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This special report documents the work of the FHI AIDS Control and Prevention Project in the Dominican Republic from 1993 to 1997. Topics covered by the report include empowering core groups; investing in workers' health; reaching youth; supporting women at risk; promoting sustainable prevention efforts; and sharing lessons learned.
Table of Contents III. Investing in Workers' Health (See Below) VI. Promoting Sustainable Prevention Efforts III. Investing in Workers' Health Every year more than a million foreign tourists vacation in the Dominican Republic. Many are drawn to the country's northern seashore resorts in the city of Puerto Plata and other nearby communities by the bright sun, long sparkling beaches, night clubs with rhythmic merengue and salsa music, colonial-era stone forts and charming Victorian-style wood houses. Thousands of Dominicans also flock to Puerto Plata, looking for jobs in hotels, restaurants, shops and other businesses catering to tourists. But there is a darker side to the alluring tourist attractions and promising employment opportunities of the Puerto Plata region: the area has a thriving commercial sex industry and one of the highest HIV prevalence rates of any region in the Dominican Republic. In response to that grim reality, the Puerto Plata NGO COVICOSIDA carried out a highly successful three-year project to slow the spread of HIV and other STIs among local hotel employees. The AIDSCAP-supported effort reached nearly ten thousand Dominican workers, as well as their families and neighbors, with prevention messages that helped change workers' attitudes about HIV/AIDS and their sexual behavior. Just as successful were a series of AIDSCAP projects that targeted Dominican employees in the manufacturing and assembly plants and other businesses of the "industrial zones" in and around the capital city of Santo Domingo. Called "Trabajo y Salud" ("Work and Health"), the four successive projects were implemented by another AIDSCAP NGO partner, COIN. Between September 1992 and April 1997, COIN peer educators reached more than 113,000 of their coworkers with health messages. Initially faced with skepticism from many company owners and managers, COIN persuaded numerous business leaders to play influential roles in the effort to protect their workers' health and guard them against HIV infection. Through the COIN and COVICOSIDA workplace projects, AIDSCAP achieved one of the major goals of the strategic and implementation plan created for its program in the Dominican Republic in the fall of 1993: carrying HIV/AIDS prevention messages to the general population of the Dominican Republic. While core groups such as sex workers and men who have sex with men had been hit hardest by HIV/AIDS during the early years of the epidemic, research by AIDSCAP and other organizations showed the epidemic had moved into a second phase, with steadily increasing infection rates among the sexually active population as a whole. There were persuasive public health reasons for targeting people in workplaces, including such economically vital segments as tourism and industrial zone enterprises. Many of the workers in those two sectors are young, single and sexually active. Even male employees who are married or in a steady relationship frequently have other sexual partners. By the early 1990s, some 73 percent of the country's reported AIDS cases had resulted from heterosexual sexual contact. Approximately 86 percent of all the cases had occurred among people aged 15 to 54, the years when they could be contributing the most to the Dominican economy. Since the 1970s, tourism and the industrial zone businesses have grown rapidly and become far more important to the Dominican economy than such traditional sectors as farming and mining. The number of foreign visitors climbed from 480,000 in 1980 to 1,500,000 in 1996. Tourism now accounts for one-fifth of the country's gross domestic product, provides over 150,000 jobs, and brings in more than twice as much foreign currency income as agricultural and mineral exports. The Dominican industrial zone businesses are also a major contributor to the country's economy. This is especially true for one type of industrial area, the "free trade zones." In these districts foreign and local manufacturers can set up assembly and production plants that benefit from major tax incentives, as well as an abundant supply of eager workers. Employment in the free trade zones climbed from some 16,400 in 1980 to 141,000 in 1992, and the value of the zones' exports rose from $117 million to $1.7 billion. Those foreign exchange earnings from the free trade zones, as well as the tourism sector, are crucial to paying off the country's international debt. The economic importance of the tourism and industrial zone sectors provided another rationale for the AIDSCAP workplace projects. It was hoped that once the enterprises' owners and managers understood the value of HIV/AIDS prevention to their businesses, the proprietors would provide financing to help make the interventions self-sustaining over the long term -- another AIDSCAP goal. There were also practical reasons for focusing on the tourism and industrial zone sectors, according to Dr. M. Ricardo Calderón, director of AIDSCAP's Latin American and Caribbean Regional Office. During the program's first year in the Dominican Republic, AIDSCAP supported COIN and COVICOSIDA projects targeting sex workers and their clients. Among those customers were many employees of the hotels and of the industrial zones. During that same year, AIDSCAP financed a COIN project focusing on workers in the industrial zone of Haina, just to the west of Santo Domingo. The existing activities, contacts and expertise of those two groups enabled AIDSCAP to put HIV/AIDS prevention activities in place rapidly. A final advantage with the industrial zones, said Dr. Calderón, was the concentration of a large number of employees in a relatively small geographic area. This would make it easier to expand and replicate COIN's activities in other divisions of the same company or in nearby businesses once the NGO's efforts gained momentum and recognition. Reducing Risk Among Hotel Workers In the country's booming tourism sector, the single largest concentration of hotels -- about 35 percent of all the rooms -- is in the Puerto Plata region. Research by COVICOSIDA and other groups has shown that sexual relations are common among hotel employees and also between those workers and foreign guests. In addition, many hotel employees and international visitors also patronize Dominican sex workers. According to research AIDSCAP carried out in Puerto Plata and four other major Dominican tourist destinations in 1996 and 1997, some 17 percent of the hotel workers reported they had had sexual relations with tourists. That type of involvement was three times as likely for the hotels' entertainment or activities staff members, such as the life guards and disc jockeys. These staff interact regularly with international visitors, organizing leisure events that include swimming pool exercise sessions and horseback riding during the day and dance parties and folkloric shows in the evening. And while 39 percent of all hotel employees reported having had multiple sexual partners during the preceding year, 55 percent of the entertainment workers had had more than one partner. In the AIDSCAP workplace project, COVICOSIDA focused its prevention efforts on the employees of 13 first-class hotels in the Playa Dorada resort complex, which is seven kilometers (four miles) east of the center of Puerto Plata. The target audience included workers in food and beverage services, maintenance, administration and activities functions. COVICOSIDA recruited and trained health messengers from among hotel workers to reach other employees. These volunteers gave talks and distributed condoms and informational materials at hotel departmental and "employee of the month" meetings, as well as in one-on-one discussions. The project also staged entertaining and educational "provocative theater" sociodramas during hotel staff meetings and at bus stops where hotel workers gathered. Health messengers and COVICOSIDA staff focused on three primary objectives: expanding the workers' knowledge of HIV and other STIs and appropriate protection methods, increasing their use of condoms and reducing the number of their nonregular sexual partners. Because of the large number of persons regularly entering and leaving employment with the hotels, the NGO found it had to present those themes over and over, while also adding new information for the workers it had already reached. "The employees might have heard about AIDS before from television or somewhere else, but learning about it directly was very helpful," said Ignacio Pérez, general manager of Puerto Plata Beach Resort and Casino. Other hotel managers praised the quality of the education COVICOSIDA staff and volunteers provided. "It's one thing for me to read a magazine article and talk with my employees," commented Cornelia Paulini, human resources manager of the Paradise Beach Club & Casino in Playa Dorada. "It's another thing to have people like those from COVICOSIDA who are specialists, who know how to make presentations and talk to people." To relieve hotel managers' fears that the HIV/AIDS interventions would disrupt employees' work, COVICOSIDA made sure no educational activity lasted longer than 25 minutes. The NGO supported the presentations with such written pieces as brochures, posters, fliers, comic books and flip charts. Hotel workers' attitudes and conduct changed over time, according to the businesses' managers. "When COVICOSIDA first started working with the hotel employees, they felt ashamed to ask questions about HIV and AIDS," said Rafaela Arvelo, manager of personnel of the Dorado Naco resort in Playa Dorada. By the end of the project, however, workers felt much freer to seek out the information they needed, she reported. End-of-project statistical data also showed increased knowledge and significant behavior changes. One objective had been to raise from 80 to 90 percent the proportion of hotel employees who could identify two HIV prevention behaviors. Surveys in 1996 found that 100 percent of workers could do that. Another goal had been to increase from 37 to 47 percent the proportion of employees who reported having only one sexual partner during the preceding twelve months. At the end of the project, that figure was 59 percent. Among hotel employees who reported having sexual relations with tourists, 95 percent of the workers said they had used a condom in their most recent encounter, up from 85 percent three years before. (See 3.1. AIDSCAP Establishes Other Linkages with the For-Profit Sector.) Changing Behavior in Industrial Zone Workers COIN's strategy for promoting HIV preventive behavior among the employees in Santo Domingo industrial zone businesses was similar to that of COVICOSIDA. The volunteer health educators COIN recruited talked to their fellow workers and distributed attractive, informative printed materials. The content of the messages was also comparable: HIV/STI transmission and prevention, proper condom use and greater acceptance of and support for coworkers and other persons who become infected with HIV. The COIN health messengers also reached out to their family members and their neighbors. Some of those encounters were informal, just one person talking to another. Others were more structured, such as special events staged during the annual December commemoration of World AIDS Day and during Easter week, which is one of the most important holidays for Dominicans. COIN found that imparting the same message outside of the workplace reinforced the information employees were receiving on the job. Those behavior change communication strategies proved highly effective with the industrial zone workers, COIN surveys at the end of the project showed. Some 96 percent of the employees knew where to obtain STI services and 94 percent knew where to get condoms. Personnel managers in the industrial zone companies also reported a noticeable drop in the number of STI cases among their workers. Attitudes toward people living with HIV/AIDS changed as well. The percentage of persons who said that an infected coworker should be kept on the job more than doubled, from 27 percent to 71 percent. One COIN health messenger who has seen those changes is Alejandro Molina, the head of local purchasing for Fábrica de Refrigeradores Comerciales (FARCO), a manufacturer of commercial refrigeration units located in the Haina industrial zone of Santo Domingo. Molina began working as a COIN volunteer in 1996. At that time, he said, "I was impressed by people's lack of information about STIs, especially AIDS." Since then, he said, the shift has been dramatic. Molina points to the progress with the condoms the COIN project has distributed. "At the beginning, many people said, 'No, I don't want them.' Now they say, 'We want condoms.' That shows they have accepted the message of taking care of themselves." Over the life of the project, COIN health messengers gave away some 34,000 condoms and sold 135,000 more. The NGO trained the volunteers in condom social marketing, as well as educational methodology, human sexuality and the Dominican AIDS law. Leovigildo Liranzo, the head of personnel for another Haina manufacturer, has also seen employees' attitudes evolve. He gave the example of a woman worker who came to the personnel office with another female employee to ask for some of the condoms that COIN provides to participating plants for distribution. "That's rare for women to ask openly for condoms, but she did," he said. "The other woman was very surprised." Part of that worker's new-found resolve may have come from the gender-focused activities COIN added in the later years of its workplace project, as more and more women began asking for efforts to address their special concerns. The NGO created new educational materials and training sessions for its health messengers that addressed such gender issues as the social and health situation of women, sexuality, reproductive health, couples relations, self-esteem and sexual and reproductive rights. (See 3.2. Lessons and Recommendations.) Promoting Policy Change COVICOSIDA and COIN have both championed broader environmental and structural changes beyond the level of individual workers' knowledge and behavior. Part of that effort focused on protecting the rights of persons living with HIV/AIDS. Another major goal was generating long-term financial support, in order to continue the workplace prevention activities after AIDSCAP's funding ran out. A recently passed AIDS law bars Dominican employers from giving HIV tests to job applicants or current employees. Nevertheless, many businesses -- including some hotels -- continue the illegal practice. COVICOSIDA pushed the hotel managers to follow the new law. "Many hotels think they solve the problem [of HIV/AIDS] by testing everyone," said Yobanny Ferreira, subdirector of COVICOSIDA and the manager of the hotel employees project. "The tests cost around 150 pesos (U.S.$11) per employee. We suggested they invest in education instead." COVICOSIDA also worked to inform hotel employees of their rights under the new legislation. As a private institution, the NGO couldn't sue hotels that violated the law by giving HIV tests. COVICOSIDA encouraged individual workers to take hotels to court, but none has done that yet. "Because of the high unemployment in Puerto Plata," noted Ferreira, "people are afraid they would lose their jobs if they filed a suit." During the project, however, COVICOSIDA did intervene successfully with two hotels that planned to fire four workers who had tested positive for HIV. "We were able to convince the hotels to keep them on," reported COVICOSIDA Executive Director Bayardo Gómez. "Most hotels send them [HIV-positive persons] home, pay them for maybe six months and then one day stop paying them." The hotel managers most supportive of the COVICOSIDA project were lower-level ones. "Many of them [the managers] changed from not supporting to supporting the project," commented Domingo Vásquez, a hotel employee who served as a volunteer health messenger. "Often the personnel manager was the first one convinced and that person persuaded other managers." Paulini of the Paradise Beach Club & Casino explained why she and other human resources managers may have been the strongest backers of the COVICOSIDA efforts: "We work more directly with our employees and we see the value of educating them." COVICOSIDA's biggest challenge remained gaining the attention and support of large numbers of the general managers of hotel chains and the top executives of the individual hotels. Those high-level company officials were in the best position to quickly facilitate the NGO's access to their employees and to possibly provide future financial support for the prevention efforts. From May 1994 to August 1996 COVICOSIDA staff members contacted hotel managers -- at all levels -- nearly 140 times. Part of the reason for many hotel executives' reluctance to support HIV/AIDS policies and programs may have been their fears that foreign tourists would be frightened away from the Dominican Republic by more aggressive public HIV/AIDS campaigns. One way to help turn around those managers' attitudes, COVICOSIDA officials believe, would be to work through hotel or tourism industry associations. And while some enterprises may want to receive credit publicly for assisting prevention efforts, other business executives -- such as hotel owners and managers -- may prefer to provide their assistance anonymously, AIDSCAP and its NGO partners found. Another route to influence the tourism sector could be through the assistance of government officials, such as tourism ministry officials. Senior representatives of that agency did step up their pressure on the hotel sector after seeing the results of a 1997 AIDSCAP study on the relationship between tourism and the HIV/AIDS epidemic. Ministry executives began encouraging hotel owners and managers to include HIV/AIDS educational sessions in the training programs for new hotel workers and make condoms more readily available to hotel guests. COIN officials had an easier time persuading upper-level business executives in the industrial zones to back HIV/AIDS prevention efforts. COIN staff and volunteers made more than 280 contacts with Santo Domingo-area company managers and union leaders between 1994 and 1996 alone. Some 40 of those persons became official "associates" of the project, endorsing it publicly and providing some support, such as the use of company photocopying machines to reproduce COIN flyers and other educational materials. Many companies also changed their practices with respect to HIV-infected employees, according to Ruth Esther Romero. She is an industrial nurse at the Q-TEL company plant in the Itabo industrial park in Haina and also serves as a coordinator for some 30 volunteer health messengers in the park. "Two or three years ago," she said, "the attitudes were different. They [the companies] might have even fired those persons. Now they [the employees] can continue working if their health allows." One reason for COIN's success persuading business leaders may have been the socioeconomic impact analysis AIDSCAP performed of the Dominican Republic's free-trade zones and released in early 1996. "When they [managers] saw the results of our economic studies," said María del Carmen Weise, a field officer for AIDSCAP's Dominican Republic country office, "they were shocked by the high costs of the [HIV] blood tests, for example, as compared with the low cost of prevention measures." According to the AIDSCAP study, each free-trade zone worker who becomes sick with AIDS is expected to cost employers some U.S.$1,550. Businesses' expenses will increase for health care, support to families of deceased workers and recruitment of replacement workers. Companies' revenues will fall due to HIV-infected workers' absenteeism and the initially lower productivity of their replacements. Effective, comprehensive prevention programs could be operated for just U.S.$15 to U.S.$25 per employee per year, the researchers estimated. That kind of data will be key as COVICOSIDA and COIN search for private sector revenues to replace AIDSCAP's financial support. Both NGOs are exploring charging businesses a fee for their services, rather than providing them free. Another alternative, COIN staff members believe, would be to seek financial support from industrial associations or consortiums and from business taxes. AIDSCAP's Dominican Republic country office helped the two NGOs develop financial self-sustainability plans and produce marketing materials in English and Spanish that the groups can use in diversifying their funding sources. By the fall of 1997, those promotional efforts had started to show results. Some industrial zone businesses were continuing their support to COIN, and four Puerto Plata-area hotels had agreed to help COVICOSIDA pay for the costs of the group's prevention project for hotel workers. Such new funding sources will be essential as COIN and COVICOSIDA continue their work to educate business leaders, change the behavior of individual workers and reach out to more members of the general public -- all vital tasks in promoting the health of individual Dominicans and the Dominican economy.
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