VII. SUGGESTIONS FOR PREVENTION

(Note: readers who are not interested in the subject of prevention may skip this chapter and turn to the Epilogue).

We cannot implement effective prevention measures unless we are familiar with the sexual culture in which we are going to work. Even when we think we are familiar with it, our points of reference may be very different from those of the target population. In the case of prisons, two parallel cultures exist which interact with each other: the culture of the prison staff and that of the inmates. Because each culture assigns a different meaning to common terms, communications may sometimes resemble a “dialogue between the deaf”. To a prison officer, for example, a homosexual is a man who has sex with other men, regardless of what he does in bed. For an inmate, a man who has sex, with women or with men, is not considered to have renounced heterosexuality, provided that he practices penetration. When a prison official gives a workshop which covers the subject of homosexuality, participants may understand very different things. The Health Ministry’s AIDS prevention campaign, with its emphasis on monogamy or fidelity for heterosexuals and condom use for homosexuals (and indifference towards bisexuals), means that inmates get the message the wrong way round: they are “faithful” to their women and do not use a condom with them, but they do use condoms with men. “I pay a lot of attention to what Dr Herrera says (director of the Department for the Control of AIDS)”, says Pico de Lora. “I’m totally faithful to my wife, and I use a condom with men. That’s what the old broad always says the few times she’s been here.” This behavior has a certain logic, though it is counterproductive in the prevention of HIV infection. We have seen that the word “bisexual” does not have the same meaning for prison inmates as it does for prison staff. For inmates, a bisexual is a man who engages in active and passive anal penetration. “Bisexuals are the ones most at risk, because they give their ass,” explains Toro. “In the case of “cacheros”, we don’t do it. When the nurse asks me if I’m bisexual, I say ‘no way!’. So, she tells me that I won’t have any problem with infection.”

Prevention cannot be enforced. The Health Ministry has promoted AIDS testing among inmates as a means of prevention. In theory, all inmates should take the test. But in practice, the Ministry does not have the budget to cover the cost of tests and figures from the Department for the Control of AIDS show that only 10% of the prison population has been tested. Even if it were possible to test all inmates, the fact that HIV anti-bodies may take weeks, months or even a year to develop, undermines the effectiveness of the testing process: hundreds of already infected convicts may enter prison without showing signs of anti-bodies. In order to be effective, AIDS testing must be carried out frequently, not just annually. But this would further increase costs.

When we are not aware of the reality of a situation, campaigns can be misdirected. For example, confronted with the growth of HIV infection among heterosexual women, the Department for AIDS Control has launched an information campaign, directed at women, which promotes condom use. However, in a ‘machista’ society, the housewife who is faithful to her husband will be unable to introduce condom use, unless her spouse agrees. Husbands, however, are a much more difficult group to reach than housewives, and few efforts are being made to reach them. For this reason, prevention is ineffective. The same happens in prisons. Distributing condoms to transvestites and obvious homosexuals is an easier task because they are more visible. But it is the “cacheros” and the clients who decide whether or not a condom is used. These hard-to-access groups should also be the targets of prevention campaigns. “It’s very difficult for a transvestite to make her partner use a condom,” Lulu tells us. “When I tell my guy that it would be better to use one, he asks me if I’m sleeping with other men. ‘No way!’, I tell him, all serious, ‘don’t you know how much I love you?’ I ask indignantly. I play the fool, because if he ever finds out that I get the drugs he takes by whoring, he’d kill me.”

I hope that this book has shown that the separation of homosexuals from the rest of the prison inmates is a fantasy. Some prisons in Central America believe that placing “homosexuals” in separate cells is one way to prevent sexual relations. However, as we have seen, what the prison authorities regard as homosexuals are generally transvestites and very effeminate men. The inmates themselves agree that the latter are the only real homosexuals, even though in practice they may also be: nearly 70% of prison inmates have sex with each other. “Look,” says Pico de Lora, “ if you want to separate the gays from the rest, you’d have to build a new prison and only leave the old guys that nobody wants to touch. Prison is one great gay bar and if someone doesn’t join in, it’s because he can’t get it up,” he concludes with a smile.

The approach taken by the Costa Rican Ministry of Justice is, in fact, the best alternative: prevention through education and the participation of the target population.

Given the high level of sexual activity in prison and its complexity, the non-governmental organization ILPES agreed to implement an AIDS prevention program in the penitentiaries, in close collaboration with the Ministry of Justice. In Costa Rica, both this Ministry and the General Directorate of Social Adaptation, which is charge of prisons, have pursued a very intelligent and practical policy with respect to AIDS prevention. Instead of forcing inmates to undergo mandatory AIDS testing, or to persecute those who are sexually active, they have placed themselves in the vanguard of Latin America as far as education is concerned. Their approach has been to stop the epidemic with the participation of the inmates themselves in efforts to prevent the spread of HIV infection and related factors, such as drug consumption and violence. This plan rejected, from the outset, the Health Ministry’s more repressive policy of trying to stop the spread of the disease through mandatory AIDS testing and the persecution of homosexuality.²⁴

Despite the fact that prison medical facilities are controlled by the Ministry of Health, many education programs are under the jurisdiction of the Justice Ministry. This has made it possible to implement two parallel initiatives in the country’s penitentiaries: the Justice Ministry’s program, which may be termed holistic, and the Health Ministry’s program which follows the biomedical model of prevention.

There is no single biomedical model, but many versions. However, these share the following characteristics:

1. Information is considered the main tool to combat an epidemic. If people are well informed of how an infectious agent is transmitted and prevented, they will adopt the necessary hygiene measures to control it.
2. Information should be presented in clear, scientific language and conveyed in an authoritative manner, to prevent misinterpretation or confusion among the target population.
3. Epidemics are fought with health experts (mainly doctors) who have received appropriate training to combat these. It is assumed that these “experts” are respected in the community and that their advice is accepted and followed.
4. The main actor in prevention efforts is the state, since one of its functions is to safeguard public health.

DRAWBACKS

While these principles are almost unquestionable, they are not altogether effective.

1. Many studies question the fundamental role of information as the sole vehicle of prevention. In epidemics such as AIDS, people are well aware of how the disease is transmitted but do not automatically apply this knowledge in practice. A number of attitudes and emotions come into play, so that knowledge is not the fundamental issue. Condom use, as we have seen, is influenced by alcohol or drug consumption, for example. If people are intoxicated, they will possibly not use a condom, no matter how much they may know about prevention.²⁵
2. People are not blank screens towards which information is directed. Attitudes determine whether messages are received or repressed. Boring scientific messages are generally rejected by target populations. Unless creativity is used to make people pay attention to the message, there is a degree of saturation.²⁶
3. Health “experts” tend to belong to the middle and upper social classes. This reduces their impact among the popular classes who tend to mistrust their motives.
4. In Third World countries, the state is generally a bureaucratic body with little flexibility and credibility, and seldom commands the people’s trust.

THE HOLISTIC MODEL

This model has many variations and different origins. In the United States, it is associated with the birth of alternative medicine during the 1960s and studies on the role of the emotions in health. Although a branch of ancient psychiatry studied the connection between personality and disease, the holistic boom began with work in fields such as bio-feedback, the role of emotional attitudes in curing cancer and studies on nutrition, diet and health. These different currents are based on a common premise which is that individuals can produce and cure diseases, and that these are the result of imbalances in their lives. According to this view, prevention and cure depend on the individual, and Western medicine, with its emphasis on curing through surgery and synthetic medicines, is mistrusted.

For a prevention model to be considered holistic -- in other words, one that takes account of body and mind -- it must fulfill some of the following basic criteria:

1. Emotions play as important a role as reason. If a person is not emotionally convinced of the need to adopt prevention for his or her own good, or does not have help in doing so, he or she will not be able to make the necessary changes.
2. Prevention cannot be undertaken in an authoritative manner. The individual concerned must be a participant in his or her own well-being. This means that the target population must be actively involved in the prevention campaign, not as a mere passive spectator.
3. For people to feel that a problem concerns them, it is important for them to see others like themselves, with their resources and ideology, becoming involved in the struggle. “Experts” tend to deny power to individuals by portraying themselves as the ones with all the answers.
4. The community and the individual are the main vehicles of prevention. It is at this level that we find awareness of local conditions and the main obstacles.

We can say that the Ministry of Justice has adopted a holistic approach to AIDS prevention, while the Health Ministry has adopted a biomedical one. The explanation for these ideological differences between the two ministries would require a separate book. However, we can say that officials of the Justice Ministry -- lawyers, psychologists, social workers and criminologists -have a training that is closer to the humanist principles of the social sciences. Moreover, during the 1970s, Costa Rica’s penitentiary system underwent major reform and shifted its focus towards the education and social reintegration of prisoners. This spirit remains alive today, and justice officials feel proud of the fact that they do not promote punitive policies towards offenders. The Health Ministry, on the contrary, adopts a more conservative approach. With a few exceptions, the doctors who work in the prison system follow the traditional model of prevention, through information alone.

The holistic approach to AIDS prevention in prison is based on the following principles:

1. Respect for inmates’ relationships

It is assumed that homosexuality is common in prisons and all types of couples or sexual orientations are welcomed and encouraged to participate in the program.

2. Participatory methodology

The methodology used to conduct the sessions is participatory. In other words, it is a process in which members of a group participate on an equal footing. To this end, a horizontal system of communication is established through games, exercises, role play, meditation, videos and other mechanisms. In this participatory process, an inmate’s freedom to be and do is a priority. So too is his spontaneous, active, creative and reflexive expression, so that he can contribute to individual and collective decisions concerning matters related to AIDS and his own life-style.

3. Empowerment

Workshops are initiated by facilitators trained by ILPES and the Justice Ministry, but training is also given to prison leaders themselves so that they can replicate the workshops and assume responsibility for prevention efforts.

4. Administrative independence

Although the workshops are endorsed by the Justice Ministry, they are autonomous. This gives the prisoners confidence that whatever they say will not be used against them.

The workshops consist of eight sessions and cover the following subjects:

1. The rules of the game. In the first session, the inmates establish, by consensus, the conditions under which they wish to participate. In addition, they evaluate different aspects of prison life which tend to increase the risk of HIV infection through sexual transmission.
2. AIDS and safer sex. In this session, inmates familiarize themselves with the key aspects of the disease: terminology, means of transmission, prevention, safer sex and the AIDS test.
3. Overcoming anger. During this session, participants analyze the advantages and disadvantages of uncontrolled anger, and explore how to identify and control it and the effect that a lack of emotional self-expression may produce in the individual.
4. Sexuality. The idea is to create gender awareness (what it is, how it is developed, differences between masculine and feminine) and in addition, an attempt is made to lessen hostility towards people who do not fit in with established sexual stereotypes.
5. Self-esteem. In this session, participants explore critical factors which affect the development of self-esteem, specifically incarceration and the marginal status of prison inmates.
6. Holistic health. This session tries to create awareness of the connection between body and mind, to help inmates understand how they can take charge of their own health.
7. Alcoholism and drug-dependence. Available information is shared: origin, detection, consequences and therapy alternatives, among others. Denial of the problem is also discussed as well as how prison can contribute to make inmates more vulnerable to addiction.
8. Power. This session considers the inmates’ situation and the power which they can develop in a prison environment through solidarity, working together, the care of infected inmates and their contribution to prevention among their companions.

To date, this module has been used with more than 1,000 prison inmates (in groups of 10 to 15 participants), or approximately 20% of the prison population. Workshops have been given at prisons throughout the country, including the following: La Reforma, San Jose (San Sebastian), Puntarenas (El Roble), Cartago and Heredia. The prisons of Limon and Guanacaste were included in the process during the second half of 1993.

In analyzing the information, it should be noted that each participant was given a pre-test at the start of the first session and a post-test at the end of the last session. The questionnaire, which was completed individually by each participant, was the same at the beginning and at the end, and was designed around a series of questions which attempt to measure the impact of the various themes discussed at the workshop sessions. According to the results of the evaluation, the holistic workshops are more effective than the biomedical ones: they provide greater knowledge about AIDS and prevention, reduce the tendency to reject condoms and increase condom use. Moreover, they enhance the participants’ self-esteem and sexual communication.²⁷ However, although the results are good, they are not sufficiently effective to halt the epidemic, since more than 60% of inmates still do not always use condoms. Despite the capacity of the prison staff, more radical measures may be necessary.

SEXUAL EDUCATION

During the initial diagnostic phase, each new inmate should be given a sexual education workshop. We have seen how an individual who has been convicted and sentenced undergoes a short period of observation prior to entering the cells. This preparation time, however, does not include information about the sexual culture he will encounter in jail. Many new inmates arrive and witness homosexual scenes for which nobody prepared them. Others do not know how to avoid rape. Many are traumatized within 24 hours of their arrival. Whether we like it or not, it is necessary to explain the rules of the game of this culture to all new inmates.

Sexual education should include everyone in the prison. One of the positive aspects of the Justice Ministry’s campaign has been precisely to improve awareness of sexual culture and AIDS among all prison staff, from the policeman at the prison gate to the prison officers, to the prison director. Reducing disinformation about the dangers of infection and homophobia has made it possible to create a climate of universal support for the prevention programs. Guards who once searched inmates for condoms, supposedly to prevent homosexuality, no longer do so. Prison officers who once punished those discovered in the act of “sodomy”, have become more tolerant. However, it is necessary to ensure that this more liberal attitude is reflected on paper, that it becomes “official”.

ACCEPTING THE LESSER EVIL

If we hope to do prevention work within different sexual cultures, we must respect that culture’s own leaders and institutions. In our case, this means suspending moral judgements and accepting what exists.

One example of this has to do with danger. For a middle-class, non-criminal population, any risk should be avoided. But for prison inmates, danger is part of life: they have risked danger to rob, kill, swindle, deal and commit many of the crimes for which they are in jail. It is only to be expected that risk is present in their relationships. We have seen how couples are formed and how they live immersed in situations of risk: rape, death threats, intimidation, prostitution and drugs. HIV infection is simply one more risk among the many that exist in prison -- and perhaps not the worst or the most immediate. With people who live amid so much danger, possibly one form of prevention may be to reduce the risk, rather than try to eradicate it completely. Inmates, for example, are willing to use a condom in their furtive relationships, or with prostitutes, but not in their intimate relationships. In the latter, the condom is a threat. Making promises which generate certain risk may be more important to them than we think. Nevertheless, the “cachero” and the transvestite or the “güila” who swear to be faithful to each other, are practicing prevention, though not necessarily in the most effective manner. Challenging this decision as “ineffective” is perhaps not the best response. Perhaps we shall have to content ourselves with promoting 70% rather than 100% effectiveness. This may not be easy to accept for officials and NGOs involved in prevention work. However, failure to consider this option may be even more counterproductive if a target population feels that a campaign deprives them of their pleasures and their promises. By striving for the optimum, we may lose the possible minimum.

RECOGNITION OF HOMOSEXUAL COUPLES

The connection between love, trust and fidelity as forms of prevention lead many to take unnecessary risks. The hostility of some prison officers towards homosexual relationships accentuates this problem. If inmates could have support in their relationships, and even official recognition that would allow them certain benefits such as conjugal visits, privacy, medical tests and counseling for their particular problems, then prevention would be more effective. For example, if a couple opted for fidelity as a means of prevention and were officially registered as a couple in order to receive this type of support, they could be offered optional AIDS testing, condoms privacy and counseling. Instead of punishing them and separating them, as sometimes happens, this official recognition would serve to promote safe sex. Instead of spending hundreds of thousands of colones on blood tests for the entire prison population to detect HIV anti-bodies, which is the Health Ministry’s somewhat ineffective policy, the test would be available to those who need them.

As Penelope tells us, “we’re not idiots, we know we can get infected. What happens is that they won’t leave us in peace with our husbands. Any officer can separate us if he feels like it or if we have an argument, but who doesn’t fight in this world? So then they separate us and instead of being alone with your man, you end up being raped by ten guys in another block.”

Recognition of couples in jail will not be an easy step, even for one of the most progressive government ministries in the continent. However, it will be necessary to take it.

ASSISTANCE IN DETOXICATION

No prevention campaign can isolate itself from other problems that affect prison inmates. Drug consumption is a factor related to unsafe sex. If we do not implement a parallel campaign to prevent the risk of intoxication, we will not succeed in halting the spread of the HIV virus. Once again, it is a matter of choosing the lesser evil. It is very difficult to completely eradicate drug use in prisons. Since we must reluctantly accept this evil, our objective should be to persuade inmates to use condoms, even when they use drugs. Disposable hypodermic needles should be supplied to whoever needs them, in the same way as they are made available to intravenous drug users on the streets. Those who consume marihuana and crack should be taught techniques to avoid being caught without condoms in the case of having sexual relations. Prevention should begin before drugs are consumed. It is at this time that the inmates can think clearly. Some inmates who do not take drugs can be trained to supply condoms to their intoxicated colleagues. Others can take turns at looking after them.

PREVENTION OF VIOLENCE

We have seen how group rapes are anything but loving sexual encounters. That means that all messages urging people to use condoms as a way of taking care of their partner are useless under these circumstances. Inmates also use sex as a form of punishment. A prevention campaign should include workshops on violence with a view to reducing such attacks. ILPES has developed a behaviorist workshop to control violence, known as TICO (Intensive Control Workshop) which has produced very good results. However, it is necessary to offer alternatives to inmates who have been raped, such as anti-proteasic drugs to counteract possible infection and emotional support. An information campaign should include the issue of rape as a possible source of infection, to ensure that all inmates, including the rapists, are made aware of the dangers.

PLAYING WITH FREE TIME

When a sentence is long, time seems eternal. This is especially true if the prison offers no education or work activities. Part of the attraction of intoxication is precisely to shorten time: to make the days go faster. All prevention campaigns should take account of the need to offer an alternative to drugs. In fact, one of the tasks facing ILPES and the Justice Ministry has been to think up ingenious “alternatives” to drugs, such as workshops based on the concept of magical realism and cooperatives which the inmates find so exciting, that they have less need for drugs.

One successful experience has been the Experimental Workshop on Addictions. Its main objective is to show inmates the reasons why they need drugs and suggest alternative ways of “getting high” without them. The program does not assume that all participants will stop taking drugs. Nor does it moralize about drug use. Instead, the workshop uses a wide range of approaches, from music to magic rituals, such as painting blue unicorns. The inmates enter into a “magical” world in which mystical experiences are stimulated, either to stretch time or make it shorter. The idea is to give inmates different tools so that they themselves can play with time without the need for drugs. Considerable wisdom has been required from the prison officers for them to accept rhythmic dancing sessions, aerobics, weight training, mural painting, meditation, Gregorian chant, Caribbean music and other unusual activities in the prisons. Some complain that the inmates enjoy too many entertainments that they do not deserve. However, this daring program has given good results. Many prisoners enjoy the activities so much, that they do without a marihuana joint or a dose of crack.

MICRO ENTERPRISES

Parallel to these workshops, considerable imagination has been used to train inmates in how to establish small businesses which are “addictive”. When the Justice Ministry and ILPES introduced computer classes as a form of AIDS prevention, few understood the connection. However, the introduction of computers was well considered. “Which educational tool has color, light and sound and at the same time creates an addiction similar to a drug trip?” This was the question we asked ourselves before coming up with the idea. In fact, the computer makes time “fly” just as fast as any “hit” from marihuana or crack. Inmates who participate in workshops to obtain a certificate in computer studies spend hours sitting in front of a computer screen and they have set up creative businesses such as their own newspaper, desktop publishing and other services. Other creative ideas have been the ecological projects, such as the breeding of iguanas and tepezcuintles (agouti paca, small Central American mammals), hydroponics (growing plants and vegetables in water), and the art exhibitions. However, these programs reach only a small number of inmates so their impact is still limited.

To conclude, it is important to recognize that Costa Rica’s Ministry of Justice and ILPES have been leaders in the field of AIDS prevention in prisons. However, they are committed to continue taking new risks. Just as sexual relations between inmates involve risk, so it is also necessary to take risks in the prevention of AIDS.

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²⁴ For an analysis of the Costa Rican Health Ministry’s repressive campaign we recommend the book, “La formación de una contracultura. Homosexualismo y sida en Costa Rica”, Editorial Guayacán, 1989.

²⁵ Madrigal, Johnny. Primera encuesta nacional sobre sida: informe de resultados . (First National Survey on AIDS: report on the results) Johnny Madrigal Pana; Jacobo Schifter Sikora; Costa Rican Demographic Association, San Jose, Costa Rica, ADC, 1990.

²⁶ Abrahams Vargas, Maritza. Impacto de los mensajes sobre salud reproductiva transmitidos por radio y televisión en los adolescentes de los centros educativos Metodista y José Joaquín Vargas Calvo. (Impact of reproductive health messages broadcast on radio and television among adolescents at the Methodist and Jose Joaquin Vargas Calvo high schools).
Thesis submitted to obtain a masters degree in nursing. University of Costa Rica, 1993.

²⁷ Madrigal, Johnny. Impacto de la prevención del sida en privados de libertad costarricenses. ILPES, San Jose, Costa Rica, 1993, p.1.