Indigenous Peoples Development Plan: Brazil AIDS IIl Project 1 - AIDS and Indi2enous Peoples Indigenous Peoples: Brazil has an estimated indigenous population of some 350,000 Indians. This population is distributed over almost every state in Brazil, comprising 587 officially recognized Indian reservations (terras) and some 215 different societies and cultures speaking 180 languages. Almost 55% are located in the Northem Region, with the State of Amazonas accounting for 26% of Brazil's total indigenous population; 17% are in the Center-West region, 18% in the Northeast, 2% in the Southeast, and 8% in the South. However, it should be noted that this information does not include those Indians now living in the metropolitan areas of Brazil's major cities. This population is estimated at approximately 50,000 Indians, with the greatest concentrations in the cities of Manaus and Manacapuru (Amazonas), Campo Grande and Dourados (Mato Grosso do Sul), and Aguas Belas (Pemambuco), together with lesser concentrations in such metropolitan regions as Sao Paulo, Porto Alegre (Rio Grande do Sul), Brasilia, Chapec6 (Santa Catarina), and Londrina (Parani). Migration to and settlement in major urban areas varies enormously, from temporary movements for health care, work and education, to relocations rooted in the individual mores and practices of certain indigenous cultures resulting in the presence of sizable Indian population groups in urban areas, which Stephen Baines has described as representing "large temporary villages for paid work." It is also important to draw attention to the urban areas of Brazilian cities bordering on other countries, such as the regions of Tabatinga/Benjamim Constant (Peru and Colombia); Rio Branco (Bolivia); Boa Vista (the Guianas); Guajara-Mirim (Bolivia); Corumba (Bolivia); and Foz do Iguacu (Paraguay). The areas with the greatest concentrations of Indians that are most vulnerable to HIV/AIDS are listed below, by tribal groups: STATE TRIBE CASES DE AIDS Amazonas: URBAN AREA Manacapuru Apurina Manaus - Conjunto Satere-Maue X Santos Dumont BORDER Ticuna X Benjamim Constant Tabatinga Roraima: URBAN AREA Boa Vista/Bairro Guianese X Pintolandia and Raiar Indians do Sol Acre: URBAN AREA Rio Branco Various groups Mato Grosso do Sul: URBAN AREA Dourados Guarani X Campo Grande Terena X BORDER Corumba Terena 1 RLE COFY Pernambuco: URBAN AREA Aguas Belas Fulni-6 X Sao Paulo: URBAN AREA Jaragua Guarani Favela Real Parque Pankararu X Favela Parais6polis Pankararu Rio Grande do Sul URBAN AREA Cases of AIDS and STDs: The CN-DST/AIDS (STD/AIDS National Coordinating Office - Coordenacao Nacional de DST/AIDS) received reports of 52 cases of AIDS among the indigenous population over the period 1986-2001. The first case of AIDS among indigenous peoples was reported by FUNAI (National Foundation for the Indian - Fundacdo Nacional do Indio) and the MS (Ministry of Health - Minislt6ro da Saude) in 1988, in the State of Santa Catarina, in the southern region of Brazil.' Since then, additional cases were identified in other regions. The epidemic affected mainly Indians who had regular contacts with the surrounding society and who traveled relatively frequently to the cities or were in contact with populations living in border cities.2 Currently the indigenous population that has been most severely affected by the epidemic is that in Mato Grosso do Sul. The principal characteristic of this region is that it has the largest number of Indians living in urban areas. Thus, the distribution of cases of AIDS and of STDs within the indigenous population cannot be viewed in a uniform manner, as from an epidemiological point of view there are significant differences in vulnerability, since many of these Indians are in regular contact with the population living in villages. Regional distribution of AIDS cases: The regional distribution of AIDS cases among the indigenous population confirms the general tendency discussed above, namely that the number of cases of AIDS is greatest in the Center-West and Northern regions and that it is to be found in urban areas and in small and mid-sized municipalities. This tendency shows how important it is to gain a better understanding of the interaction networks that develop from contact with the surrounding society and associated risk factors. The table below shows the number of cases and a percentage breakdown by region. The spatial distribution of the indigenous population in the South and Southeast regions, where the first cases were reported, is characterized by the presence of villages located very close to urban areas and with a highly mobile population, resulting in more frequent interethnic interactions. The Center-West region has today, the largest number of cases, and has shown a higher growth in cases than other regions. This contrasts with other parts of the country, since most of the cases being reported in the Center-West involve Indians living in urban areas, with women being those most affected. The variables that come into play here include poverty, prostitution among Indian women, and alcoholism. The first of the graphics appended to this report shows the spatial distribution of AIDS cases by DSEI (Special Indigenous Health District - Distritos Sanitcirios Especiais Indigen as). ' Flavio Wiik, Contato, epidemia e corpo como aeentes de transformacao: um estudo sobre a AIDS entre osindiosXokln6 de Santa Catarina Cadernos de Saide Publica, 17 (2): 397-406, Rio de Janeiro, 2001. 2 Leonardi, V.; " Fronteiras Amaz6nicas do Brasil Saude e Hist6ria Sociar' Ed. Marco Zero & Paralelo 15. Brasilia, 2000. 2 50% - 40%-- 30%- 20%- /_ _ _ _._. 10% 4 0%- ___ (%) North Northeast Southeast South Center- West Regional Distribution of AIDS Cases among the Indigenous Population - 2001 Distribution of AIDS cases by sex and age group: In Table I we show the percentage distribution of AIDS cases, by age group and sex. The age group most affected are individuals between the ages of 20 and 34, representing 68.0% of total cases, or 65.2% for males and 79.2% for females. It should be noted that women are becoming the most vulnerable group and consequently those who bear the greatest impact of the socio- cultural changes affecting their group. In general, the increased frequency of contacts with individuals outside the group, particularly for male Indians who travel regularly to cities and towns near their villages and/or who move back and forth between the cities and the villages, together with increased prostitution among Indian women, alcohol consumption and the sexual mores of the group, are all factors responsible for the spread of the epidemic among village Indians. As regards the reporting of AIDS cases in urban areas, it should be noted that many cases involving the indigenous population are likely to be underreported. A recent study by the Centro de Referencia Terapeutico in Sao Paulo, based on a review of patient records, showed a much larger number of AIDS cases among Indians than had been expected, with 22 patients identifying themselves as Indians. SINAN (the Reportable Diseases Information System - Sistemna de Informac5es sobre Agravos Notificaveis) only started including the race variable in 1996. Percentage Distribution of AIDS Cases among the Indigenous Po ulation - 2001 AGE GROUP (YEARS) MALE FEMALE TOTAL 15 to 19 01 (4.3%) 01 (4.2%) 02 (4.0%) 20 to 24 02 (8.7%) 04 (16.6%) 06 (12.0%) 25 to 29 06 (26.1%) 11 (46.0%) 17 (34.0%) 30 to 34 07 (30.4%) 04 (16.6%) 11 (22.0%) 35 to 39 04 (17.4%) 01 (4.2%) 05 (10.0%) 40 to 44 03 (13.0%) 01 (4.2%) 04 (8.0%) 45 to 49 - 50 to 64 02 (8.2%) 02 (4.0%) Age unknown No data No data 03 (6.0%) TOTAL 23 (100%) 24 (100%) 50 (100%) Source: CN-DST/AIDS - Ministerio da Saude In sum, the major tendencies and characteristics of the AIDS epidemic among the indigenous population are as follows: (a) The epidemic is growing and is expanding among Indians living in urban areas who maintain frequent contacts with their villages; (b) The younger population is the most vulnerable, with individuals between the ages of 20 and 34 representing 68.0% of total cases, or 65.2% for males and 79.2% for females; (c) As a category, young women are the most severely affected group with a sex ratio of 1/1, and their vulnerability is linked to various factors, such as early sexual initiation, differing sexual mores across tribal groups, cross-lactation, school attendance, and the socioeconomic impact of major projects. But these factors can only be understood on the basis of existing risk and vulnerability differentials within the population.3 The social networks that people form are rather complex, and require an effort in terms of characterizing and identifying them in their anthropological and political dimensions, and determining how they operate in the spread of disease. Thus each ethnic group needs to be placed within the context of its own particular situation and related to the broader dynamics of interethnic contacts, such as: (a) interethnic contacts resulting from the entry into native areas of garinmpeiros (unlicensed miners), woodcutters, farmers and ranchers, and development projects, e.g. construction of hydroelectric power plants and building of roads); (b) interethnic contacts involving indigenous peoples in border areas; (c) seasonal mobility and migration of Indians to urban areas in search of work, education and health care; 3 Ministerio da Saude: Povos IndiQenas e a prevencdo as DST, HIVe AIDS Manual de diretrizes t&nicas Brasilia, DF, 2000. 4 (d) kinship structure and sexual customs among some tribal groups that may increase risks and promote vulnerability, such as cross-nursing, scarification rituals, polygamy, and early sexual initiation; (e) breakdown in traditional structures of community authority; (f) conflict between the concepts of traditional medicine and the Western concept of the health/disease process, as a result of which many health professionals find themselves unprepared to cope with these situations and reject traditional beliefs, making preventive measures difficult. INDICATORS FOR RISK AND VULNERABILITY DIFFERENCES FOR INDIGENOUS PEOPLES External Factors Increasing lnternal Factors within Vulnerability of Indigenous Indigenous Communities Institutional Responses Communities Increasing Risk and Vulnerability 1. Exploitation of forest I. Level of purchasing power 1. Situation regarding resources and schooling regularization of title to indigenous lands 2. Authorized and 2. Level of political power and 2. Existence of Indians employed unauthorized mining capacity to mobilize support by public institutions who travel operations on indigenous lands frequently 3. Roads and/or railroads 3. Balance in kinship relations 3. Presence of community and gender issues development projects 4. Leasing of indigenous land 4. Level of knowledge about 4. Existence of special indigenous health situation and how health districts and access to diseases are transmitted health services 5. Power sector projects 5. Permanent residents from 5. HR policy for the training of outside the group and mobility indigenous health agents of higher-status individuals within the group 6. Squatter invasions 6. Inter-group and inter-ethnic 6. STD/AIDS programs relations established in the DSEls 7. Rural centers and land 7. Indigenous presence in settlement projects urban centers 8. Presence of regular travelers 8. Sexual mores within the group 9. Presence of indigenist agencies Cases of STDs In Figure 2 (see Annexes) the coefficient of incidence shows just how serious the STD problem is in some districts. In general, in nearly all of the DSEIs, cases of STDs are higher than among the population in general, with incidence rates usually above double digits. But particularly deserving of attention are situations where incidence rates reflect general epidemic conditions, as is ihe case in Manaus, Altamira, Alto Jurua, Alta Purus, Maranhao, Ceara, Pemambuco, Culab6, 5 Xingu, Araguaia, Amapa and northern Para. The data do not indicate what type of infection is most frequent, as the reporting system adopted by the DSEls does not classify cases by etiology. Nevertheless, it is important to stress the need to prioritize STD prevention and treatment measures, as a correlation with HIV infection is more likely in situations like these where high STD rates are prevalent. The spatial distribution of STDs also coincides with what the data reveal about the distribution of AIDS cases. Once again, young people and women are the segments of the population who are most affected. II -The Government's Response Legal framework governing indi2enous health: Responsibility for indigenous health currently resides with the Ministry of Health, which regulates and implements health actions - both prevention and treatment - through a care model based on 34 Special Indigenous Health Districts (Distritos Sanit6rios Especiais Indigenas) or DSEIs. Each DSEI has centralized (p6lo) care units which conduct health operations within the villages. Most of this network is operated by civil society organizations (NGOs) under agreements with the National Health Foundation (Funda,do Nacional de Saiude - FUNASA) for basic care activities. For more complex operations, the system operates through agreements and incentives with the SUS (Sistemna Unificada de Satde - Unified Health System). STD/AIDS operations are conducted in the DSEIs, and the CN- DST/AIDS provides technical assistance in program implementation, training of health care professionals, and standardization of activities in conformity with indigenous health care policy. Social oversight is exercised through the District Councils and by the Inter-Institutional Committee for Indigenous Health (Colnissdo Interistitucional de Saude Indigena - CISI) and by the National Health Council (Conselho Nacional de Saude - CNS). The AIDS Committees (CominissJes) of the states and municipalities play a complementary role in this social oversight, as does the Office of the Public Prosecutor (Mintst&rio Ptublico) in the case of human rights issues and invasion of Indian lands. With respect to AIDS/STDs prevention, treatment and care responsibility for coverage is shared between FUNASA and the National AIDS/STD Coordination as established in the National Conference on Indigenous Health of 2000. The AIDS/STD program is responsible for the development of technical norms and guidelines, educational materials, monitoring and evaluation, training of local administrators at state and municipal levels and the provision of technical assistance to DSEIs. Actual basic care and prevention services delivered in indigenous conmmunities are the responsibility of the DSEI/FUNASA, and of the States and Municipalities, who can contract NGOs. Thus, under AIDS III, there are three types of financing mechanisms for indigenous health (AIDS/STD): a) strategic projects with NGOs/civil society; b) fund-to-fund transfers to states and municipalities who include activities directed to indigenous health in their PAMs (pianos de acoes e metas); and c) transfers to DSEI/FUNASA through an intersectoral agrcement to finance activities agreed in an Action Plan. Given that both FUNASA and the CN belong to the same ministry, no formal agreement is required. History of response by the National STD/AIDS Pro2ram The STD/AIDS National Coordinating Office (Coordena,do Nacional de DST/AIDS - CN- DST/AIDS) began its work among indigenous populations in 1989. At that time, its operations were carried out jointly with the National Foundation for the Indian (Funda,cio Nacional do Indio - FUNAI), its main objectives being to train health sector professionals and support field research into STDs and AIDS. These activities were generally not carried out in a continuous fashion and 6 did not result in the creation of consolidated structures to support systematic prevention and treatment measures. Starting in 1994, with the signing of the AIDS I loan agreement with the World Bank, under the umbrella of the PREVINA program, operations targeted at the indigenous population became more institutionalized and grew in scale, as awareness grew of the perilous health conditions afflicting indigenous peoples, together with evidence of localized STD epidemics. These activities, it should be noted, were conducted on case by case and emergency basis. Not until the period 1996-98 did a concrete proposal emerge targeted at STD/AIDS prevention and treatment among indigenous peoples. Thus, a national response was developed, based on strengthening indigenous organizations and Indian support groups, with regularly scheduled and continued training of indigenous health agents, and the establishment of a specific forum for discussion of the issue of STDs and AIDS within indigenous communities. One major problem in implementing the proposal was the fragmentation of indigenous health care activities between FUNAI and the National Health Foundation (Fundaf ao Nacional de Satrde - FUNASA)4 and the lack of communication between the health care systems coordinated by the two foundations. FUNAI responded with treatment and social support services, while FUNASA took responsibility for preventive measures, primarily control of malaria and other endemic diseases. This dichotomy gave rise to countless institutional conflicts and torpedoed the movement toward the establishment of a health care system geared to the realities of indigenous life, which had been the aim since the first National Conference on Protecting the Health of the Indian (Conferencia Nacional de Proteqa^o ci Sacide do Indio - I CNPSI) in 1986, the First National Indigenous Health Forum (I F6rum Nacional de Sau'de Indigena) in 1993, and the Second National Health Conference for Indigenous Peoples (II Conferencia Nacional de Saude para os Povos Indigenas - II CNSPI) in 19935. There was no properly structured and coordinated system, making it difficult to gain access to treatment services under the Unified Health System (SUS). Access was difficult for a number of reasons: (a) long distances between SUS treatment centers from the communities; (b) health professionals were poorly prepared to cope with the indigenous peoples; (c) tardy application of the law establishing the DSEIs; (d) the indigenous health agents were poorly trained; (e) absence of specific programs (e.g. for STD/AIDS, reproductive health, or tuberculosis) established in the communities. Given the lack of a formal health structure at the time, the program gave its support to indigenous organizations and NGOs working in the area of indigenous health care. Signing of the AIDS 11 loan agreement made it possible to consolidate the proposals envisaged earlier and gave new impetus to preventive measures. The current approach was changed, and the concept of vulnerability was adopted as the theoretical/operational reference point. This period was marked by the decisive influence of actions undertaken by CN-DST/AIDS in regard to Brazil's indigenous health policy. Starting with local organization of prevention campaigns, awareness was created for the formulation of an indigenous health policy led by the Ministry of 4 Athias, R & Machado, M.; " A saude indigena no processo de inplantacdo dos distritos sanitarios discursos antropol6gicos e mndicos". Communication presented to the meeting of the Associacao Brasileira de Sauide Coletiva, Sao Paulo, 1999. 5See the technical reports presented at: I ConfereAncia Nacional de Protecdo a Saude do Indio, Relat6no Final, Brasilia, Minist6rio da Saude, 1986.; 1 Confer6nca Nacional de Saude para os Povos Indigenas, Relat6rio Final, Brasilia, 1993; I F6rum Nacional de Saqide Indigena, Documento Final, mimeographed text, Secretaria de Estado da Saude de Sao Paulo, 1993. 7 Health.6 This process was only made possible by two significant steps: (1) publication of the draft Law 63/1997 authored by S6rgio Arouca; (2) Provisional Measure No. 1911-8/1999, which transferred responsibility for the health of indigenous peoples to FUNASA. This period was marked by a number of sectoral conflicts, both inside and outside the government apparatus. It was also a period of direct conflict between indigenous peoples and homesteaders (posseiros), illegal miners (garimpeiros), mining companies, dam builders and with federal and local government authorities.7 The strategy pursued by CN-DST/AIDS changed with the establishment of the Special Indigenous Health Districts (DSEIs), and began to place priority on coordination with FUNASA in order to strengthen local response, with the establishment of DSEI-based STD/AIDS prevention and treatment programs. Support for projects began to be directed toward issues regarded as of strategic importance, with priority focus on measures targeted to young people, Indian women, and groups living in border areas. Assistance measures are being carried out jointly with FUNASA. Access to Preventive, Diagnostic and Treatment Services for Indigenous Peoples: Prevention: Preventive services are provided by the DSEI organizations and involve five strategic lines of action: (1) mobilization of the community and its leadership on the issue of HIV/AIDS and other STDs; (2) training of indigenous health agents and other professionals working within the DSEI to spread information on reproductive health, sexually transmitted diseases, and counseling and guidance on HIV antibody testing; (3) training of teachers and students at indigenous schools in health promotion techniques, particularly in regard to reproductive health and prevention of STDs and HIV/AIDS; (4) intersectoral linkages with other parts of the government involved in indigenous affairs; and (5) support for strategic projects in areas of increased vulnerability and risk. With regard to the mobilization of indigenous peoples, special mention should be made of the work of the District Councils and of the Inter-Institutional Committee on Indigenous Health (CISI) within the National Health Council (CNS). These social monitoring bodies have been the designated address for requests and complaints from the sector, while also serving as important actors in formulating policy proposals for the health sector. The AIDS committees of the states and municipalities have also played an important role in representing the social monitoring function. Proper linkages between decision-making bodies and programs in the area of indigenous health are needed to avoid duplication of effort and overlapping decision-making in STD/AIDS matters. This segment of the population is also served by the National Conference on Indigenous Health (Conferencia Nacional de Saude Indigena), a strategic body for defining national policy guidelines. The Third National Conference on Indigenous Health is to be held in May, and for the first time STD/AIDS will be included on its agenda. Wiih strategic projects, the object is to link together a network of stakeholders and institutions with the aim to reduce the epidemic's impact on the most vulnerable and endangered groups, namely: (a) indigenous reserves that have been invaded by outsiders or are close to where mining 6 Brasil: "Politica Nacional de Atenicdo a Saude dos Povos hidiQenas." Minist6rio da Saude, Brasilia, December 2000. 7 Varga Van Deursen, I & Adorno, R.C.F, "Terceirizando a indianidade? Sobre a politica nacional de saude para os povos indigenas. aos 500 anos." Mimeographed text, Universidade Sao Paulo, Faculdade de Saude P1`blica, 2001. 8 operations are taking place, including informal mining operations (garimpos), together with woodcutting operations, large-scale farming and livestock projects, and dam and highway construction sites; (b) indigenous communities within urban areas; (c) indigenous communities located in border areas; and (d) impoverished communities. Strategic projects are those more especially designed to improve the situation of populations not covered by ongoing prevention and treatment campaigns and who also find themselves at a social, cultural and epidemiological disadvantage in coping with the HIV/AIDS epidemic and other STDs. Also classified as strategic are those projects designed to encourage the development of sound practices and innovative technologies in the areas of prevention and treatment. The partners in developing these projects are indigenous organizations, non- governmental organizations active in indigenous affairs, state and municipal level STD/AIDS coordinating offices, and the DSEIs. Projects supported and resources deployed: Twelve projects, representing an investment of BRL 338,000 for indigenous peoples, were supported in 2002. These projects are viewed as strategic by the National Coordinating Office (CN) as they are designed to subsidize the implementation of specific STD/AIDS programs. The decline in the number of projects for this segment of the population is justified by the fact that programs of this type are being incorporated into the DSEIs, as recommended by the National Conference on Indigenous Health. All of the projects listed below are preventive in nature, encompassing the training of indigenous health agents in community intervention activities, promoting awareness among community leaders and traditional healers, organizing young people and women, and guaranteeing access to condoms. The projects include direct representation of community leaders. The Coordinating Office does not give the project its final approval until it has been endorsed by the indigenous community. Support for STD/HIV/AIDS Prevention within the Indigenous Health Program, 1998 to 2002 Product 1998/99 Coverage 2000 Coverage 2001/2002 Estimated Major results January to coverage achieved - July for the STD/HIV/ year AIDS 2001/2002 1 -Project 1998 - 27 97,702 10 N= 323,000 15 projects N= See situation support projects Indians projects 193,800 350,000 report 1999 - 17 (30.2%) (60.0%) 258,400 projects (74.0%) 2 - Educa- 1 video 32 DSEIs I direc- 100% DSEI 1 textbook tional (02 (100%) tives materials tapes) 27 CE- docu- 100% NGO 1 STD/ AIDS ment AIDS (100%) 100% CE manual 100% of 1 serial coopera- album ting NGOs 9 3 -Working 3 regional I regional offices for offices office establish- ment of STD/AIDS programs in the DSEIs HIV testing: Under the AIDS II project, a proposal to monitor the course of the AIDS epidemic and other STDs among indigenous peoples was developed in conjunction with FUNASA, based on an analysis of areas of greatest vulnerability and highest risk, on the basis of the indicators mentioned earlier. A surveillance model was drawn up that took account of the cultural characteristics and differences among each of the tribal groups. It was agreed that measures would be taken to monitor the HIV situation among pregnant women, and patients diagnosed with STDs and with tuberculosis. Implementation of this project was dependent on approval of the use of quick tests by ANVISA. Access to testing for indigenous peoples is guaranteed through the CTAs (testing and counseling centers - centros de testageni e aconselhaniento), but testing is still in an early phase and is not yet being conducted on a regular basis. There is a proposal to train the DSEI teams to enable them to guarantee and expand access to these quick tests as a diagnostic tool. Access to Treatment and Care. As regards access to treatment for individuals suffering from STDs and living with HIV/AIDS, we should like to stress two points: (1) basic care and prevention services are provided by the DSEI units, in the form of training for health care professionals in setting up programs using the syndromic approach, and also in the form of training for indigenous health agents, teachers and community leaders in the areas of education and community health promotion; (2) as regards secondary and tertiary care, referrals are made to the SUS (Unitary Health System), via SAE (Specialized Outpatient Services - Servi9os Ambulatoriais Especializados), ADT (Home Therapeutical Care - Assist6ncla Domiciliar Terapeutica), and the credentialed hospital network. These services receive specially earmarked funds for treating the indigenous population. Responsibility for basic care and treatment rests with FUNASA, while CN-DST/AIDS is charged with providing guidelines with regards to the establishment of services and standardizing procedures and routines. The CN provides training of health care professionals in the syndromic approach to STDs, together with training in counseling, training of indigenous health agents in developing prevention campaigns and specific educational materials. With regard to access to anti-retrovirals and monitoring of pregnant women, the DSEls send their requests to the SAEs, which in turn register the patients and continue to monitor them in conjunction with the technical staff of FUNASA. In regions where distances between the community and available services make access difficult, the National Coordinating Office has been mobilizing other sectors, such as the Armed Forces medical services. Major challenges and lessons learned The program faces the following challenges: (1) to reduce the current levels of rotation of health professionals within the DSEIs; (2) finalize the process of coordination of state and/or municipal programs with the DSEIs in order to implement specific actions targeting indigenous peoples on the basis of criteria established by the National Coordinating Office (CN) and FUNASA; (3) reduce barriers relating to access to services, testing 10 and treatment in conformity with cultural and tribal differences; and (4) guarantee additional resources to keep strategic projects going. We would list the following successes: (1) integration at the national level of the work agendas of FUNASA and CN-DST/AIDS; (2) development of culturally appropriate educational materials in various indigenous languages; 3) progress in the process of creating programs within the DSE-Is; (4) monitoring of major trends in the epidemic among the indigenous segment of the population; and (5) coverage based on enhanced vulnerability and risk as the relevant criteria. As regards NGOs carrying out direct activities among indigenous peoples, it is important to note that many of these organizations have no experience working with STD/AIDS, making it necessary for them to strengthen the capacity of their teams; in addition, the NGOs have frequently come into conflict with the communities, with resultant interruptions in work programs. For these reasons, the National Coordinating Office has preferred to work with recognized indigenous organizations and Indian support groups and to strengthen the response capability of the Indians' own organizations. III - Plan of Action: Objectives: I - Improve the local management process and encourage the programming of joint actions by the DSEls and local STD/AIDS administrators; 2 - Mobilize additional human and technical resources to train DSEI health teams; 3 - Strengthen the task force to monitor the establishment of STD/AIDS programs within the DSEIs; 4 - Prioritize prevention and treatment measures aimed at members of the indigenous population living in urban areas, through strategic measures coordinated with state and municipal authorities and non-govemmental organizations; 5 - Establish a joint plan of action for assistance measures between FUNASA and the National Coordinating Office, by defining guidelines, priorities, flows and counter-reference for STDs and HIV/AIDS; and 6 - Establish instruments to match, at the local level, information collected by the Indigenous Health Care Information System (Sistema de Informa,Jes da Aten,do ai Saude Indigena - SIASI) and the Reportable Diseases Information System (Sistenia de Informa,ces sobre Agravos Notiflcaveis - SINAN), in order to reduce the underreporting of STD and HlIV/AIDS cases among the indigenous population. Indigenous Development Plan: > Support for behavioral modification projects and health campaigns being executed jointly with non-govemmental organizations, indigenous organizations, and Indian support groups, to train indigenous health agents and teachers as disseminators of information; 11 34 projects/year (at least one project in each DSEI) = BRL 5,100,000.00 for the three years covered by the AIDS III Project ' Organization of macroregional meetings to define STD/AIDS prevention strategies, promote social monitoring in the health area, and mobilize the indigenous peoples, by bringing together the health care institutions making up the Unified Health System (SUS), FUNAI, non-governmental organizations, and institutions representing the indigenous communities; 7 meetings/year (21 meetings over the 3 years of the project) = BRL 630,000.00 > Basic and advanced training of indigenous agents and Indian schoolteachers as information disseminators to help develop prevention programs in indigenous communities; 12 training courses (4 in each year of the project) = BRL 600,000.00 > Guaranteed supply of needed inputs (condoms and quick tests) to develop preventive measures for health in general and STD/AIDS in particular; Included in the general project total > Conducting of seroprevalence studies in selected (sentinel) sites to identify the risk situation and exposure to HIV/AIDS and syphilis among segments of the indigenous population at greater risk and/or with heightened vulnerability; 1 seroprevalence study = BRL 120,000.00 > Production of technical documentation and instructional material to assist in intervention measures among the indigenous community; Included in the general project total for Information, Education and Communication (IEC) > Reduction in the prevalence of STDs within indigenous communities by providing support to DSEI technical staff and training physicians and nursing staff in a syndromic approach to STDs. 30 courses on the syndromic approach over the 3 years of the project = BRL 900,000.00 > Sustainability of preventive measures and of the civil society institutions carrying out the intervention projects. For this component, meetings will be held with the administrative agencies (Coordinating Offices at the national, state and municipal levels, together with FUNASA) to discuss the inclusion of "additional funds" to finance the prevention campaigns for indigenous peoples at PAM medical posts, and to guarantee financing through indigenous health care. It is important to emphasize that, in every stage of preparing this plan of action and the strategies to be employed, the CN-DST/AIDS has included representative organizations of the Indians themselves, both in the social monitoring bodies mentioned earlier, and in committees and advisory groups. The resources should include counterpart funds from FUNASA for training activities and administration of STD/AIDS programs within the DSEls. 12 Potential Monitoring Indicators: Number of NGOs working with Indigenous Peoples. Number of indigenous people covered. Amount of financing allocated to Indigenous services. % of those municipalities with indigenous populations that included activities for indigenous health in their PAMs. No. of indigenous health agents trained. Prevalence of AIDS amongst indigenous people. Prevalence of STDs amongst indigenous people. SITUA(;AO DAS DST NOS DSEIs EM 2001 Indd_d_a Conheada de por D _S - iE3A12001 Etla No HV Pop InOJlOhb - 1 Alto PJo Juru 231 0 7 061 3Z.7 . 2 AltoiR.P.- N2o ( 5i44 39.0 3 - Alt. o Wlgro 114i 32 43 4 .AJtoNRO OSirlfOs 2 2 281907 0,1 5 o Malus 29 0 11108 18.0 I ~~ AM t PA /~~~~~V 7 Mli.MdloNtoP,,moo0 300 t 671 5 F.M6dIo04Fin0. - 2 0 -610M - 53 7 -M611 SJ6. 3 - - i 250 7 ¢ 7 5 /S [,,1 r5 ,#>^MA ,1 t1~~~~~~~~~~~~8 P-rtins 10t _ 7 9t4 12t tt <,f fSl :~~~~~~~~~ 7 g ~~~20 9 - C+ 90 Vdojawr ma 42' ( 255 16,2 10,1 -L LJtd. FrW.. 22 08910ol - 1, 12 PortoVelho t 7 t 6041 11,1 13. Vilhomn2o 4! 6,7 14 .A3tooira 5 - 6T7 92.i 15 -Ch.oArTO 36 0 3.69 9,7 16 - iV..p6 . PA 1 0 12t3 0.31 17.R.oTpj6. 29 Z 4.S 5 IS .A aoto a Nxte do Po 115 0 8201I 16. 19 - TOomtr 34 6.9454,3 220- Mroh9 So1 0 19 021 35.8 21 - Ca d 21- - t119 31. S4 7 _>4 22. Potygla 6-4 9 701 E69 >19 f SP _ 24 - Agoss o Srgippe 1 - 6997 0,1 25- Bh,a t t 14 9E 0.0 29.Min-, Goro. fESmto 16 70 9212 17,4 27 -LUtorl Sul 19 0 31 5. 2R- Intenror Sul 3 0 1-7, '12.4 2 30- Aragli 10 0 2 39.8 30- WO1 0 4 4521 - 31 - K-.pd.MT - 940 5.0 3 g. 2I - -9 3992 ,3 13Moto ~0OS0 400To 13 DSEls COM CASOS DE HIV/AIDS 1 1-Alto R,oJu,uA-AC 2 2 - Alto Rio Purus - AC I AM NOTIFICADOS - 1998 a 2001 3 3-AltoRioNegro-AM 4 4 - Alto Rio Sohm6es - AM 02 5 5 - Manaus -AM 02 6 6 - M6dio Rio Purus - AM 7 7 - Mddio Rio SolimOes - AM 8 8 - Parintins - AM I PA 9 9 - Vale do Rio Javari - AM 10 10 - Lesto de Roraima- RR 03 11 11- Yanomaml - RR AM \,Altf ¢ 2 PA .; 2 12 12-PortoVelho-RO/AM 4 7 I.. 5 / MA 13 13 -Vilehna- ROIMT t s Q1/ 7 7 h 20 1 1 C 14 14 - Altamira - PA 15 15 - Gua m Tocantins - PA 1' 2 16 16 - Karapo - PA 01 17 17 -Rio Tapaj6s -PA 10 19 - Amop6 a Norte do Pari - AP I PA 02 . I , 1 19 19 - Tocantins - TO Ml sz-tT MG 20 20 - Marainho - MA 21. 21 - CearA -CE 22 22 - PoAiguiar - PB 01 23 23 - PCnuabaco - PE 01 GO ~~~ ~~~~~~24 24 -Al'agoas oSergipe .AL ISE 01 25 25 - Bahla - BA 01 M:C n326 26 - M Gerais a Esp Santo - MG I ES 01 27 27 - Ltoral SuL- RJ ISP IPR ISC IRS 01 28 28 -Interior Sul -SP IPR /SC IRS 29 29 - Araguaia - GO I MT 03 30 30 - Culab4 - MT 31 31 - Kalap6 - MT 32 32 - Xavante - MT 33 33 - Parque Indigena do Xlngu - MT 34 34 - Mato Grosso do Sul - MS 24 14