Meet the Experts: Street Outreach
XI International AIDS Conference, Vancouver, July 10, 1996

?: I think the standard at these meetings -- we have to see them as kind of informal meetings. "Meeting the experts" -- so that is meeting. That means that here are some people who have experience, but more people on your side who have more experience. So I would say that after shared introductions and presentations we will take it over to you to find a dialogue. What does it mean, street outreach? I would invite you to focus on three issues: what is the experience until now, what can be learned from that, and what will be our next policy; next steps. Do you go on in the same way, or is it really necessary to change how we do it?

Before I give the floor to the speakers, I just want to introduce myself quickly. I'm Franz [?]. I'm working for a Dutch agency. We support AIDS problems in the developing countries. We've been doing that for ten years, and we do have a lot of experience, through those programs, with street outreach work in Latin America, Africa and, unfortunately, also it is common more in Asia, India, and other countries. But I will now give the floor to Ann [?]. Ann is a nurse administrator from British Columbia, here in Canada, and has a long [?] nursing experience from the hospital and [?] to community mental health. She has experience since 19[?] administration [?] frontline work.

Ann: Thank you, Franz. Can you hear me? I have to have my notes in front of me, 'cause I always get nervous at these sorts of things. But my understanding of these sessions is that they are supposed to be very interactive. I was really intimidated when I was invited to come to this session as an expert, because there's a lot of expertise out there. And I mostly attribute that expertise to the clientele that we see in our program.

What I'd like to do is give you a short rundown of the program as it exists here in Vancouver, to give you a little context of what my experience is, and then pass you along to Paulo, and then hopefully open the floor for questions. So I want to give you some quick views on health promotion and harm reduction from the perspective of the street nurse program. Because these form the foundation for our street outreach strategies and interventions. We regard harm reduction as an integral part of health promotion. Health promotion being, as defined by the WHO, the process of enabling people to increase control over and to improve their health. Or, to phrase it another way, the ethical provision of health care; a continuum of client-centred services.

Such care delivery places a high value on the inherent worth of the individual and his or her right to self-determination. If we accept this, we assist others to further their self-determined goals, while at the same time reducing or avoiding harm. Reducing fear for clients, care providers and the community must be a major consideration. To be effective, we must be willing to share knowledge with and provide clients with information, tools and access to appropriate services, or to advocate for such services if they don't exist. And most experience has been that the needed services are lacking.

The goal of the street nurse program is to reduce HIV transmission, in particular with the street-involved population of Vancouver. We operate three storefront clinics in areas of Vancouver where our clientele are most concentrated. In addition to the nine community nurses in the program, we have two health-care workers who liaise with and provide services to the South Asian and Hispanic populations. We visit clients in the local jails and detoxes. We meet clients on the street, either on foot or through mobile outreach, five nights a week, in our van. Staff on the van provide health care and educational backup to the Vancouver Needle Exchange van during their nightly rounds as well. We deliver education and direct health care on the street. We attempt to give clients what they need: user-friendly, accessible services at no cost to them. A safe place to verbalize their feelings, fears and hopes.

On the streets, we seek to meet our clients in their territory. Our immediate goal is risk reduction, and we carry needles to exchange and condoms for distribution. Our longer-term goal is to establish trust with our clients so that they will eventually choose to come to us with their concerns. These are clients who, for the most part, aren't connected with the health care system. Whose trust is often hard-won and requires an investment of time and patience. We may see a client a few times on the street before we even approach them. This gives them time to become familiar with our faces and perhaps ask their peers who we are and what we're about.

When we do approach them, we are clear that we're on their turf, and are respectful of that. We'll introduce ourselves and our service, offer condoms and needles, and perhaps leave it at that. Any more might be seen as intrusive, or cause the client to become suspicious of our motives. It might take a number of encounters before we get a name -- if clients choose to give us a name; we don't care -- let alone any idea of their risks and concerns. All the while we try to make our good intentions clear and keep our encounters short, consistent and respectful.

With our established clientele, street encounters can be as simple as a quick greeting, distributing a few condoms, and maybe exchanging a couple of needles. It could be changing a dressing on an abscess or administering Narcan to a client who's overdosed on heroin. Given our clients' general reluctance to seek out traditional health care facilities, we often encounter health care concerns that would probably have gone unattended if we hadn't met them on the street. We'll either treat them on the spot, or accompany the client to one of our clinics or to another health care provider, depending on the nature of the concerns.

Clients' basic needs and rights to stable housing, nutrition, health care and safety must be taken into account. The priority of daily needs often outweighs the importance of taking measures to improve health and prevent disease. Isolation, fear, violence, language and cultural differences, and limited education or employment options are further obstacles to overcome.

In the early days of our program, prostitution was concentrated in a few areas in this city. Since the inception of "Shame the john" type campaigns, sex trade workers have regularly and systematically been shifted out of neighbourhoods. The result has been a scattering throughout the city of various pockets where prostitutes work. These are always moving, depending on the tolerance and attitudes of the communities where they choose to locate.

To respond to this demand, we have expanded our mobile outreach. Five nights a week, staff drive the streets, identifying areas where sex trade workers are located, and offer condoms, needle exchange and an introduction to our services. We have identified a number of shooting galleries, where we've become known and trusted by the clients. We exchange needles, offer [?] maintenance education and often respond to minor concerns, such as dressing an abscess, or major concerns, such as arranging admission to hospital for endocarditis or extensive cellulitis.

There are dynamic, ever-changing needs presented to us in the street nurse program. As new clients make their way to the street, they seek to find their own way and place in that community. This constantly presents us with new challenges: to identify the client and their particular needs, and strive to deliver an effective, accessible, acceptable service based on those needs.

There are opportunities to share knowledge, and a willingness to explore our own and our clients' values and beliefs -- including their relationship to drugs. These are important considerations in order to help clients come to well informed, self-determined goals -- goals that are rooted in their own realities. Inclusion of clients and their affected communities should not be overlooked when developing program strategies and specific outreach interventions. They are the experts. Peer education can promote a possible change in the client's social structure. Flexibility and innovation, advocacy and support, planning and evaluation are all necessary program components.

I have a few other comments -- which I think I will make after the next speaker, when we get into the question and discussion period -- about some important considerations in establishing or setting up outreach programs.

Thank you.

MC: Is it wise to ask you, because you said you had some comments after the presentation of Paulo, that we do it then? That we give Paulo the floor now? I think it is better, because then we can combine those two things.

Paulo Longo has a long time experience working in AIDS fields in Brazil, particularly in Rio de Janeiro, where he himself has worked as a street outreach worker for quite a long time. He now coordinates a program on it. He said to us in the beginning that he, not he but the organization, is desperately looking for support, so funders in this room, listen. Paulo please...

Paulo Longo: Thanks, Mum. Isn't it great that the chair of the session is, "Thanks, Mum."

I coordinate this project in Brazil , Programme Pegacao. It was started in 1989, It has become a big organization since that time. I told a little bit of the story of this project yesterday during the sex workers session and I would be glad to share this with you after the session if you come to the booth of the sex workers where we can talk more about the project, the network and you can also come and buy some postcards of our organization to support our project.

What I would like to share with you here is. Firstly, that I am surprised to come here invited as an "expert". because It was really something surprising to me. Especially because the point is street outreach and street outreach is for me is a concept that I have now been really thinking for four years already. I have been really thinking about looking forward to change or at least to talk a little bit about some misconceptions that are very often related to street outreach concept. The first idea is the idea that someone has to be reached.

So you design this project because you have to reach someone. and generally in these conferences and these projects and these large organizations like GPA and UNAIDS and large ones they have developed that concept that there are groups that are "hard to reach." So, they come with this concept that if they are "hard to reach" then they have to design strategies to reach them. This concept sounds really strange to me because I don't find that sex workers, for example, are "hard to reach." Because their clients reach them very easily if they want. So it's not really hard to reach, see. And sometimes this concept is used in a political way, very strange political way -- say that someone is hard to reach, so keep them apart. Let's design some very strange and complex strategies to reach people that are just at the street. If you go there and if you really want to reach them, you reach them, they're there. So This concept of hard to reach is something that I would like just to stress here, and make us think about.

The other thing, is that generally projects such as outreach projects are projects that aim to service providing for a target group for a specific group and generally these groups have never been reach before by other projects or by other service providing. And these people are not very used to this service providing. So it sounds very strange when I think about the street boys in Rio De Janeiro or the transvestites and transsexuals when I think about them that they had never anything and suddenly people started to come with boxes of condoms. Giving them condoms when their basic needs are other. They don't face this as a need. And they started with this wonderful service providing. Now you have STD clinic where you can go to, now you can have this HIV testing if you want and we can even make this testing here at the street if you want. Of course it will help the research. This idea that you come with service providing for a group that is generally not used to it. It's another point that I would like to stress here.

Another dangerous concept that has come from street outreach is the concept of "peer education." I have been sharing this with you in Japan and I would like to come back again to the same point. Because generally this idea of peer education reinforces that first idea of hard to reach people. So if they are hard to reach, if they are in a specific group, if they are something that we can't be in touch with, they are a very strange and isolated part of society so let's encourage them to do this peer education. So sex workers educate sex workers and street youth educate street youth and so whatever. And homeless education homeless. And then I really feel that its a very strong excuse for health authorities to deny their responsibility with the people. So they just come and say so prostitutes educate prostitutes and homeless educate homeless and we don't have to do anything. All we have to do is to say that now these people we have never paid attention to will get a very nice certificate from the Ministry of Health and they will become educators. And it really is something that annoys me because it creates lots of problems. One problem that we face very strongly in our projects in Brazil was the problem that generally this concept does not face diversity. Peer education is like everything is in a whole block and everyone is the same. So male sex workers are male sex workers so just because they are male sex workers they are able to educate others. They are able to do the service and it's not true because there is a very strong . And this diversity is generally denied in the model in peer education so that's another point I'd like to stress.

The other one is that it often generates identity problems. We have lots of boys on the streets in Rio De Janeiro that do not either consider themselves as sex workers or as gay or whatever. When you go to one of these boys at the streets and you start to talk to them and you ask what are you doing here? They say, "I'm waiting for someone to buy me a drink" or something like that. They never say "I am a sex worker." It's very, very hard to get this. So you imagine when this goes into the peer education model. First they have to take the identity of being sex worker they have to take the identity of being gay and now they have to take the identity of being an educator. So it's quite complicated and complex this large number of identities they have in one second. The other thing is that generally this peer education model has been interfering in the work itself. People are there to do sex work they are not there to be reached by someone. They are there to do their job, they are there to find the client, to get the money from the client and that's all. They are not there to wait for a wonderful guy with a T-shirt from a project who comes and gives them something. So this interference is something that generally people like donors for example, they have a very strong prejudice against street outreach projects and about peer education and all these things. The first prejudice is about salaries. They say, "We will not pay salaries because this work must be volunteer." I really think that we can't we can't talk about volunteer work in Brazil where people in sex work must see at least ten clients a day to survive. And then these people come and say, "It must be volunteer, we don't want to create a dependency relationship. We will not pay salaries for these people because they must look for their work and for their survival." They say that They must generate their own income sources but they want them to do extra work that has not been included in the agenda of sex workers, but they say, "No, no salaries."

The other thing that's very difficult for them to understand is "outreach expenses." Of course when you go to a prostitution area, a sex work area, you take the boy out of his work to talk to him. Because we don't just go there just to give out condoms we go there to talk and to create a regular relationship of intimacy. And for that we need to go to sit down at a bar or a restaurant or somewhere. And it's a very good way to keep people talking. So when we include in our project outreach expenses, people say, "We cut this. We don't want to pay for your food. We don't want to pay for your drinks. I have seen donors that came to see the project in Brazil and they say "Oh, so that's what you do with the money you buy beer for these boys." I say, "Of course we pay beer for the boys because here, first of all we are talking about pleasure. People are here for pleasure." If it is not a pleasant relationship, we stop it. So this is another concept that's difficult for people to understand.

It's is very common also that projects like ours and other outreach projects are used very often by researchers as a bridge between the researcher and the target group. (I hate the words "target group.") It's like they cannot not reach people that they think are "hard to reach" so they use the intimacy and this very strong relationship that we have with the group to do their research. Which sometimes is interesting research but most of the time are awful. They just come to research like, "How many clients do you have a day?; and "have you been sexually abused in your childhood?. And never had it been helpful to any of us; it has never been helpful to any of the boys. They are not interested in statistics and beautiful graphs and tables.

Another problem in outreach projects that I can share with you is that we have very weak indicators for monitoring an evaluation. Generally, the indicators are always the same. It is: number of condoms distributed number of people attending STD clinics; number of pamphlets produced, for us it is not useful because most of the boys are illiterate but it is a very good indicator, you see. And they always come with the same indicators. And it's been very boring and tiring for us. If you are talking about these projects and you are sharing these projects with some people, they always want to find these indicators. And if you get some funding (it is really hard to get but when you get it) people want these indicators, they say, "How many condoms have you distributed? How many boys have you attended? How many of these boys go to an STD clinic and are diagnosed with gonorrhea, condoloma, or whatever?" And we think these are very weak; they are not good indicators for the success of an outreach project. For us a good indicator is the increase in self-esteem of the group. And we don't talk about self-esteem as a very abstract concept. We talk about getting representation in a large way, like all over the country. And this project which started as a very small outreach project in Rio De Janeiro, has got lots of international attention, has got an evaluation from the World Health Organization and now the organization represents 400 organizations in the National AIDS Commission. This is for me a good indicator, because there we can have political action, interfering in campaigns, interfering in the prevention policy in the country and even interfering in the policies for treatment, medicines and all these things. So for us this is a very good indicator because this is the real and concrete concept of solidarity we face everyday in our project. We don't need numbers of condoms distributed and all this sort of stuff. And in the very moment that I am speaking here as an expert, my organization is moving. We are leaving the building where we used to work because we are totally out of money to support the rental of our building. So sometimes all these big things do not help. The real solidarity I have now, is that I have sex workers here watching, people from my organization here watching, and I know that all those volunteers, all those people "hard to reach" are there packing and helping to move the organization to another place because we always know that something good is coming again. So we are very optimistic, and that is what has maintained and sustained this project for seven years. Thanks.

Moderator: Thank you very much, Paulo. Your speech is also an invitation to the audience to come up with some good [?]. As you mentioned yourself -- I know that, working with one of those donors -- I'm not afraid to see all those [?] because I know how the work has been done. I think this is a very good example. But it is also inspiring. Probably somebody here can come up with some other good indicators of how we have to work and how we have to go on working. And the same way, what you said about the research. Until now, it has not been helpful at all for the real work in the outreach itself. So, before I give the word to Anne, to give her comments, is there somebody willing to stand up and add something to what has been said?

Aud: My name is John Vesales and I'm from Brazil -- actually, Rio de Janeiro -- and I do work with the AIDS Office in San Francisco. I just wanted to congratulate you -- coming from there, I know how hard it is to do outreach in Brazil. I wanted to let you know that we are starting this budget to try and help outreach work in Latin America. We're trying to send some money to Brazil to help you guys out.

Aud: Hi, my name is Beth Wolgemuth. I'm from the Sex Workers Alliance of Toronto. Until recently, I was with Maggie's, which is the Toronto Prostitutes Community Service Project -- the only funded prostitutes' organization in Canada. Which brings up another problem with organizations that are supposedly marginalized -- made up of, or doing outreach to, marginalized people. We have money from the Feds, from the Provincial Ministry of Health, and locally. But we were told recently that, when another organization started up in Vancouver, they were told, "There's already a prostitutes' organization in Canada; they're already funded." So this whole idea that "we have a group serving this marginalized population; therefore that group represents everyone" is in itself going to guarantee that Maggie's, the group in Ontario, fails. And it is, in fact, under huge internal and external pressures that are causing it to self-destruct. As for the issue around funding -- if we were to say, "Oh, we're only going to fund one Native American organization in the whole country, and you people have to represent everyone," we would all think that was ridiculous. No one in this room would think there should only be one African group in Canada. It's ridiculous to think that one prostitutes' group speaks for all prostitutes. And yet, when I was with this organization, we were asked to do not only what the funders wanted us to do -- which was, as Paulo said -- I mean, I got so sick of going, "Oh, shit -- how many boxes of condoms did we give out this year?" They didn't want to hear how many times we'd gone to court with people, how many times we'd gotten people lawyers -- because that wasn't AIDS prevention. How many times did we help find housing? No, no, no. We helped a lot of people keep their kids. But that's not AIDS prevention. Jesus fuck, of course it is! Poverty is a big issue. Just like the boys don't care the first time you walk up and say, "Do you want a condom?" They're, like, "No, buy me a beer." The same sort of thing happens to organizations in North America. And Maggie's is in the process of being de-funded because it's not representative. And I would put out to you in the audience, if there are any funders here, that that is a ridiculous notion. To force us to be something greater than the rest of the community -- to be somehow more representative, to provide more service for less money, which is something we get all the time too -- is ridiculous. To say, "You're only funded to do AIDS prevention" -- well, there are so many barriers in this country to doing AIDS prevention. If I can't also work to help a woman keep her kids, then what good am I to my supposed community? This whole notion that there's a prostitutes community, or a sex workers' community -- and that we're all the same. Like Paulo said, of course not. There's a huge diversity in the community. And just to remind people -- this is also a North American issue -- but funders say -- I had someone say to me, "Oh, there's already a prostitutes' group in Brazil. There's one funded, you know." [?] hopefully there's more. I mean, Jesus.

My name is [?] and I belong to the same organization as Paulo. I want to raise this question: What are the sex workers' reactions when a health agent asks a question such as "Are you a sex worker" in Vancouver?

?: That's now what we ask. I'm not quite sure -- are you asking me whether there's a reaction to the fact that we are health care workers? I didn't quite understand the question. I don't ask that. I just ask them if they need anything, and let them know [?]

?: This is really an important question. Prostitutes' rights groups never got funding, or even notice -- prostitutes were never noticed -- until AIDS. So you'll find that we all have funding, but only through AIDS funding. Which is why I can't do all the other work -- all the other activism that needs to be done around just plain human rights issues. Everything I do -- and I know Paulo has said this in the past -- I have to frame somehow -- I have to find some esoteric connection to AIDS. Not that it isn't important. But when we have researchers and reporters in this town, in Vancouver, [?] being a good example of someone who goes down to the Lower East Side, identifies people as prostitutes and addicts, and then says ridiculous things in the newspaper, like "Junkies and prostitutes are vectors of HIV into the mainstream population. And when we confronted her on this, she said she didn't really say that, but she didn't offer a public retraction from the newspaper. Which to me says that she is of course saying it. I've read her research. She is saying it. So she doesn't go up and ask people, "Are you a sex worker?" She goes out into the community, makes the assumption about people's identities, and freezes them there, in her research. So it's really important to unfreeze the identity. I would say that, as a health worker, your job is probably working with people who need access to health care. And labels are not helpful.

?: Exactly. And we try not to use labels.

Aud: My name is Ron, and I do outreach in the United States, in Nashville, Tennessee. A lot of what you all are talking about, I don't encounter there. All I do is, I go out into the community, and I meet the people where they are, whatever their needs are. I don't go back and say, "I went to court with somebody, therefore I had to spend this money on that or on this." I just do whatever needs to be done, and that's it. The indicators that Paulo was talking about -- you're right, those are not very good indicators, 'cause every year you have to say, "We gave out 50 million condoms, and blah, blah, blah."

I was going to address your needle exchange thing. I live in the Bible Belt and, man, are we having a lot of problems with needle exchange. But a long time ago, when I was young, I found out that, wherever you work, there are going to be people telling you what to do. So you say, "OK" -- and then you do what you want to do. They won't allow us to do needle exchange. So I say, "OK," and I pack my bag full of needles and go out and pass out sterile syringes."

Aud: I have something to say in support of what you were saying, about researchers asking questions. My name is Pat and I'm a director of counselling services in [?] group. I have had hands waved at me at national meetings by researchers who say, "We have to count on these people for access." Yes, you do. And, if there are researchers here, I want to tell you a little story about something that happened to us. We were asked, for the Canada Youth and AIDS Study, to round up kids who were involved in the sex trade, so that they could contribute to the study. The kids were taken away to a quiet place, and they were given a fucking hamburger, and about ten bucks. And then they were asked a lot of intimate questions. So they had this little intimate experience, for ten bucks and a hamburger. It took about 45 minutes, during which time they could have been doing way better. And then they were left. They weren't debriefed. And they ended up very sort of rattled and upset. So now when researchers come and say, "Aren't you one of the people that we have to depend on for access?" I'm not that happy to identify myself. So it's true -- it's just that all the help that we could have from research, we end up with our clients sometimes being very abused. And it seems to me that 45 minutes for an intimate experience, for a hamburger and ten bucks, is essentially abusive.

Aud: I'm Judy Ray from the AIDS Committee of Durham, which is in Ontario. My question is for Ann. Ann, could you tell us about the funding of your program?

Ann: We are very privileged in terms of the funding for our program. We're funded through the BC Ministry of Health. The way the funding developed for this program was that there was a recognition and a request from community agencies in the city that there was health care needed out on the street. And, in fact, it was initially funded as this mini little pilot project that nobody really knew about. But then there was some recognition that this was a useful thing to be doing. I don't know whether I should tell you this, but I'm going to anyway. In the first few years of the project, what it really involved was taking the ministers of health out on the streets and basically giving them a good talking to. Saying, "This is important. This really needs more funding." So we have been privileged in terms of getting government support for our project, and ongoing government funding and regular staffing. To me, one of the great values of working in this program -- I must tell you that, prior to starting in this program, I had basically given up on nursing, period. Because I didn't find nursing to be client-centred at all. It didn't take client needs into consideration. And when I started with the program, I wasn't even sure that this was going to be such a program. But it is. And the staff that I work with -- recruiting that particular, committed staff -- I love it. It's wonderful. It's great to work with people who are really committed to delivery of client-based service, and looking at client needs. We operate under a very restrictive mandate. The mandate of the program is to reduce HIV transmission in, again, specific, targeted groups, like street-involved people. That's what it says. What we do is everything and anything.

?: So this is a nice example about the clients' needs and the government funded and recognized it: let government go more to the street. I'll just give you one example myself. [?] working in the developing countries. [?] in Amsterdam, some of the needle exchange -- it has been [?] financed by government. That's a good example to have in mind, that [?] there are some examples [?].

Aud: Thank you. My name is Emily [?]. I work with Family Health International AIDS Care Project in the African Regional Office. I'd like to ask questions, particularly of Ann, but Paulo may feel free to answer. I'd like to know -- you said establishing trust is what is most important. What strategies do you use in approaching these persons on the street, and how do you identify yourself, and how do they establish trust in you? That's not all I want to ask. How do you follow up those you refer to clinics, to make sure that what you have done for them has actually worked, and that they've actually followed your recommendations? Also, how many of them are migrants? Are they always there? Do you follow up to check if they're there? Are they just migrants passing through? And if they are, do you check to see where they came from and where they went to? And then, how do you gauge that you've actually succeeded in your interventions?

?: There are now many people who want to participate in the discussions, so please make it brief. Give short statements, and tackle all the issues.

Ann: I'm not sure how to answer -- that's a very complicated question, and I'm not even sure I remember the beginning of it! But, how do we establish trust? Time and patience, and just being there. Being respectful of people. There's no magic to it. There's no trick. I think it's looking for basic human similarities. We're all in this together. I can't give you a prescription.

And do we follow up? We follow up as we can. It's not always possible. And yes, some people are migrants. Some people are transient and come through our program. Some of our clients we may only see once. Others I've known for years.

Aud: My name is [?]. I'm from Indonesia. I'm working with street children in Jakarta and other cities in Indonesia. Maybe this is a similar [?] situation. My question is, when we give information about AIDS, what is your experience in dealing with the value of life? Because for them, for our target group and also for sex workers, they feel like dying is better than living sometimes. So how do you deal with that situation, which is that, with AIDS, it's better if you die sooner. [?] target group, how much you already reach. And then the last question is, what media do you develop for intervention, for peer educators?

?: [?] Regarding the question about values, and whether it's better to die than t live: It's interesting, because when we first started talking about AIDS, people were very connected through the Brazilian government campaign, which was saying, "AIDS kills." And the boys were really not interested. They said, "Okay, AIDS kills. But hunger kills. The police kill, very often. This is known about Brazil, all over the world. So it was not a matter of living or dying, you see?

What we do in our work is that we want to make sex work healthy. Because they even used to feel that doing sex work was something very sick. Something morally sick, which is even worse than physically sick. So what we do is that you can have sex work healthy. You can do this healthy. Like any other job. So we bring this back to working rights -- working conditions. Like any other job, you have to have working conditions. So if you have sex work, you must have it in a good way. You must use condoms, you must have this and that. So that's the way we talk. We don't talk about "bad," and these things. We talk about quality of life. We talk about the quality of the work itself. So you will be a better . . . whatever you choose -- sex worker, if that's the case -- if you do this in a nice way.

The other thing is monitoring. We monitor the work by the results that I just told you. Like when we have the possibility to influence policy changes -- like when we go to the Ministry of Health in Brasilia, and we have the seats on the National AIDS Commission, and we go there and we discuss with the government what are the priorities for the communities, I guess this is a very good monitoring evaluation result of this. We have also this WHO evaluation that I told you, with lots of external things and blah, blah, blah, but it was not very interesting.

About the media -- they're not very interested in us now. They are just interested when they want some tragic stories of those people who have lived in the streets. It's like I always say -- I feel like I'm on top of a building which is burning, and everyone is downstairs, waiting for us to jump. It's the situation that we face very often, isn't it? Everyone is expecting the next one to jump. That's exactly how we feel when we have to talk to the media. So we don't talk very often, and when we talk, we charge a lot.

The second question, about monitoring and tools -- I think that is so complicated we should almost have another session to do that, and how to deal with the donors and so on; so I won't address it, because there are so many speakers. But it is important, really.

Aud: My name is Rand Frew. I'm an Anglican priest, and I'm the founder of AIDS Action International, out of New York and Florida. I also work overseas in Asia. My question is, what kind of involvement -- and I don't care whether it's positive, negative or indifferent -- but would you describe the involvement of the religious communities, which is both Christian, Moslem, Hebrew -- whatever community we're talking about. I'd like to get some image of what kind of influence, if any, and interaction you have with religious communities, in your own context. Thank you.

Ann: In terms of our program directly, we are not really directly connected to any particular religious organizations. But there are many organizations out there that do volunteer work. And we do interact with them at street level. But beyond that I can't say there's much direct involvement.

Paulo: In Brazil we have a very close relationship to Afro-Brazilian religions, which are the religions that often people in the streets have, like the boys and the transgender groups, they are very connected to these religions, like [?], [?]. There are lots of rituals and things like this that are of concern specifically in regard to AIDS, because in [?] we use these cuts, and people share these cutting things. So we've been working together developing some kind of projects for that. But also we use some of the beliefs in the work. Like, there is one belief that if you have sex and go to the ocean afterwards, you will purify your body or something like that. So we made some papers, you see? So that between the person and the sea there is a bridge of condoms -- using the natural beliefs. But we have lots of problems with the Catholic Church in Brazil. They hate us. I've been fighting with the Bishop every day. They hate us. They say that we incite promiscuity.

Aud: I know in Toronto we have -- I like to sit, eh? I used to be a stripper and I'm not used to standing in front of crowds anymore, unless I have my clothes off, not on. In Toronto we face a lot of problems. I work the streets in Toronto, because it's become very dangerous to work indoors. Actually, because of all the murders, it's becoming dangerous to work the street. But the religious outreach that we face -- that we have tried to work with -- the last time I worked the streets, somebody came up to me and said, "Aren't you worried about AIDS?" I went, "I'm an AIDS worker," and he said, "Oh how interesting for you." And I said, "No, I'm really not concerned about AIDS at all. And he said, "But Jesus is worried about you getting AIDS." So this sort of situation, with me, as a prostitute, equals AIDS, is a very negative context. And I know that's happening all over Toronto.

Aud: [?] I belong to a project for the deaf community, and I'd like to know if there are deaf sex workers in Vancouver. If so, how do you communicate with them? Because in our project you communicate using sign language.

Ann: We do the same.

Aud: As far as I know, there is just one -- they have transvestites and no male sex workers in Rio. What about Vancouver. And how do you communicate with them? In American Sign Language? Quebec Sign Language?

Ann: We have within our program one nurse, at least, who does communicate in sign language. We also have a few staff within the program who speak various languages, because we encounter a lot of people whose first language isn't English. We try to make every attempt to ensure that we can communicate, and if we can't do it ourselves, we'll get someone from another agency or program to help us with that.

Aud: [?]

Ann: Are there many? There are some. I couldn't give you a number, but, yes, there definitely are.

Aud: Hi, I'm [?] from Brazil also, and I'd like to ask you something more technical -- if you believe that the only goal of street outreach is to share information, or is the goal sometimes to bring people to public health centres? When you see, for example, that they need special treatment, to bring them to hospitals, or whatever? I have been doing street outreach in Brazil, with transvestites. I believe that it's kind of hard, sometimes, to bring them into the public health centres.

Ann: It is extremely difficult, and one of the things we try to focus on in the program is not only to provide education out on the street, but to act as an entry point into the bigger system of health care. Which, for the most part, is really hostile and inaccessible. So part of what we try and do is educate that system as well, by providing education sessions within other agencies and in the bigger health care system. So that's how we attempt to do it.

Aud: It's the same for us, but I would like just to add that we have a strong problem with our boys: most of them are minors. So their access to clinics is really difficult, because they must have authorization; they must have a responsible person, and other things. So it's very common that we go to the hospital late at night and make a big scandal in order for a young boy to be attended to. It's really a problem.

Aud: This is a question for Ann. What level of medical sexual health care do you provide actually on the street? And how do you find the division between bringing statutory services to the people actually on the street, on site, as opposed to accessing those services by advocacy?

Ann: When you said, "What level," could you be more specific?

Aud: Particularly things like STD screening and treatment. Do you have health care workers who can diagnose and prescribe on site, or do you use your advocacy outreach workers to take them to the clinics?

Ann: All our nurses provide STD screening, HIV screening, diagnosis and treatment. The actual screening and testing -- we do some testing directly on the street. Obviously, STD screening, we can't do on the street, but we do that out of our storefront offices. And it's the same staff out on the street as it is in the office. So you can literally take someone with you. They're not seeing different people.

Paulo: [?]

Aud: [?]. First of all, I'd like to say on religious acceptance that if religious acceptance means we have to apologize for being prostitutes, then no thank you. If we have to claim that we're victims, then no thank you.

With regards to AIDS funding for prostitutes' groups, take it; do the work. Make sure you get money again the following year, but make sure that you use it for other things as well.

Paulo: This is advice on monitoring. I think it's very nice advice.

Aud: Just briefly, could you tell us what kind of research you think would be helpful?

?: [?] Until now research didn't help at all. What's you're reaction?

Paulo: So far, I haven't seen very much useful research. Generally they are sole incidents, or sociodemographic profiles of male sex workers, or this sort of thing. And, like I told you, we are not very interested in this, because it does not help. Even the evaluation -- the external, big GPA evaluation of our project -- it was not very useful. Because it did not bring anything back to us except invitations to go to international conferences and all these things, you see? So I really don't know. I would like someone to show me research that was actually useful. [?] I don't see any.

Aud: I wonder if research on educating other people, other than the street-trained workers, would be more beneficial?

Paulo: The doors are now open. If you want to come forward, you can do it now.

Aud: If anybody would like to join an international listserv and share information on street outreach, there's a sign-up list going around, and I would certainly invite the panel members. I'm a communication researcher who is finding that there might be some things that we could share that would help the street outreach.