FHI - Empowering Core Groups

Table of Contents

I. Introduction

II. Empowering Core Groups (See Below)

III. Investing in Workers' Health

IV. Reaching Youth

V. Supporting Women at Risk

VI. Promoting Sustainable Prevention Efforts

VII. Sharing Lessons Learned

Glossary of Acronyms

II. Empowering Core Groups

As in many other countries around the world, the persons most affected in the early years of the HIV/AIDS epidemic in the Dominican Republic were individuals in "core groups," such as sex workers and their clients and men who have sex with men, who frequently engaged in sexual behavior exposing them to risk of infection. Even as early as the mid-1980s, men who have sex with men in Santo Domingo had HIV prevalence rates of 15 percent and higher. Data for sex workers showed median national HIV prevalence figures of 3.3 percent in 1991 and 5.1 percent in 1992.

AIDSCAP responded with a series of innovative interventions. These efforts improved the quality of life of thousands of men and women in the core populations by building their knowledge of HIV transmission and prevention and by addressing such vital issues as violence and self-esteem. The program also made effective use of the limited resources available with a strategy designed to help slow further spread of HIV/AIDS to the general population. Experiences in Thailand and other countries with more advanced epidemics had shown that rapidly rising HIV infection rates among high-risk populations were often precursors to increasing prevalence levels in the wider society.

Some of the most impressive examples of AIDSCAP's lasting impact on the lives of those affected by the epidemic occurred with the sex workers the program reached. Many transformations came at the individual level, as women learned to negotiate condom use with clients and gained a growing sense of empowerment and self-respect. Other changes were broader in scope, such as an increasing sense of solidarity and mutual support among the women. This solidarity was reflected in the new activities and institutions that were established, including an association to represent sex workers, a regular newsletter that the women themselves produced, and a national congress for sex workers.

Many of these changes were achieved as a result of a series of AIDSCAP-supported projects for sex workers, their clients and other men involved in the commercial sex industry, such as the owners and employees of bars, brothels and night clubs where the business flourishes. Called Avancemos ("Let's Move Ahead"), the interventions were carried out by two local NGOs, the Centro de Orientaci�n e Investigaci�n Integral (COIN) and the Comit� de Vigilancia y Control del SIDA (COVICOSIDA). COIN operated projects for sex workers in Santo Domingo, several other cities on the country's southern coast, and Santiago, the nation's second-largest city, located in the north-central part of the nation. Based in the northern coastal city of Puerto Plata, COVICOSIDA focused its efforts on that community and several nearby beach resort towns popular with Dominican and foreign tourists. (See 2.2. Participatory Training Approach Breaks Down Resistance to New Approach to STI Management.)

Communication for Behavior Change

In the NGOs' projects, a guiding principle was the use of the adult education methods developed by Paulo Freire. A Brazilian educator, he gained fame for his adult literacy instructional techniques grounded in the social and economic realities his poverty-stricken students faced. COIN and COVICOSIDA trained sex workers in Freire's philosophy and teaching methods, as well as the basic facts about the transmission and prevention of HIV/AIDS and other STIs. These health messengers reached out as equals to other sex workers, providing them with information and skills needed to reduce their risk of HIV/AIDS.

Day to day, the health messengers carried that life-saving information to other women in one-on-one conversations and small-group discussions in bars, night clubs, brothels and other locations. Their work was guided by messenger leaders who had more training and experience. Many of those leaders were women who were once employed in the sex industry but had found a way to leave "the business" -- as they call their work -- or were in the process of doing so.

Altagracia de la Rosa decided to volunteer for COVICOSIDA after meeting health messengers in the cabaret where she was working. She served as a messenger for a year, then became a messenger leader. "I can share my information with other women, most importantly prevention," she said. "They trust me and they like getting the information." De la Rosa also presents her prevention messages to sex workers' clients. "I talk with Dominicans and foreigners," she said, "and they do listen."

One reason for the success of de la Rosa and other health messengers is their ability to provide information in language that is simple, direct and not too technical. That approach has also worked well with the broader community. In Puerto Plata, for example, the proprietors of bakeries and other businesses impressed with COVICOSIDA's work with sex workers asked for the NGO's health messengers to come and talk to their employees. "The business owners know the health messengers are knowledgeable and know how to talk so that people will understand," said Tanya Medrano, program coordinator for AIDSCAP in the Dominican Republic. (See 2.3. Building Self-Esteem Central to Work with Men Who Have Sex with Men.)

COVICOSIDA and COIN supported their peer education efforts with "provocative theater" presentations in bars and brothels and on the street. The short, entertaining sociodramas grabbed viewers' attention while conveying serious prevention messages. (See 2.1. Street Theater Provokes Attention to HIV/AIDS Prevention Messages.) At the end of the performances, the actors -- usually health messengers or messenger leaders -- distributed informational publications and sold or gave away condoms.

Avancemos health messengers found that theater technique was especially important for reaching sex workers on the streets, who typically have less information about HIV/AIDS and have lower self-esteem than women working in bars or brothels.

COVICOSIDA and COIN produced posters, brochures and other written materials that reinforced the messages presented in provocative theater mini-plays and the one-on-one and small-group discussions.

The NGOs also used a series of comic books whose friendly, supportive lead character Maritza advised other women working in the business. One of the first themes the comics covered was the use of condoms. When COIN began its work with sex workers in the late 1980s, said Luis Moreno, a COIN project coordinator, "sex workers didn't think they could negotiate condom use with their clients or their regular partners." The Maritza comics offer practical negotiation strategies and present examples of sex workers who successfully negotiate with men.

Maritza comics dispel myths, such as the belief that STIs can be cured with certain herbal remedies. They also address the misperception that well-dressed, higher-income clients cannot be infected with HIV and that it isn't necessary to insist that such men use a condom. (See 2.4. Lessons and Recommendations.)

Involving Men

The Avancemos projects also targeted BCC messages to the women's regular partners and clients and to other men involved in the sex industry. A comic book for that audience features Mario, a young single man who learns basic facts about HIV/AIDS transmission, proper condom use and the importance of using a condom even in a steady relationship.

The Avancemos NGOs held regular workshops to encourage proprietors of brothels and other commercial sex establishments to support prevention efforts. Those sessions approached the HIV/AIDS epidemic from the owners' perspective -- and their desire to attract more customers. "We told them, 'If you have fewer infected women, your business will have a better image,'" said COIN's Moreno.

Impressed with the quality and benefits of the NGOs' services over the years, a number of the enterprises recently began to pay small fees to support the two groups' work. "That's a big change," said AIDSCAP staff member Medrano. "Before [Avancemos began] they were resistant. Now they want these activities."

New Issues

As they continued their work, the Avancemos NGOs saw they could make their HIV/AIDS prevention messages more effective by increasing their focus on other concerns that were important to sex workers. "There was a need for a more integrated strategy, a more complete vision [of the lives of the women]," said COIN's Moreno. The two NGOs had seen that as women became more effective in various areas of their lives, their self-esteem increased and they felt more empowered to make behavior changes that would reduce their risk of HIV infection.

Many sex workers, for example, wanted bar and brothel owners to treat them with more respect. The women also faced problems with the Dominican legal system. Courts were taking away their children and giving custody to their husbands, even though that violated Dominican law. Some women began meeting with each other in their homes, rather than where they worked, so they could talk more freely. The sex workers and the NGOs also began discussing the violence committed against women and issues of self-respect.

Moving Ahead

By providing technical information on HIV/AIDS and raising the sex workers' self-esteem, the Avancemos projects achieved just what they had set out to do: improve the women's perception of HIV risk and decrease unsafe behaviors.

In the summer of 1996, surveys of sex workers in the Puerto Plata area showed that more than 70 percent had changed their sexual behavior because of HIV/AIDS. Every one of the surveyed women identified at least two HIV/AIDS prevention measures. Some 94 percent of the sex workers were using negotiation strategies -- such as the ones taught by the COVICOSIDA health messengers and included in the Maritza comics -- to convince clients to use condoms. Ninety-eight percent of the women reported using a condom with their most recent client, and 97 percent said they had done so with their last five clients.

COIN reported equally impressive results from Santo Domingo and the other cities where it had been working. More than three-quarters of the sex workers indicated they had changed their behavior because of HIV/AIDS. The percentage of women who could identify at least two HIV/AIDS prevention measures reached 99.5 percent, compared with 83.2 percent in a 1992 survey. Sex workers saying they had used a condom with their most recent client rose from 80 percent in 1990 to 97.5 percent in 1996.

Representative of this change in attitudes and behavior were the firm statements a Santo Domingo sex worker told AIDSCAP researchers she uses with potential customers: "Look, I am barely 22 years old and it does not help me one bit to earn 600 pesos and get infected with a disease that will cost me my life. So if you want to use it [a condom], fine, and if you do not want to use a condom, then I will give you back your money and we can leave [the hotel]."

United Women

While encouraging sex workers and their clients to make positive behavior changes, the Avancemos project also helped establish institutions and activities that will continue beyond the AIDSCAP program in the Dominican Republic. One example is the union of sex workers founded with COIN's assistance in the summer of 1996, the Movimiento de Mujeres Unidas (MODEMU), or Movement of United Women. Many of the group's founding members were COIN messenger leaders who had left commercial sex work.

MODEMU's formation was one result of the sense of solidarity that came out of the first-ever congress for Dominican sex workers. Organized by COIN, the May 1995 event drew more than 350 participants, including sex workers, health professionals, and COIN and COVICOSIDA volunteers.

"Now, if a woman has a problem with a [sex work] business owner, there's a group to help," said Marina Ure�a, MODEMU's director of public relations. "We want respect for our rights, both civil and labor, and to be treated as equals with other professions."

Ure�a's early experience was similar to that of many other MODEMU members. The 28-year-old mother of three got into sex work because of financial need and the lack of other employment opportunities. "My country doesn't offer good wages," she said. "You go and look for work, and they say, 'There are no positions.'" She left sex work in 1994 after three years in the business. "The risks are high," she said. "You go out with a client, and you don't know if he's going to kill you."

A periodic newsletter started by the Avancemos NGO health messengers has largely been taken over by MODEMU members. Called La Nueva Historia (The New Story), the publication covers reproductive health, sexuality, self-esteem and other subjects of interest to the women. Articles in recent issues dealt with migration and the traffic in women, MODEMU activities, the link between STIs and HIV transmission, and family support for persons living with HIV. One regular feature is testimonials from women whose major life changes can inspire other sex workers. Some articles conclude with a "conversation guide" encouraging readers to talk with each other about the story's subject, such as how to confront violence directed at women.

The newsletter even has horoscopes with predictions reinforcing the Avancemos HIV/AIDS prevention messages. In one recent column, Libras were warned about dishonest persons recruiting women for employment in other countries as "actors" or "dancers" -- but actually sex work. "Be careful with illegal trips," the newsletter counseled. "You could have serious problems. If you decide to go, get information from MODEMU." Sagittarians were advised, "Spend more time with your family and make good use of your free time. Attend the events organized by your health messenger."

Future goals for MODEMU include expanding the group's membership and working with sex workers in more cities of the Dominican Republic. The organization also hopes eventually to set up a credit union, where the women could place their savings and obtain loans to move out of the sex industry and set up their own small business ventures.

Leaving "The Business"

The Avancemos projects have already helped some sex workers get out of the business, a difficult step due to the lack of job alternatives for many women. The sex workers who have had the most success finding other employment are the health messengers; COIN officials estimate more than half of its volunteers have moved into other work.

"Nobody tells them to leave the profession," said Francisca Ferreira, a COIN project coordinator. "They themselves choose." Some start small enterprises, such as selling clothes. Others stay in the bars or brothels, but with a different job, such as cashier.

One woman who began a new career with help from COVICOSIDA is Nancy G�mez. She entered the sex business in 1987 to support herself and her three children, who were then 10, 12 and 16 years old. Her husband had left for the United States, promising to send back money for the family, but never did.

"The [commercial sex] work was hard," explained the small, slender G�mez. "Your self-esteem goes down. You have to do things you shouldn't. But if you have children, what else can you do? You can steal or you can sell drugs, but I wouldn't do that."

In 1988 G�mez was in a group of sex workers who heard a talk given by a COVICOSIDA health educator. "She touched our hearts," said G�mez. "She talked about HIV, AIDS and STIs. It was like a call to us, to work with the community and not to become infected."

G�mez began as an unpaid volunteer for COVICOSIDA, talking with her peers. As she learned more and committed more time to the educational work, the Puerto Plata NGO began paying her a small stipend. In 1993, G�mez left sex work entirely to become a full-time COVICOSIDA health educator. She has continued her work with sex workers, and also works with adolescents, schoolchildren, families in the community, labor unions, taxi drivers, bakers and hotel employees.

While her COVICOSIDA salary has grown along with her skills and responsibilities, it's now just 2,500 Dominican pesos ($U.S.180) per month. "I'd like to earn more," G�mez said, "but I do the work with love for the community."

Another woman who has left the sex business is Petronila Brazob�n, a COIN health messenger who discovered in 1992 that she was HIV-positive. Brazob�n considered committing suicide after she found out she was infected. "It was really hard," she said. "My family supported me. I began to reconsider things. I thought about my children, my work [as a health educator]. I decided there were thousands of people who were infected that I could help."

Brazob�n went on to establish the first support group for HIV-positive persons in the Dominican Republic. "I formed the organization," said the 36-year-old mother of two, "because of the rejection, discrimination and marginalization in the society."

The group works with some 40 HIV-positive persons, providing them with information on how to take care of themselves physically. They learn strategies for maintaining their self-esteem, as well as meditation and other relaxation techniques.

The support group also works with the relatives of those who are HIV-positive. "We try to educate the family," said Brazob�n, "and we've had good results. Families have changed their attitudes and behavior."

Brazob�n has been active with the Dominican news media, pushing for recognition of the rights of persons living with HIV. Her group has also lobbied the Dominican government and has helped individuals file lawsuits when their employers have illegally fired them for being HIV-positive.

As the organization acquires more resources, Brazob�n would like to help establish similar support groups in other parts of the Dominican Republic. Other goals include assembling a pool of funds that members could draw on in times of need, and establishing a residence for HIV-positive persons who have been rejected by their families.

Those are the kinds of possibilities many women once trapped in the sex business have been able to consider as they have transformed their lives with the help of COIN and COVICOSIDA. While talking about her experience with the Puerto Plata organization, Nancy G�mez could just as easily be describing the impacts large and small that both groups have had on the lives of many women: "It comes over time, from the orientations from COVICOSIDA and from living. It happens bit by bit. You have to have support to do it, and that's what COVICOSIDA provides."

2.1. Street Theater Provokes Attention to HIV/AIDS Prevention Messages
Bienvenida gets out of a white car at the far corner of the intersection and slinks across the street in her leopard print mini-skirt and four-inch heels. As she approaches, a group of men sitting on their motorcycles offer her shy smiles of greeting.

The conversation begins slowly. The men, all middle aged, speak with Bienvenida about the weather, the people passing on the street and the increasing price of gasoline for their motorcycles. Ten minutes pass before she begins her negotiations. "Do you like what you see?" she asks. All the men agree they do.

As they argue over who will leave with Bienvenida, another woman yells across the street to her. "Bienveniiiidaaa, is that you?" Ingrid shouts. "Bienvenida, what are you doing out on the street tonight?"

"Go away," Bienvenida says. "I'm doing business. Stay away from us." The men stare curiously at the persistent Ingrid, who joins the happy group.

"You shouldn't be out tonight," Ingrid argues. "I saw you at the clinic last night. You have gonorrhea! You shouldn't be working."

The group of men now stand silent. They stare at Bienvenida, waiting for an answer.

"I got treated last night," she says. "What I have won't hurt these men. You're strong, healthy men, aren't you?" She cozies up to one of them. "We can have fun tonight, you and I."

Ingrid frowns and asks, "Did you at least bring your condoms?"

"Condoms!" says one of the curious group of men. "I never use condoms. They ruin all the fun. I'm healthy and I only choose healthy-looking women."

"See," says Bienvenida, "I don't need to worry here. Now go away. We don't want you here. We're having fun on our own." A grunt from the group of men around her signals their agreement with Bienvenida.

"But it doesn't matter how someone looks," counters Ingrid. "Anyone could have an STI [sexually transmitted infection], or even worse, AIDS! Condoms are the only way to protect yourself during sex. Anyway, Bienvenida, you aren't cured of your gonorrhea yet. You should be home taking all your medicine and not out on the street tonight."

"Leave us alone!" one of the men says to Ingrid. As she turns to cross the street, flinging a last warning over her shoulder, a man named Joselin comes barreling past her.

Joselin grabs a surprised Bienvenida and begins to shake her. When one of the men jumps to her defense, he turns and says, "Don't have sex with her. She's unclean. I didn't use a condom and she gave me this uncomfortable disease. My wife will never speak to me again!"

"Don't have sex without a condom," Joselin says as he walks away. "The same thing can happen to you."

"You better leave now," one of the men tells Bienvenida. "There is no business for you here until you've taken care of your STI."

Ingrid pulls an embarrassed and confused Bienvenida across the street and around the corner with her. There, Bienvenida, Ingrid and Joselin hug each other to celebrate yet another successful "provocative theater" intervention on the streets of Santo Domingo.

After several minutes of debriefing, the trio return to the stunned but good-natured group of men and explain that they are actors from an organization that works to prevent HIV/AIDS and other STIs. The men ask the actors many questions. Before leaving, the performers distribute condoms and comic books and other educational materials.

Joselin and another friend first experimented with provocative theater on public buses in Santo Domingo, where the two would take on different personas and engage other passengers in conversations to see what would happen. The two soon realized the power of this approach as a learning tool, and began gearing their "acting" sessions to cover health issues.

Joselin brought the approach to COIN, a Dominican NGO, to use in its HIV/AIDS prevention project with sex workers and their clients in Santo Domingo bars and brothels. Provocative theater, conducted in the night clubs and on the street, proved popular and effective with the target audiences. Sex workers said they appreciated the opportunity the performances gave them to speak with their clients and bar owners about condom use, HIV/AIDS and related concerns. Even bar owners began approaching COIN's health leaders asking when and where their next theater performance would be.

"The acting is so good," said Luis Moreno, a COIN project coordinator, "that sometimes people get worried and want to leave the business [bar or brothel]. We sometimes put a person at the door to explain that this is just a theatrical presentation."

COVICOSIDA, COIN's partner in the AIDSCAP-supported Avancemos Project for sex workers, also uses these educational sociodramas extensively. Both NGOs employed provocative theater in workplace projects, COIN with industrial zone workers in and around Santo Domingo and COVICOSIDA with hotel employees in the Puerto Plata region.

While continuing to address condom use and basic facts on HIV/AIDS and other STIs, the two NGOs created skits on new themes. COVICOSIDA's repertoire includes a presentation encouraging men to patronize only sex workers who have had regular health check-ups. COIN added performances dealing with self-esteem, violence against women, and "trips" to Europe for women who are promised jobs as dancers or models but who end up in the sex business.

Amigos Siempre Amigos (ASA), an AIDSCAP-supported group that focuses its prevention efforts on men who have sex with men, gives provocative theater presentations in gay discotheques. Some disco owners provided funding to help cover the costs of the ASA performances.

Dominican youth became involved in the provocative theater in early 1997, when 29 young people from four NGOs received training from Manuel Chapuseaux, head of the Teatro Gayumba and one of the Dominican Republic's best-known theater directors. Chapuseaux showed the youthful dramatists how to create their own presentations and draw in audience members. He followed up the first workshops with more individualized instruction with each of the NGOs.

One of the first skits the young people created dealt with responsible sexuality. Another NGO did a piece on an unexpected pregnancy. To address the need to protect others from infection, youthful actors from Profamilia, the Dominica Republic's largest family planning organization, portrayed a young woman who had an STI but was symptomless. Another Profamilia drama concerned a young man and a young woman who meet each other after a long separation. Deciding to renew their sexual relationship, they argue about whether or not to use a condom.

Some of the works are loosely scripted, allowing the actors to improvise. At other times, the actors stop the performance and ask the audience members for recommendations. Sometimes the performers act out the suggestions, and at other times they ask audience members to play the roles. After the performances, the young actors talk to audiences about the issues presented in the dramas.

Chapuseaux attributes the success of provocative theater to this interaction between the actors and the audience. Such performances are more tangible than those presented through television and other media.

"Theater is a tool with characteristics that other educational methods don't have," said Chapuseaux. "It's not like the movies, where the actors are further away. With provocative theater, both the audience and the actors feel like it's their own."

2.2. Participatory Training Approach Breaks Down Resistance to New Approach to STI Management
AIDSCAP helped a number of countries around the world to upgrade the training that physicians and other health care providers receive in the management of sexually transmitted infections, often by improving the "continuing education" courses that medical personnel are required to take periodically after completing their university studies.

One of the nations lacking that tradition of continuing medical education -- and the benefits it could bring to the prevention and control of HIV/AIDS -- is the Dominican Republic. To help remedy that situation, two AIDSCAP-supported institutions created an innovative, participatory educational program that trained more than 300 Dominican physicians, plus over 500 health messengers and other nonclinicians who are involved in health care but who don't treat patients directly.

The training covered "syndromic management," a relatively new way to diagnose and treat STIs. This approach is especially suitable in locations such as the Dominican Republic where medical resources are limited and the demand for STI treatment services is high.

Strengthening STI services is a vital component of HIV/AIDS prevention and control because studies have shown a strong relationship between STIs and sexual transmission of HIV. In the Dominican Republic, more than three-quarters of the country's cumulative AIDS cases have been the result of sexual transmission.

For decades, many health care providers have used laboratory tests to identify STIs and select treatment. When those lab results are unavailable, unaffordable or unreliable, medical personnel usually apply clinical diagnosis, performing their own analysis by examining an individual and taking the person's medical history. Unfortunately, with clinical diagnosis, the likelihood of misdiagnosis is high.

With syndromic management, medical providers use simple flow charts of algorithms, or diagnostic pathways, that guide them through STI signs and symptoms and treatment and prevention options. They base their treatment on syndromes, or groups of clinical findings and patient symptoms. Once a particular syndrome is identified, treatment is given for all the infections -- often more than just one STI -- that could cause that syndrome. While easy to use, the diagnostic charts have to be based on rigorous scientific research in order to create valid algorithms appropriate to a particular country or region.

An approach promoted by the World Health Organization, syndromic management offers several advantages in resource-poor settings. Providers can make an immediate treatment recommendation without the cost and time needed for laboratory tests. Funds once used for expensive testing can be applied to other needs, such as paying for drugs for STI treatment. The approach is also simple enough to be used as a diagnostic tool by health personnel with limited medical skills and experience, thus increasing the number of providers and facilities that can treat STIs.

In the AIDSCAP-supported program in the Dominican Republic, 325 clinicians and 16 laboratory analysts participated in the two-week course, which was offered 15 times. "It was a very participatory type of training," said Dr. Rafael Alc�ntara, of the Instituto Dermatol�gico Dominicano (IDD). "The courses weren't just lectures. It was discussions and practical application of the material, with a lot of active participation. We even gave them a blank copy of the algorithmic flow chart to fill out [during the course]."

Working through its Centro de Enfermedades de Transmisi�n Sexual y SIDA (CETS), the IDD jointly planned and conducted the syndromic management training with the Instituto Tecnol�gico de Santo Domingo (INTEC). The IDD/CETS instruction was primarily done in laboratories and was clinically focused. INTEC's teaching was offered in classrooms and was more theoretical.

To make the courses better reflect the students' interests, CETS and INTEC waited until the end of the two-week sessions to distribute a comprehensive reference manual. That way, the text could be customized according to questions and issues that had come up during the training.

The courses for the physicians covered four primary areas: human sexuality, techniques of syndromic management, counseling, and training methods they could use to share their new knowledge with other medical professionals.

Many of the physicians were initially skeptical about the CETS/INTEC approach. But those attitudes changed dramatically as the classes progressed, reported Dr. Miguel Suazo, coordinator of INTEC's health services unit. "At the beginning, some of the doctors didn't like the approach," he said. "At the middle and the end of the training, some of them said they had never learned so much in a class.

"One doctor said he learned more gynecology in this course than he did in his medical residency. This was the first time they had used this [participatory] approach. As they went along, they found out they were learning both the content and the approach of syndromic management."

A formal evaluation of the clinicians' training found similar enthusiasm for the courses. More than two-thirds of the trainees ranked as "very good" such course characteristics as the instructors' knowledge of the subject, presentation clarity, theoretical content and up-to-date subject matter.

The training for the health messengers and others who wouldn't be directly caring for patients was similar to that for the clinicians, but with less emphasis on treatment and more focus on educational techniques for encouraging treatment compliance and STI prevention. A major goal with the nonclinicians was to teach them to better recognize STI symptoms and to make appropriate referrals to physicians and clinics.

CETS and INTEC held 20 two-week training sessions, reaching 513 non-clinical health personnel. Trainees came from government agencies and many of the NGOs working with AIDSCAP on other HIV/AIDS and STI prevention activities.

The nonclinicians were just as favorable as the clinicians in their evaluation of the CETS/INTEC training. A follow-up survey found that three-quarters of them were using syndromic management techniques in their work.

While the clinical and non-clinical course participants comprise only a small proportion of all the medical professionals in the Dominican Republic, they could sway hundreds of other care providers. Many Dominican physicians, for example, work in more than one hospital or clinic, thus increasing the number of colleagues they could influence.

Another influential group is the trainees from Profamilia, the largest family planning agency in the Dominican Republic, which sent 31 clinicians and 121 nonclinicians to the CETS/INTEC courses. "They have nationwide coverage," explained Dr. Alc�ntara, "and they're even in the remote areas of the country. The persons who go to Profamilia are ones who are sexually active and could most benefit from the syndromic management approach."

Presentations describing the training program have drawn attention and praise at several international conferences. Impressed by the program's innovative, participatory approach, persons from more than 30 countries have requested copies of materials from the Dominican courses, according to Dr. Suazo.

2.3. Building Self-Esteem Central to Work with Men Who Have Sex with Men
fforts to address discrimination, self-esteem and sexual identity were essential elements of AIDSCAP's interventions for men who have sex with men in the Dominican Republic. As the program progressed, it became increasingly clear that building self-respect was the only way to achieve the levels of behavior change needed to stem the explosive spread of HIV in this target group.

Limited surveys of Santo Domingo homosexuals and bisexuals in the 1980s had revealed HIV prevalence rates as high as 15 to 17 percent. Research with similar populations in Puerto Plata found an 18.6 percent prevalence rate in 1986. Between 1983 and 1986, 43 percent of the country's reported AIDS cases were men who acknowledged having sex with other men. And while that proportion later decreased, it was due to a rapid rise in heterosexual HIV transmission rather than any lessening of the seriousness of the problem for men who have sex with men.

AIDSCAP's response was implemented by two NGOs, COIN and Amigos Siempre Amigos (ASA). In their joint Triunfadores ("Victors") Project, the two groups applied many of the same techniques that COIN and another NGO, COVICOSIDA, had used with sex workers in the AIDSCAP-supported Avancemos Project. With COIN taking the lead in management and administration concerns and ASA focusing more on educational activities, the two groups trained health messengers who reached out to their peers in the community of men who have sex with men. These volunteers used individual and small-group discussions, along with brochures, pamphlets and informational bulletins, to promote condom use and to deal with such topics as HIV/AIDS and STIs, safer sex and emotional support.

During the four years COIN and ASA worked together, there were significant improvements in both awareness and behavior among men who have sex with men. Baseline research found that only 30 percent of the men surveyed perceived some risk of contracting HIV. By 1996, that figure had more than doubled to 71 percent. And while 38 percent of the men in the baseline study reported they had used a condom in their last sexual encounter, that figure had reached 63 percent in the follow-up research.

In 1996, ASA staff members and volunteers took a critical look at their strategies to determine how they could achieve even higher levels of risk perception and behavior change. The group especially wanted to increase condom use.

Research in the Dominican Republic had shown that homosexual men with lower self-respect experience more depression and anxiety, consume more alcohol and engage in more behaviors that place them at risk of HIV infection. Therefore, ASA decided it would promote further behavior change by expanding its efforts to build self-esteem and a strong sense of sexual identity among men who have sex with men.

ASA's new project, entitled "Alto al SIDA" ("Stop AIDS"), was modeled on successful interventions carried out in Puerto Rico and cities elsewhere in the United States. During the six and a half months the project lasted, from October 1996 through April 1997, ASA staff and volunteers visited discotheques, bars and theaters to publicize the project and to invite men to participate in discussion groups and other new activities. Visiting that variety of locations was key to reaching the diverse Dominican population of men who have sex with men, which includes such self-identified subgroups as bisexuals, transsexuals, transvestites and homosexuals.

To broaden and deepen its outreach efforts with this diverse population, ASA also held four "Podemos Hacerlo" ("We Can Do It") workshops in February and March of 1997. The meetings addressed self-esteem, alcohol, drugs and STIs, sexuality and behavior change. ASA invited the workshop participants to join ongoing support groups to discuss the impact of HIV/AIDS within the gay community, antibody tests, safer sex techniques and the relation between the transmission of HIV and other STIs. The sessions also provided a reassuring atmosphere where the men were free to discuss their feelings about HIV/AIDS and where they could learn to view themselves as worthy and productive members of Dominican society in spite of the strong negative stereotypes they often encounter.

2.4. Lessons and Recommendations
Lessons Learned

Empowering sex workers can help them protect themselves from HIV/AIDS and give them opportunities for other employment options that expose them to less risk of HIV infection.
Including self-esteem, violence against women and labor and human rights within projects targeting sex workers is essential for effective prevention efforts since women with greater self-respect are more likely to be able to reduce their risky behavior.
Working to educate men involved in the commercial sex industry, including long-term clients, brothel owners and sex workers' fixed partners, is essential for effective prevention efforts.
Provocative theater is an effective tool for engaging people's attention and encouraging discussion of sensitive issues, such as condom use and negotiating safe sex.
Special strategies such as broad use of provocative theater presentations are needed to reach street sex workers, who generally have lower self-esteem and less knowledge of HIV/AIDS prevention than women working in bars and brothels.
HIV/AIDS prevention efforts with men who have sex with men are more effective if they include such issues as homophobia, sexual identity and low self-esteem.
The larger population of men who have sex with men includes various subgroups, such as men who identify themselves as homosexuals, bisexuals, transsexuals and transvestites. Separate intervention strategies and educational materials may be needed to meet the needs of each subgroup.
Effective, engaging teaching methods and materials can overcome the reluctance of some health professionals to upgrade their skills and can promote the acceptability of the syndromic approach to managing STIs.

Recommendations

The integrated, innovative approach AIDSCAP used to reach female sex workers and other persons involved in the commercial sex industry is a model for future interventions with these target populations. Programs should incorporate a gender component that addresses both the social and biological vulnerability of women, as well as their surroundings in the commercial sex world, in order to deal with the factors contributing to high-risk behavior.
Programs with sex workers should continue to seek financial support for prevention activities from the owners of bars, brothels and other establishments involved in the commercial sex industry.
Interventions to encourage individual behavior change should be supported by structural and environmental efforts, such as the Dominican Republic's experimentation with replicating Thailand's 100 percent condom policy for commercial sex establishments.
Given the many self-identified subgroups within the population of men who have sex with men, specific strategies and materials should be developed for them. Members of those subgroups should be involved in the intervention design process from its inception.
The syndromic management training course AIDSCAP developed should be replicated throughout the government's Ministry of Health infrastructure and through medical-training residency programs in such areas as urology, dermatology,and gynecology and obstetrics.

Meeting the Challenge of the HIV/AIDS Epidemic in the Dominican Republic: The AIDSCAP Response, 1992-1997