AIDS cases in Brazil have risen so dramatically for married women that the state of Sao Paulo decided that it must attack a basic cultural practice in Latin America: Their husbands don't practice safe sex.
Last month, the government of Brazil's megalopolis started promoting the newly released female condom.
Many of the new AIDS cases in Brazil are married women who have children, according to a report released last month at the Pan-American Conference on AIDS in Lima, Peru. Worldwide, women constitute the fastest-growing group of those diagnosed with HIV. Of the 30.6 million people who are diagnosed with the HIV virus, 90 percent live in poor countries.
One Brazilian mother, Rosana Dolores, knows well why women cannot count on male partners to use condoms. She and her late husband never thought of protecting their future children against AIDS. "We were married. We wanted to have kids," says Mrs. Dolores, both of whose children were born with HIV. "These days, I would advise young people to always use condoms. But married couples ... who is going to?"
Brazil, with its 155 million people and the largest population in South America, has the second-highest number of reported HIV infections after the United States, according to a report released Nov. 26 by the United Nations agency, UNAIDS.
Public health officials say one reason why AIDS prevention efforts have failed is many Brazilians just don't like condoms. While use in Brazil has quadrupled in the past six years, it is still the least popular method of birth control - a touchy issue in the predominantly Roman Catholic country. Another reason is that condoms cost about 75 cents each, making them more expensive here than anywhere else in the world, health officials say.
Plus, Latin-style machismo leaves women with little bargaining power. Only 14 percent of Brazilian heterosexual men used condoms in 1996, according to AIDSCAP, an AIDS-prevention program funded by the US Agency for International Development. In other studies, many women said they would not ask their partner to use a condom, even if they knew he was sleeping with others.
"Women are afraid of asking their men to have safe sex, afraid of getting beaten, afraid of losing their economic support," says Guido Carlos Levi, a director at the health department at Emilio Ribas Hospital. "This is not Mexico, but we're quite a machistic society here."
The frequency with which Latin men stray from monogamous relationships has compounded the problem. In studies conducted in Cuba by the Pan American Health Organization, 49 percent of men and 14 percent women in stable relationships admitted they had had an affair in the past year.
In light of statistics showing AIDS as the No. 1 killer of women of childbearing age in Sao Paulo state, public health officials here launched a campaign in December promoting the female condom.
The hope is that it will help women - especially poor women - protect themselves and their children. But the female condom seemed unlikely to spark a latex revolution when it hit city stores Jan. 1. The price is $2.50 apiece - more than three times the price of most male condoms.
The Family Health Association is asking the government to help subsidize the product and to cut the taxes on condoms that make them out of reach for many poor Brazilians. "We're looking for a pragmatic solution to prevent the transmission of HIV-AIDS," group President Maria Eugenia Lemos Fernandes said.
"Studies show there is a high acceptance of this method because it's a product under the control of women."
While 75 percent of the women and 63 percent of the men in a pilot study on the female condom said they approved of the device, many women with AIDS say they would have been no more likely to have used a female condom than a conventional one.
Part of the problem is perception: 80 percent of women and 85 percent of men in Brazil believe they are not at risk of contracting HIV, according to a study conducted by the Civil Society for the Well-Being of the Brazilian Family.
Also at risk are married women, 40 percent of whom undergo sterilization as an affordable way of getting around the Catholic church's condemnation of birth control, health officials noted.
"It's mostly married women who are the victims. You just never think it could be you," says a former hospital administrator who was diagnosed with the virus after her husband had several extramarital affairs. He died two years ago.
"I knew everything there was to know about AIDS - I worked in a hospital - but I never suspected he was going out like that. He always denied it," she says.
While the HIV virus is making inroads in rural areas and among teenagers in Brazil, Fernandes says it doesn't have to reach epidemic proportions as in Uganda or Tanzania. "There is a very big window of opportunity here."