The following report is produced by the Blue Diamond Society, and reprinted here with permission.
BLUE DIAMOND SOCIETY

GPO Box 8975
EPC No. 5119
Kathmandu, Nepal
Tel/Fax: 977-1-438-600

OUTREACH WORKERS TRAINING REPORT

Trainings held May 8-9 and May 24-25, 2002

I. Background

Blue Diamond Society (BDS) is a registered non-governmental organization (NGO) that addresses male sexual and reproductive health, sexually transmitted diseases, HIV/AIDS and is primarily addressing MSM (males who have sex with males) issues within Nepal, offering social support and health promotion advice to MSM in Kathmandu. BDS has implemented an HIV/AIDS and sexual health intervention program for the MSM community living in the Kathmandu Valley through Family Health International funding. Condoms and lubricants have been generously supplied through our friends at the Foundation for Integrative AIDS Research (FIAR) located in New York City, USA.

Men who have sex with men (MSM) are generally a hidden population in Nepal and there is little understanding of the social, cultural and behavioural dynamics of their lives as they may relate to HIV transmission and other aspects of sexual health. Whilst community based research elsewhere in South Asia has begun to shed some light on hitherto hidden aspects of male to male sexual health, Nepal remains largely unexplored in respect to these concerns.

Recent preliminary outreach and health promotion work for MSM conducted by the Blue Diamond Society in cruising areas where MSM meet in Kathmandu has allowed the opportunity for some initial exploration of male to male sexual health issues. Indications are that there is a high prevalence of unprotected anal sex amongst MSM coupled with a high incidence of sexual partner change. There is little knowledge about HIV/AIDS, safer sex or other sexual health issues amongst MSM in Kathmandu. Due to social stigma many MSM are not open about their sexual orientation with friends and family and as such often suffer from low self-esteem. These feelings of disempowerment affect the sexual lives of MSM. Diminished self-esteem seemingly reduces the capacity for sexual decision-making and apparently contributes to the high incidence of abusive sexual experiences reported by many MSM in Kathmandu. For many men forced sex often occurs in the context of their work. Due to a lack of other employment options many MSM sell sex on the street or in nightclubs and dance bars. All of these circumstances put MSM in vulnerable sexual situations, increasing their risk of exposure to HIV and other STI's.

The Blue Diamond Society's Liaison Office in Kathmandu, Nepal, held two trainings for MSMs between May 8-9 and 24-25, 2002. 50 participants took part in these training programs. The 2-day intensive workshops took participants through the Training Manual designed by BDS.

Issues covered in the workshop included knowledge of HIV/AIDS/STD and sexual health, safer sex, sexuality, social and legal issues, etc.

Workshop Objectives:

By the end of the workshop, participants will be able to:

  1. Know how HIV is transmitted.
  2. Know the progression of HIV to AIDS.
  3. Know how HIV attacks the human body.
  4. Know the current state of the disease in Nepal.
  5. Understand sexual hygiene
  6. Know the proper way to use a condom.
  7. Describe "Safer Sex". What sexual behaviors put people most at risk?
  8. Know what constitutes safer sex
  9. Know what STDs are
  10. Know who is vulnerable
  11. Know what are risk behaviors
  12. Know "Practicing safer sex."
Number of Participants: 50
Duration: Two days
Date: 10th -11th , 24th 25th May, 2002

Procedure and Schedule

DAY ONE

10:00 AM - 10:30 AM Registration and Breakfast
10:30 AM - 11:00 AM " Introductions, Ice Breaker"
Before the first activity the facilitator describes the objectives and schedule of the workshop.

(The object of this exercise is to help the participants to get to know each other.) In this icebreaker each participant will give their introduction and share their first sexual experience. The purpose is to get people feeling more open and comfortable.

11:00 AM 12:30 AM What are STDs

Facilitator Presentation

Explain that some STDs are symptomatic. That such infection can be transmitted through unprotected anal, oral and vaginal sex.

Show overheads of range of STI symptoms. Ensure that such pictorial information includes anal and oral STIs.

Discuss issues of treatment, re-infections, Partner notification, in particular wives and children.

Ask Participants about local terms for these infections: Gonorrhea, Syphilis, Herpes, Cancroids, Genital warts, Hepatitis B, Pubic lice, HIV/AIDS, Chlamydeous, Procititis, Thrush, Others.

Important points are recorded on chart paper. Review the points and ask for feedback from the participants.

12:30 PM - 1:30 PM Lunch

1:30 PM - 2:30 PM "Teaching: How to put on a Condom".

Give each person part of the progression of how to use a condom on a card. Then have them arrange themselves in the proper order. The cards will say the following: Meet someone attractive, Feel aroused, Invite him/her home, Kiss, Become aroused, Undress penis, Pinch the top of the condom, Unroll condom over penis, Insert penis, Hold condom at the base of the penis, Withdraw penis, Tie condom closed, Discard condom, Fall asleep.

Demonstrate "the proper way to put condom on", ask each group to do the same.

Discuss questions asked by the participants.

2:30 PM - 3:30 PM HIV/AIDS

Facilitator presentation and Group Discussion

Facilitator shows participants overhead indicating the meaning of HIV and AIDS.

Describe in general terms what HIV does to the body.

Describe the common symptoms of AIDS.

Describe the limitations of tests used to detect HIV antibodies.

Be clear and explain that what is often called an "AIDS test" or an "HIV test" does not test for the AIDS or HIV, but the antibodies that developed when a person becomes infected with HIV.

During the presentation/ discussion, emphasize the fact that the symptoms being described occurs in what is often termed as "full blown AIDS". Use the overhead about symptoms.

Remember, people can be infected with HIV for many years before they develop HIV related illness (AIDS).

People can also infect others with HIV during this time, even as they look healthy.

Use the overhead on "Who has HIV?"

Following this display, encourage participants to ask questions and/or comments through the discussion. Point out that there is no cure for AIDS and there is no vaccine against HIV. People die from AIDS.

3:30 PM - 3:45 PM Tea and Khaja Break

3:45PM- 5:00PM "Current State of Affairs of HIV in Nepal"

What statistics are available concerning affected groups.

Statistics and social perceptions.

An HIV/AIDS related video film will be shown.

 

DAY TWO

10:00AM: 10:30AM: Breakfast

10:30AM - 10: 45Am: Feedback from yesterday

10:45 PM -11:45 PM HIV/ AIDS and Risk Behavior

Facilitator presentation and Group discussion

Using overheads, discuss the methods of STD/HIV transmission. Indicate the level of risk for each method of transmission.

The primary route of transmission is through penetrative sex:
  1. Anal sex
  2. Oral sex
  3. Vaginal sex

Describe the various issues that these three sexual behaviors raise regarding STD/HIV transmission.

Present the overheads" How you can get HIV" and HIV/AIDS is not spread by...

Answer the questions posed by participants throughout the presentation and discussion.

Record all the important points on newsprint sheet.

Review the important points and ask for feedback from the participants.

Tell the participants that there are only two ways to stop STD/HIV infection.
  1. Stop having sex- is this possible
  2. Change the way you do sex
  1. Non- penetrative
  2. Stop sharing fluids- use condoms

11:45 AM - 12:00 AM Tea

12:00 PM- 12:30 PM Who is vulnerable? Who is most at risk?

In groups participants are asked to discuss the previous issue

Transmission of STD/HIV and Risky behaviors

They are to identify in terms of male sexual behaviors, who is the most vulnerable to STD/HIV infection. Ask the recorders to write as bulletin points why the group thinks that their particular choice(s) have been defined as the most vulnerable.

Following this bring all the groups together and ask each group to make their presentation. Answer all the questions as they arise in the discussion.

12:30 PM - 1:30 PM Lunch

1:30PM- 2:30PM: What are Risk behaviors?

In groups ask participants to make a list of all sexual behaviors on one side of a flipchart sheet.

Then with the information they had gained yesterday, each group is to list the sexual behaviors under one of three headings: No risk (safe), low risk (less safe) and high risk (unsafe).

Ask the participants to discuss each sexual behavior with regard to transmission of STDs/HIV.

Following this, bring all the groups together and ask each group to present their discussions.

Develop a merged single list from this presentation.

Discuss with participants:

  • The list of sexual behaviors; add to this list if necessary
  • The headed lists no risk, low risk and high risk
  • Ask participants why they have placed certain sexual acts under their particular headings.
  • Discuss with participants the differences between "safe" and "safer"

Show overheads of "Estimated risks of HIV transmission", "Low risk and high risk sexual activities", and cartoons of low risk activities.

Facilitator will need to spend some time in a discussion about oral sex in terms of Risk taking.

2:30pm -3:00PM Tea and Khaja

3:00 PM - 3:30PM Sexual Hygiene

Explain to participants the issues of genital hygiene and the implications for STD and HIV infections.

Explore the issues of oral hygiene and health in relation to STD infections.

The facilitator will need to discuss the issues of washing under the foreskin everyday, and shaving/trimming back pubic hair, particularly in the heat and humidity of Nepal.

Discuss bathing facilities available, privacy, methods of bathing (i.e. nude or with underwear), and quality of water.

Contexualise the discussion within Nepali socio-cultural frameworks around genital hygiene.

Good oral hygiene is also important.

Bleeding gums, sores etc. can increase risk of transmission in terms of oral sex. Regular brushing with clean water- but not before having oral sex, and dental check-ups need to be done.

3:30PM -4:30PM Practicing safer sex

Remind participants regarding the discussion on risk behaviors. Show overheads on "low risk and high risk sexual activities." Discuss with the participants preferred sexual practices amongst themselves, their partners and their friends. Discuss what choice do males who have sex with males have to protect their lives, their partners and their families.

  1. Don't have sex
  2. No penetrative sex
  3. Using condoms

Ask the participants what is practical for them, and those they know.

Explore the methodology of anal penetration in the Nepali context.

Ask participants what problems exist:

  1. Rapid penetration?
  2. Low condom usage by partners?
  3. Anal bleeding?
  4. Anal soreness, sores, etc.

Condoms and lubricant: Discuss the issues of lubrication and lubricants. Why do you need to use lubricants? What lubricants do participants use? Lubrication to reduce anal damage, and to reduce risks for possible condom damage. Stress the need to use only water based lubricant in condom use. Demonstrate ID-Glide. Use (available only in Blue Diamond Society). Discuss issues raised and questions asked by participants throughout the discussion. Record important points and ask for feedback from the participants.

4:30 PM - 5:00 PM "Evaluation"

(Plus and wishes) What have they learned in the Workshop? What can be done to improve the program? What was most helpful? Do they still have questions about the work? Recommendations?

Did the venue work? Was the food adequate? Etc.

II. Summary Outcome of Activity - Impact and Achievements

The programme ran successfully and it was very fruitful since there was more than the expected number of participants. Many others showed great interest to enroll in the seminar though the limited requirement was only twenty-five. Through this workshop every participant was able to learn some of the concepts and issues that came up on the floor. But the organization was not able to give other potential participants an opportunity to join; however, BDS let them know that we would have additional seminars in the days to come on the same issue.

The first day of the workshop went well with the arrival of all the participants though there were some delays due to the rain. The programme was followed by breakfast in the beginning and then started with introduction of each participant. They talked about their first sex with a male partner, which was really wonderful and interesting. Through this introductory programme, the trainer learnt that many of them were having unsafe sex with their male partners and at the same time, to avoid societal constraints, they were having sex in a variety of locations.

The participants had only limited or no knowledge or awareness of the sexually transmitted diseases. They had the concepts that having sex through mouth and anus will not cause any harm, and further did not realize that sexually transmitted diseases will transfer from male to male. But when the information was provided, then they were able to recognize and learn about the infectiousness of the sexual diseases not only through vagina and penis but also from anal and oral sex.

While discussing sexually transmitted diseases, some participants opened up about some of the diseases they had suffered. They expressed shame about how they got the diseases and also stated that the lack of right places and doctors have forced them to hide their illness. This strong feeling of stigma and discrimination has resulted in considerable suffering, lack of treatment, and the risk of further spread of untreated STDs.

When the participants were asked about the proper utilization of condoms, different responses came on the floor and it was found that many of them were not able to open the packet of condoms properly. At the same time some of them did not hold the tip of the condoms before putting them on. Some forcefully pulled them onto the penis and, similarly, experienced difficulty to properly remove condoms after ejaculation. But when they were taught about the proper usage of condoms through the experiment on the dummy-penis (dildo), the trainer felt that the participants have learnt to use properly.

The first day of the workshop focused on HIV/AIDS as one of the most important issues. First and foremost, participants were not able to differentiate between HIV and AIDS, and had taken the issue as HIV, which was inaccurate. Hence the participants had set out the difference between them. The causes and effects of HIV in the human body were presented by displaying different charts and pictures, which was very effective to the participants since they looked and raised many questions on the topic. The participants were surprised to know how HIV virus attacks the defender cells of their bodies and also about the test for HIV. For many, this was the first time they had heard about the test. This part of the programme was found to be very important and the trainer hoped that through this session they would get more awareness on HIV/AIDS.

The group returned for a second day of the workshop. The workshop began with a brief review of the first day workshop. The participants were able to get the maximum benefits from the first day workshop, and they expressed how it was very effective for them.

The second day workshop mainly focused on HIV/AIDS and risk behaviour. On that issue the participants were informed about risky and safer sex activities, which most participants did not know about. In the workshop it was learnt that apart from anal, oral and vaginal sex, discussion was held on many sex issues such as using the thigh or breast or other body parts for non-invasive stimulation, as well as telephone sex, internet, dress, etc., through which people satisfy their sexual desires.

In this situation the trainer raised the questions by stating in order to get rid of HIV/AIDS, what are the options? Should penetrative sexual intercourse be stopped? Can we live without having sex? And the answer was frankly no, since they said that it is the psychological and physical needs of living nature without which nobody can survive. Others also expressed that sexual urges were very powerful and that sometimes sex happens because of weakness against that power. But all recognized that sexual contact is a key feature of healthy living.

Later there was a discussion about the changing ways of having safer sex as non-penetrative and to stop sharing fluids by using condoms. Through the discussion, the first alternative, (non-penetrative sexual activities) was disapproved of by the participants since they felt that it didn't give sexual pleasure. However, they noted that if they stopped sharing semen and use condoms then it will give them pleasure as well as satisfaction since it will reduce the risk of many sexually transmitted infections. And all the participants approved it by clarifying the different people like drug users, mobile population, MSM, female prostitutes should be included in the group and apart from them the following group can be classified under vulnerable as:

  • Male sexual workers
  • Metas wives (individuals who are generally or exclusively receptive, i.e., "passive" or "bottom"; in Nepali culture, metas are often married, often through arranged weddings)
  • Tas (individuals who are generally or exclusively in the role of penetrator, i.e., "active" or "top")
  • Tas wives

The participants even declared that understanding and changing their own behaviourial pattern can have effects on themselves as well as others who might be vulnerable.

The guidelines relating to dangerous behaviour patterns and the degree to which sexual practices may increase the risk of infections were presented by graphs and displays. Prior to this, they were not aware of the degree of the effect of different sexual patterns. They had thought that diseases were not transmitted through anal and oral sex, for example. Hence through the graphs display, they learnt the degree of causal factors of the sexually transmitted diseases.

There was little knowledge about sexual hygiene since the participants were found to be rarely cleaning their sexual parts, not bathing frequently, not changing and washing underwear often, and some of them had problems with lice. Regular hygiene practices were discussed.

They were also given the information about use of lubricants. Most participants were found to be familiar with it and they liked it because of the smoothness. At first they didn't know whether the lubricant should be used inside the penis or on the head as gel. Nowadays it has become a recognized need of MSM. Nepal does not readily make available the water-based lubricant that FIAR has been supplying to us. These must be used with the latex condoms we provide since fat, like butter or ghee, will erode the condom.

At the end of the programme, the organizer distributed a questionnaire in order to evaluate the two days workshop. The results of 10 participants who were able to fill out the questionnaire are provided below.

A. Training session questions

  1. Did you get the concepts of HIV transmission?
  2. Yes by all

  3. Did you learn ideas of HIV transmission and its development process into AIDS?
  4. 8 yes and 2 some.

  5. Ways that HIV harms/attacks human bodies.
  6. 9 yes and 1 some

  7. How is the situation of HIV in Nepal?
  8. 1 good 5 some and 4 not

  9. Knowledge of cleaning sex genitals.
  10. 8 yes 2 some

  11. Proper usage of condoms.
  12. 8 yes 2 some

  13. Knowledge of sexual hygiene and the dangerous behaviours that increase risks to humans.
  14. 6 yes 4 some

  15. Safer sex knowledge.
  16. 5 yes 5 some

  17. Different types of sexual diseases.
  18. 5 yes 5 some

  19. Vulnerable persons.
  20. 5 yes 4 some and 1 not

  21. Dangerous sexual behaviour.
  22. 7 yes 3 some

  23. Ways of having safer sex.
  24. 7 yes 3 some

b. How was the standard of training?

B. How was the standard of training?

Almost all the participants stated it was well organized. They felt the training session given by their own friends in the community as fruitful since they were able to express their problems freely and there was a better environment to share and explore the knowledge and ideas.

C. What are the new things that they have learnt in the training?

There were different answers such as;

  • How to use condoms
  • With whom to have sex
  • How to keep the sex clean and safe
  • Knowledge of sexually transmitted diseases
  • Behaviour patterns
  • MSM and sex patterns
  • Sexual hygiene and HIV/AIDS

D. What useful things did they learn from the training?

There were different reactions including:

  • Prevention ideas while having sex
  • Prevention of HIV infection
  • How people can overcome vulnerabilities
  • Proper usage of condoms while having sex
  • Usage of condoms in any critical situations
  • Not to trust the unknown person
  • To feel confident about making choices about whom to have sex with
  • How to behave with the person suffering from HIV/AIDS
  • Not to have penetrative sex without condoms

E. Did you feel the things said in the training session as useful?

All responded yes

F. What were the most important features of training?

  • Creative and purposeful training
  • Very good food - like a feast
  • Cooperative friends
  • Time oriented
  • Skits
  • Knowledge on diseases
  • Usage of condoms
  • Knowledge of HIV/AIDS

G. Weakness of the training.

  • No proper discipline
  • Teasing one another

H. Was there any difficulty in understanding and language in the training?

Not at all.

Conclusion

The two days training provided by Blue Diamond Society taught the participants how to use the condoms properly and it was demonstrated in front of them. The pictures displayed in the training also gave them knowledge regarding different illnesses that may develop as a result of having unsafe sex. Participants presented different skits for attracting friends and spoke about their sexual desires in very effective ways. This role playing can help them when they find themselves in similar situations and thus be able to more effectively negotiate safer sex practices and condom use.

The training session was really very useful as well as creative, and it concluded very successfully as reported by the participants. Participants suggested that this kind of training should be conducted frequently so that society of MSMs could express their problems and also share their knowledge through which they can become aware of different issues related to health, safer sex, proper usage of condoms, etc. The participants expressed their best wishes to the organizing panel and thanked especially Blue Diamond Society for everything it did.

Overall the training was well organized, and it was very fruitful since everyone took part actively and learnt things taught in the two days training session. Future sessions are being planned to bring in more individuals. In addition, BDS is continuing its outreach efforts to provide Nepali MSM with condoms and lubricant.

Reporters:

Sashanka Singh Basnet
Parashuram Ram Rai
Sunil Babu Pant

FIAR, a 501(c)(3) not-for-profit, does not accept pharmaceutical or nutriceutical industry funding and relies upon your generosity to continue its efforts.

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