Final Report for the AIDSCAP
Program in the Dominican Republic
October 1993 to April 1997: Executive Summary

This report comprehensively summarizes the FHI/AIDSCAP program in the Dominican Republic (1993-1997). The report discusses program accomplishments and constraints, as well as providing behavioral outcome data, lessons learned and recommendations.

Executive Summary

Introduction

The Dominican Republic (DR) became an AIDS Control and Prevention Project (AIDSCAP) associate country in 1992 following completion of the AIDSTECH and AIDSCOM programs. In December, 1992 an assessment of the Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) epidemic in the Dominican Republic indicated that the prevalence of 1 percent to 2 percent among the general population was much higher than had been previously thought. Epidemiologic projections using mathematical models indicated that by the year 2000 between 4 percent and 5 percent of the adult population, or approximately 300,000 Dominicans, would be infected. At this time the United States Agency for International Development (USAID) changed the Dominican Republic's status from associate country to priority country. As a result, both funding and technical assistance were substantially increased.

The AIDS epidemic in the Dominican Republic has been well established since the mid 1980s. Heterosexual contact is the most common mode of transmission, accounting for more than 80 percent of infections. Several structural factors contribute to the spread of HIV in the country. International immigration, especially Haitian immigration and seasonal US/DR migration, has led to increased contact with high prevalence populations. Increasing urbanization and the subsequent marginalization of poor barrios has increased risky behavior, especially among youth. Alcohol abuse plays an important role in sexual risk-taking. Limited economic opportunities for women lead many to engage in commercial sex. Social and religious barriers to condom use hinder the widespread adoption of safer sex.

Program Accomplishments

AIDSCAP/DR worked to control the HIV/AIDS epidemic in the Dominican Republic through improved HIV surveillance, behavior change communication (BCC), the improvement of sexually transmitted infection (STI) diagnosis and treatment and by increasing the availability and accessibility of condoms.

Recognizing the importance of surveillance to HIV control efforts, AIDSCAP/DR worked with the Pan-American Health Organization (PAHO) and the National AIDS Control Program (PROCETS) to develop a sentinel surveillance program among three target populations. Seroprevalence was monitored among the following groups: women attending antenatal clinics in four cities, STI clinic attendees in Santo Domingo and commercial sex workers (CSWs) seeking routine STI check-ups in Santo Domingo.

The BCC component of AIDSCAP/DR targeted high risk populations for specific educational interventions. These populations included people in workplaces, adolescents and young adults and family planning acceptors, as well as members of core groups such as CSWs and men who have sex with men (MWM). Outcome data indicate that the BCC subprojects were successful in changing knowledge, attitudes and practices around STI/HIV/AIDS among the target populations. AIDSCAP subprojects trained approximately 21,000 and educated nearly 930,000 people. Approximately 1,500,000 educational materials were distributed through the various BCC subprojects. In addition, a mass media campaign targeting Dominican youth was tremendously successful in raising awareness of HIV/AIDS. From September 1995 to March 1997 the campaign aired 38,495 television and 454,770 radio spots. Perhaps the most extraordinary aspect of the campaign was that private sector radio and television stations donated over US $9,000,000 worth of air time to the campaign.

The AIDSCAP program helped to strengthen STI diagnosis and treatment in the Dominican Republic. STI services were improved by upgrading facilities, improving STI drug logistics and developing STI management definitions. AIDSCAP worked with PROCETS to design and implement an algorithm for the diagnosis and treatment of STIs without laboratory tests. AIDSCAP conducted 37 educational courses which trained 854 service providers in syndromic management of STIs. In addition, 550 STI treatment manuals, 1,000 laminated treatment algorithms and 1,500 STI brochures were distributed to health educators and providers.

In an effort to improve quality and increase affordability, AIDSCAP developed and marketed a new brand of condom, called "Pantera." Technical assistance provided by AIDSCAP/DR increased condom availability and accessibility by improving logistics management, community distribution and social marketing. Through collaboration with a private sector partner the Pantera condom was sold to convenience stores, supermarkets and pharmacies nationwide. Pantera is now the second most popular condom in the DR, accounting for 37 percent of retail sales. Collaborating non-governmental organizations (NGOs) arranged for Pantera condoms to be sold through hotels, motels and bars in the geographical areas where HIV prevention projects were underway. During the life of the project more than six million condoms were distributed. Of these, 4.6 million were sold through AIDSCAP's social marketing projects.

Constraints

Despite great success in many areas, the AIDSCAP/DR program did face several constraints. High staff turnover rate among various Collaborating Agencies hampered program implementation and slowed the development of national STI guidelines. Logistics problems continued to affect STI drug distribution. Many clinicians proved reluctant to introduce syndromic (rather than etiological) management of STIs. STI surveillance was constrained by the continuing problem of STI self-treatment and underreporting on the part of providers. Other constraints were political in nature. At times government officials were appointed who were not familiar with HIV/AIDS issues. Government officials' lack of experience with NGOs sometimes impeded collaboration on HIV prevention.

Despite AIDSCAP's considerable success in the Dominican Republic several factors continue to hinder HIV/AIDS prevention. High STI prevalence has persisted among the general population, suggesting that a large percentage of Dominicans continues to be at high risk of HIV infection. Beliefs in incorrect means of HIV transmission are widespread, indicating that important gaps in knowledge exist. Negative attitudes towards people living with HIV/AIDS contribute to a hostile and discriminatory environment, impeding prevention efforts.

Summary of Outcome Data

Evaluation research has shown several positive trends resulting from AIDSCAP's HIV/AIDS prevention interventions. First, HIV prevalence has been stable in several sentinel populations, and unconfirmed declines have been noted among CSWs. Second, knowledge of HIV prevention methods is nearly universal among target populations. Third, an overwhelming majority of men report having changed their behavior to lower their risk for HIV infection. Finally, condom use increased significantly among all target populations.

HIV prevalence among antenatal and STI clinic attendees has been relatively stable over the last five years, ranging from 1 to 2 percent among antenatal clinic attendees and from 7 to 8 percent among STI clinic attendees. One exception was found among women attending antenatal clinics in Puerto Plata, where seroprevalence increased from 3 percent in 1994 to 8 percent in 1996. Among CSWs in Santo Domingo, seroprevalence seems to be declining, although more data would be necessary to confirm this decline.

Knowledge about HIV at baseline varied among the target groups. One hundred percent of MWM surveyed were aware of HIV. Awareness was lower among CSWs, youth in Santo Domingo and people in workplaces (90%, 85% and 80%, respectively.) Knowledge of specific means to prevent HIV infection was considerably lower. Post intervention surveys showed that knowledge had increased to 99 percent among the target groups and that 90 percent of those surveyed after the interventions had knowledge of specific means of preventing infection.

Risky sexual behavior diminished both across the general population and among high risk groups. Nearly 85 percent of men and 26 percent of women reported having changed their sexual behavior to avoid HIV infection. A survey of youth living in marginalized, poor barrios suggested a reduction in sexual activity among young people. In 1992, 73 percent of youth reported that they were sexually active; in 1996 only 30 percent reported that they were sexually active. Among this same population the proportion reporting that they engaged in transactional sex decreased from 27 percent to 7 percent among males and from 9 percent to 6 percent among females.

Condom use increased significantly among all target populations during the life of the AIDSCAP project. Among brothel-based CSWs, condom use at last transactional sexual encounter rose from 80 percent to 98 percent. Condom use at last sexual encounter increased from 38 percent to 63 percent among men who have sex with men. In the Puerto Plata region, the percentage of hotel employees who use condoms during sexual encounters with tourists rose from 86 percent to 95 percent. In addition, knowledge of where to obtain condoms increased significantly among all target groups.

In Puerto Plata, the rate of self-reported STIs dropped from 11 percent to 7 percent among CSWs and from 15 percent to 1 percent among hotel employees. The proportion of CSWs reporting that brothel owners required regular gynecological exams increased from 89 percent to 98 percent. Knowledge of STI treatment locations improved greatly among CSWs and workers in the workplace.

Lessons Learned/Recommendations

BCC:

• Participative planning of BCC interventions must constantly reflect and accommodate the changing target population.
• Creating BCC messages for specific target populations requires an understanding of the complex subgroups within these target groups.
• BCC interventions with youth need a clear and practical approach.
• Educational interventions which address individual behavior must be complemented by strategies to change those structural and environmental factors which contribute to risky behavior.
• Workplace educational interventions need management's support in order to be effective and sustainable.
• International exchange of BCC materials can and should take place in settings where immigration is common.

STIs:

• The institutionalization of the syndromic management approach to STI treatment requires a long-term commitment and continuous support.
• Ensuring that STI drugs are available at the primary health center level demands political commitment from the top, a strong logistics system and an educated staff at the clinic level.
• Algorithms and risk assessments for the syndromic management of STIs can be effectively modified for individual countries.

Condoms:

• Overcoming religious and social barriers to condom distribution and sales is difficult and time consuming. An aggressive marketing strategy, support from mass media and systematic endorsement by public figures is necessary in order to de-stigmatize condoms.
• Policies regarding free distribution of condoms need to be carefully reconsidered to avoid disrupting social marketing programs. Careful inventory control is necessary to prevent the leakage of donated condoms into the black market.
• The change from free distribution of condoms to commercial sales requires a paradigm shift for implementing agencies, government officials and most importantly, the general population.
• Creating specific environments where condom use is expected may be a way of jump-starting social norms around condoms.

Program Evaluation and Management Lessons:

• Ongoing evaluations of interventions are vital to the success of HIV prevention programs and must be conducted through the balanced partnership of implementing agency staff and technical experts.
• Decentralization of decision making is crucial to effective program development.
• The private sector can be a valuable resource and a willing partner in prevention efforts.