egnancy
pr
during
,
yphilis
(correct answer: True)
3 o f t hese: s dia)
er, any hlamy
t answ rhea, c
(correc titis B, gonor
pa
HIV, he

h chlamydia Name
A person wit
gns of infer 2 STIs th
always has si ti a
or False? treat lity in a t can ca
illness. True ed w w u
ith m oman if se
edicin not
er: False) es.
(correct answ
(corr
these ect answe
: chla r, any
my 2
tricho dia, gono of
mon rrhea
iasis) ,

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 Gender roles and STIs 125

Activity An STI board game (continued)

STI discussion questions. To make discussion

questions, think about real-life situations and
reasons why it may be difficult for women in the
community to protect themselves from STIs. There
are no right or wrong answers to these questions.
The purpose is to discuss the situation as a group.
Here are some examples:

ed for
te b an h av e been marri
Clara and Es Esteban
ey h av e 3 children.
6 years an d th layer to
to w or k as a brick
went to the
ci ty returned,
on ey . N ot lo ng after he
make extra m discharge
a st ar te d h aving a yellow amed to say
Clar o ash
na. She is to barrassed to
from her vagi an , and o em
to
g to Es te b
anythin
worker.
tell a health
do you think
ld Cl ar a do? What
What sh ou im? Why?
w ou ld do if she told h
Esteb an

Anisha has had HIV since she was born.

To play: When a team or The government provides free medicines, and
player lands on a discussion she is a healthy young woman. A few years
question, ask them to think ago, a man she loved asked her to marry
about different solutions and him, but when she told him she had HIV,
then explain to the whole he was very upset and went away. Later
group why they think one she met Milan. They are very happy, and
solution may be better than he says he wants to marry her and have a
others. Invite others in the family. Anisha is afraid to tell him she has
group to make suggestions HIV for fear he will abandon her too.
too. What should Anisha do? What should Milan
When the game is
do? Why?
finished, invite the players to
talk about something they learned from the activity. Ask if there are other issues or
information related to STIs that the group would like to discuss or learn more about.
Use their responses to plan other activities.

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126 Preventing Sexually Transmitted Infections (STIs)

Men share responsibility for STI prevention

Ideas about masculinity often make men believe they should have control over how
and when they have sex. For some men, this includes having several sexual partners
or keeping secrets from their wives or girlfriends. Men may feel it is unmanly to
worry about protection from STIs or to take care of their health. They may also be
ashamed to admit that they do not fit the male gender role they are expected to play, for
example, having sex with other men or preferring to solve problems without using force
or violence.
But some men are also actively promoting gender equality, working to prevent
violence, and showing how men and women can have healthier sexual relationships.
There are examples of these activities in most of the other chapters in this book — see
especially Chapter 3: Gender and Health, Chapter 4: Sexuality and Sexual Health,
Chapter 6: Ending Gender-based Violence, and Chapter 8: Healthy Pregnancies and
Safe Births. Here are some examples of ways men are organizing to prevent STIs,
especially HIV.

Men as peer educators and role models

One of the most effective ways to engage men in promoting sexual health is for them
to have mentors and to be recognized and admired for their efforts. Many projects all
over the world are training men to listen to and talk with other men about what kind of
man, husband, and father they want to be.

Men in Tanzania become HIV prevention champions

The CHAMPION Project encourages men in Tanzania to become more
involved in family health as a way to prevent the spread of HIV and other STIs. The
project promotes a national dialogue about men’s roles, shared decision making in
couples, and practicing safer sex.
In politics and public life in Tanzania, men make the decisions. But in
many people’s minds, men do not step up to care for their families’ health. The
CHAMPION organizers found this was not exactly true. The organizers met with
community leaders in many districts around the country. They asked these leaders
“which man in your community stands out because of his efforts to promote the
health of his family or community?” And there were 2 or 3 men named in almost
every village. That may seem like a small number of men, but the CHAMPION
Project saw it as a good starting place.

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 Men share responsibility for STI prevention 127

One man was working to stop family One man decided to have only 1 wife and
violence and restore peace in remain faithful to her, unlike almost every
households where there was fighting. other man in his village.

The Project held community meetings where these men made presentations
about their lives, their motivations, and their efforts to promote better health.
After hearing their testimonies, each community chose one of the men as their
local champion.
Then, to show everyone there
were men like this in Tanzania, the
CHAMPION project selected a group of
men and created a national campaign
about them. The campaign included
a photo exhibit to share the stories of
12 of the men. They held a big event in
the capital city to get the attention of
the whole country. They also put the
men’s pictures and their stories into a
calendar that was distributed all over
Tanzania.
By training men about gender
awareness, the Project has drawn both
younger and older men into the work
of counseling couples, talking with
men about preventing HIV and other
STIs, and helping other men see how
gender roles can harm their health and
the health of their families.

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Community education where men gather

The best way to involve people in any activity for change is to meet them in activities
they are already involved in. Sporting and religious events, workplaces, transit centers,
and men’s social gathering spots such as bars, cafes, truck stops, and brothels are good
places to offer HIV information to men or engage men in discussions about STIs.
It is also important to take an education project to places where men in the
community seek other men to have sex or to inject drugs. If you keep showing up, and
if you show the men that you are not judging them, trying to convert them, or turning
them over to the police, they will begin to trust you. Giving out free condoms or
showing how to sterilize needles can be good ways to start a conversation.

Don’t forget
to take some
condoms before
you leave.

BEMFAM, an organization in Rio de Janeiro, Brazil, decided to do outreach

at a popular samba school where young men from the neighborhood
practiced and prepared to dance for Carnival. By training the dance
instructors to teach about STI and HIV prevention, along with samba
lessons, they were able to reach a large audience.

Opposing gender-based violence

Rape and violent sex harm women in many ways, including the spread of STIs. And
then, having an STI makes a woman a target of violence. Many women with HIV
have been blamed, beaten, and abandoned by their families. Men who oppose these
attitudes and actions play an important role in working to end violence against women.

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 Men share responsibility for STI prevention 129

Men As Partners (MAP)

Some years ago, a group of people in South Africa was very worried about
how HIV infection and gender-based violence were both increasing. They also
saw how each of these problems made the other worse. Knowing how important
it was to engage men directly in reducing both violence and HIV, they started a
group called Men As Partners – MAP. One of their goals was to encourage men to
become actively involved in violence prevention and to take more responsibility
for HIV-related prevention, care, and support. Another goal was to help men look
at their attitudes, values, ways of acting, and ideas about masculinity. MAP helps
men think about how some gender expectations lead men to harming their own
health, as well as the health of their partners and families.
To tackle the complexities of looking at gender roles and changing long-held
attitudes and ways of acting, MAP holds educational workshops with groups of
men and boys in many settings—schools, workplaces, trade unions, prisons, faith-
based organizations, community halls, and sporting arenas. The workshops use
discussions, role-plays, and other participatory activities to help groups look at
violence, sexual relationships, parenting, caregiving, and how gender roles limit
choices for both women and men.
Our survey says that
some of us think that if
a woman is dressed in
a sexy manner, it is her
fault if she is raped.
Let’s discuss this.

MAP groups also use other activities, including street theater, rallies, murals,
and other media to show men working toward more gender equality. They also
provide trainings for health care staff to improve STI services for men.
Many organizations all over South Africa have joined together to create
a MAP Network. There are now Men As Partners programs in more than 15
countries in Africa, Asia, and Latin America.

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Safer sex requires good communication

Practicing safer sex means having sex in ways that prevent or decrease the likelihood
of STIs from passing between partners. In general, this means having as little contact
as possible with the skin of your partner’s genitals, and not letting fluids from your
partner’s penis or vagina touch your genitals or mouth. For more information, see Safer
sex can increase pleasure for women and men (page 90).
Because it takes 2 to practice safer sex, a couple will need to communicate their
concerns to each other and come to an agreement. If one partner wants to practice safer
sex one way, and the other partner does not, or wants to do something different, they
will need to negotiate. Negotiating about sex can be difficult, but you can learn to do it.
For ways to practice and become more comfortable and skilled at communicating about
sex with a partner, see Communicating for healthier relationships (pages 97 to 105),
and Practice talking about birth control (page 184).
Safer sex is easier to practice when more people in the community are doing it. The
more people talk about safer sex and encourage others to learn about and practice it,
the easier safer sex will be for everyone.

Comfort with condoms

Using a condom every time a couple has intercourse is one of the most effective ways to
prevent the spread of HIV and other STIs. And more people than ever are using them.
Men and women who once rejected the idea of using condoms are now comfortable
discussing, buying, and using them.
People can learn to make condoms a normal part of sex and even sexy. Women
can learn to put a condom on a man’s penis in ways that give him pleasure. Since this
is something a woman can give and a man can receive, it can help men accept a woman
having more control over what the couple does during sex. If a man accepts that, then
a woman often feels freer to do things in ways that give her the most pleasure, and the
sexual relationship may be more enjoyable for both of them. Some men can also stay
erect longer using a condom, and many women enjoy that.
Before people can become comfortable using condoms, they need to learn how to
use them, think about how to make them more fun, and get over any embarrassment
about using them. The activities mentioned above (on pages 97 to 105, and page 184)
can also be adapted to help a woman become more comfortable asking her partner to
use a condom.
Many women and men have never seen or touched a condom. Looking at
condoms, feeling them, unrolling them, and stretching them are all part of making
condoms more familiar. It may sound silly, but playing with condoms is a great way to
help people be less shy about them.

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Activity Playing with condoms

To do this activity, you need plenty of condoms and some things to put the
condoms on. It is good to have things that are shaped like a penis, such as bananas
or cucumbers, and also some larger things, like squashes, to show how much
condoms can stretch.

➊ First give everyone a few condoms. Ask them to open one, take it out of the package
and see how it feels. Have them unroll it and stretch it out. What do they think could
fit into the condom?

➋ Ask them to pull it over 2 of their fingers. Will more fingers fit? A whole hand?

➌ You can also have a contest to see how many fruits or objects people can stuff inside
different condoms. This will also make people laugh, which helps them relax and
have fun with the activity.

Putting a gourd or melon in a condom — or stretching a condom over a person’s

head — shows that a man will rarely be “too big” for a condom. However, some
condoms are bigger than others, so people can see this too. People can also blow
them up like balloons to see how much they stretch.

➍ Using a banana (or some other

model), you can show how to
put a condom on correctly. Let
people try it themselves. Have
a contest for how fast people
can put them on, or ask people
to do it with one hand, with
their eyes closed, or with their
mouths.

➎ Keep encouraging people to play creatively with the condoms. As they do, you can
explain how to use condoms most effectively (see page 132).

You might also ask people what worries they have about using condoms, and
reassure them that condoms are safe to use. You can also explain that condoms are
less effective for preventing STIs that cause sores, such as herpes, syphilis, and HPV,
unless the condom fully covers the sores.

You can also play with female condoms. A woman will be more comfortable using
female condoms if she can first practice alone. After putting one in a few times, it
will not be difficult to do when she wants to have sex.

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My husband says it You can say he will last

will not feel as good longer and you will
with a condom. both feel good.

Important information about condoms

• Condoms should be kept in a cool, dry place and used before their expiration date.
After that date, they are more likely to tear or break when used.
• Do not put condoms in trouser pockets or anywhere they will get warm, because
they will become more likely to break.
• Only saliva (spit) or a water-based lubrication is safe to use with condoms. Oils,
butter, and Vaseline damage condoms and make them more likely to tear.
• Condoms will be more comfortable for the man with a drop of lubrication put
inside the condom, near the tip, before it is unrolled.
• Condoms will be more comfortable for the woman — and less likely to tear — if
the woman is fully aroused (wet) before the man enters her. Using a water-based
lubricant is especially important for anal sex.
• Condoms for women (female condoms) are larger than condoms made for men
and are less likely to break. The female condom should not be used with a male
condom.
For instructions about using male and female
condoms, see Where Women Have No Doctor
(pages 202 to 204).

Condom for men Condom for women

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Change — it’s a process

It takes more than knowing how STIs spread and how they harm health to change the
ways we act and communicate in our sexual relationships. People also have to change
long-time habits. But women and men of all ages and in all kinds of relationships do
change and practice safer sex in one way or another.
Changing any behavior is a long process. It is helpful to start by thinking about
the desired goal — in this case, safer sex. Then think about the gradual steps needed
to make that change. Finding ways to recognize progress and to see the steps towards
change can help people feel that change is possible.
Most changes in behavior involve 4 stages. First people think about changing
their behavior and explore their options. They might then accept the need to change
and decide on a goal. They would then try to change, and reinforce the change by
doing things that make them feel good about their decision. Remember that the process
of creating change is not usually a straight line to the goal. Sometimes people might
backtrack or get stuck. Keep encouraging them anyway. It is a big achievement to set the
goal in the first place!

GOAL: USE CONDOMS WITH A SEXUAL PARTNER

1. 
Think about change Concern about health risks.
Talk with a health worker
to learn more.
2. 
Accept need to change Decide to use condoms.
Practice to prepare
to ask partner to
use condom.
3. 
Try to make change Talk with partner and
begin to negotiate change.
Try out different kinds
of condoms.
4.Reinforce change Encourage each other about
condom use. Be proud of the
advances you have made.

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Community strategies for STI prevention

Community education and action can help prevent the spread of STIs in many ways.
Girls, boys, men, and women around the world are organizing in schools, churches,
clubs, workplaces, and neighborhoods. These community groups are finding creative
ways to make condoms available, raise awareness about safer sex, empower women
to negotiate for safer sex, reach out to youth, and provide access to STI testing and
treatment. The following pages share activities and examples of different community
strategies.

Community mapping of sexual health resources and dangers

A mapping activity is one way a group can discover and share information about sexual
health resources. The map can include places where condoms are distributed, where STI
testing is available, and where information about STIs is available. It can also include
places to avoid, such as bars or areas where people buy and sell sex. For an example of
community mapping, see Mapping the way to safe motherhood (page 218).

That bar has free HIV

testing every Tuesday There’s a clinic next
night. Let’s mark that to this high school
This area is safe during bar by drawing a that organizes a
the day, but girls have helping hand! health fair every
been attacked there
month and gives out
at night. I think pimps
free condoms.
around there also try
to talk to girls.

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Activity A treasure hunt to find resources

for community STI prevention

People may not be aware of all the resources in the community that can help
prevent the spread of STIs. You can create a treasure hunt game to help explore
resources that exist and then think about what other resources could be made
available. You can adapt the activity to focus specifically on resources for vulnerable
groups, such as adolescent girls, migrant women, or sex workers. (You can also adapt
this activity for other topics in the book.)

➊ Explain to the group that this is a competition to find as many resources as possible
in the community that support STI prevention. The team that identifies the most
resources wins.

➋ Form teams and ask them to imagine the resources or services people need for
STI prevention and where they might find those resources in the community.
These might include people, groups, organizations, schools, workplaces, markets,
pharmacies, and places people gather for transportation or recreation. If possible,
encourage the teams to visit places in the community and bring back information to
the next meeting.

➌ Bring the groups together to share what they have found, and then vote for the
team with the greatest treasure — the winner!

We learned there is a safe house for women who have

experienced violence. We also discovered that there are
friendly courts to defend us against forced marriage.

We learned the high school has a Boys

Outreach Brigade to teach other boys
about condoms and safer sex.

➍ Together, discuss the resources that have been discovered and then talk about the
gaps. Ask the group: Where is the community well equipped to prevent and treat
STIs? Where are there gaps? Are there groups of people that are not well served by
the existing resources? Ask the group to think of ideas for new resources to cover
those gaps. (This discussion can lead to developing an action plan.)

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Empowerment in all parts of women’s lives

Some communities are combining STI prevention activities, gender-awareness training,
and social or economic support for women because they see how these issues are often
woven together in women’s lives. Working on one area alone is not enough to create
change.

Sisters for Life makes life healthier for women

The Sisters for Life microfinance project in South Africa helps women start
businesses and become more self-sufficient. They also organize to stop gender-
based violence and protect themselves from STIs. The women who receive loans
are organized into groups of 5, and each group meets every 2 weeks to discuss
domestic violence, rape, and the importance of safer sex, including the use of
condoms. And they practice with each other ways to discuss these issues with their
partners.
After several discussion sessions, each group selects a leader.
These leaders meet with elders and other important
community members to ask for help
organizing workshops and
meetings in the village to discuss
domestic violence and rape.
The women also organize street
demonstrations about HIV and
STIs, and about rape and crime
in the community. These public
meetings and events mean
women are not left to confront
their partners on their own but
can speak out with support from
the community.
This project has been very successful. Most of the Sisters for Life have built
businesses, repaid their loans, and gained self-confidence. The women bring
money into their households and no longer feel they have to go along with
everything their partners want. The project has especially helped younger women
to better negotiate safer sex.

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End stigma and harmful beliefs about STIs

Shame and stigma are major obstacles to preventing STIs. When women are made to
feel ashamed of their sexuality, it’s harder for them to ask their partners to use condoms
or to try new and safer practices. When men who have sex with men are stigmatized,
they hide their sexuality and have fewer supports for practicing safer sex. Women
who have sex with women also face
stigma in the community. Although
their sex practices are not usually a
high risk for spreading STIs, if they
are forced to hide their sexuality they
won’t have the opportunity to learn
to limit their contact with body fluids
by using dental dams and other safer
sex practices.
When even more kinds of
stigma are layered on women,
gay men, and lesbians — such as
disability, sex work, using needles to inject Sex workers’ unions are demanding legal
drugs, having dark skin, or being from a protection and human rights.
“lower” class or caste — it is that much
harder for the community to prevent STIs.

Help adolescents protect themselves from STIs

HIV and other STIs are a serious and growing problem for young people, especially
young women. Many young people turn to their peers to work out their values, plans,
and choices. In many communities, especially those affected by HIV, young people may
not be able to rely on their families for support.
Programs that provide gathering places for young people can help. Besides
providing health information and sex education, they can help young people develop
skills such as ways to earn and manage money, use public services, and practice self-
defense. They can also help young people learn about their legal rights and what to
do when their rights are violated. Youth connected to caring adults may have better
access to practical and financial support, school fees, food, and help coping with family
illness. They will be less likely to sell sex for money or turn to other risky behaviors.

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Straight Talk takes on sexual health in Uganda

Straight Talk started in Uganda in 1993 as a free newspaper written for young
men and women aged 15 to 24 years old. Its main goal is to provide information
about sex and sexual health, life skills, and child and adolescent rights. The
newspaper quickly became very popular, and a second newspaper, Young Talk, was
started for adolescents aged 10 to 14 years. Then in 1999, a 30-minute “Straight
Talk” radio show started broadcasting. Today it is heard all over the country.
Straight Talk newspapers and radio
programs are produced in several local
languages as well as English. Straight
Talk and Young Talk are also published
in Braille.
To encourage young people to
participate, Straight Talk formed clubs in
many schools and communities. Many
young people write to Straight Talk every
day, and their questions, comments, life
stories, and concerns shape the content
in every issue. The newspaper also
gives out prizes to encourage letters
— a few schools might win soccer
balls for sending in the most letters in
a week.
In some ways, the newspaper
is like a giant advice magazine, with helpful
answers to many common questions. Also like a magazine, it is filled with
photos of young people, drawings, and useful tips. For example: “Believe in
yourself: Thinking too much about what other people think of you changes what
you think about yourself.”
While young people are at the heart of Straight Talk, parents and teachers are
also included because they have the most influence in a young person’s life. Straight
Talk also produces the “Parent Talk” radio show and the Teacher Talk newspaper,
and holds face-to-face sessions in schools and communities to talk about some of
the issues young people face.

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School-based programs promote sexual health in Colombia

Young people need to learn about sexual health, but they also need health
services that enable them to make healthy choices to prevent STIs and unintended
pregnancies. Putting a clinic near or inside a school makes it much easier for
students to get the help they need.
In Bogotá, Colombia, a
group of public and private
schools worked with the non-
governmental organization
PROFAMILIA to start school-
based programs that teach
youth and adults about
sexuality, sexual health, and
how to prevent pregnancy
and STIs. Young people can
visit sexual health counselors
to ask questions without
fear of being judged for
their sexuality or their concerns. The program also has regular Health Days when
students can have private health exams and also receive birth-control methods if
they request them.
At first, some people in the community felt strongly that young people
should not be given sexual health information or services. PROFAMILIA met
with community members and shared information about the high numbers of
pregnancies and STIs among students and other adolescents. This information
helped change people’s minds. Parents and teachers want to keep young people
safe, so they were willing to support programs to prevent pregnancy and STIs. And
the program involves parents and teachers, so everyone learns about sexual health
and how to talk with each other about it.
The PROFAMILIA program has also been successful because young people
are trained as peer sexual health educators, and they also participate in decision
making about the clinics’ programs and services. By creating many partnerships
between schools, community groups, health centers, and the government, the
program has been able to obtain the funding and resources it needs to continue for
a long time.

Health Actions for Women 2015