FHI - Promoting Sustainable Prevention Efforts

Table of Contents

VI. Promoting Sustainable Prevention Efforts (See Below)

VI. Promoting Sustainable Prevention Efforts

Before AIDSCAP brought them together, a partnership between Betania Betances of CASCO and Liliana Rocha of the Instituto Dominicano de Desarrollo Integral (IDDI) would have been unlikely. Faced with uncertainty about continued donor funding several years ago, their NGOs would have been more likely to compete than cooperate.

With AIDSCAP's help, however, those two groups not only learned to collaborate effectively with each other, but also carried out successful joint HIV/AIDS prevention programs targeting young people in lower-income neighborhoods of Santo Domingo, the capital of the Dominican Republic. These programs later led to informative research on the barriers to women's adoption of HIV risk-reducing behaviors, as well as a mass media campaign encouraging women to assert their right to protect themselves and urging men to support them. (See 6.1. All-Volunteer Organization Mounts Sustainable Response to HIV/AIDS.)

Other AIDSCAP-assisted partnerships focused on sex workers and their clients, men who have sex with men, and other key audiences. In those programs and others, AIDSCAP increased the skills -- and resulting accomplishments -- of its NGO partners with capacity building workshops and other forms of training. As the program moved closer to conclusion, more and more of that preparation focused on financial self-sustainability to help the NGOs find new revenue sources to replace AIDSCAP's funding.

In conjunction with those NGO activities, AIDSCAP worked to establish a national environment supportive of current and long-term prevention activities, through informational campaigns for key policy makers and the general public, support for national AIDS legislation, studies of the epidemic's impact on vital Dominican economic sectors, and collaboration with government agencies and NGOs to develop national HIV/AIDS prevention strategies.

Building Alliances

The origins of NGO collaborations such as the one between CASCO and IDDI go back to 1992, when it appeared that many of the key Dominican NGOs working in HIV/AIDS prevention would lose the funding from USAID that had sustained most of their projects. When the AIDSTECH and AIDSCOM projects ended and handed over responsibilities to the new AIDSCAP Project in September 1992, it was agreed that one-year bridging financing would be provided to seven projects the two earlier USAID projects had supported. However, funding for the NGO projects after fiscal year 1993 remained uncertain. (See 6.2. Capacity Building Leads to New Dominican Foundation.)

In the 1980s, NGOs had been among the first Dominican institutions to respond to the growing evidence of an HIV/AIDS epidemic in the country and to help the populations most affected. CASCO, for example, participated in formative research on HIV/AIDS before the AIDSTECH and AIDSCOM projects began. Several organizations that would later become AIDSCAP partners began working with sex workers in the late 1980s. Another group that AIDSCAP would later assist, Amigos Siempre Amigos, was established in January 1988 as a national support and education network for men who have sex with men.

Through that early and ongoing work, NGOs developed the broadest experience and strongest skills in HIV/AIDS prevention of any sector of Dominican society. Reliance on NGOs increased in 1990, when the USAID Mission in the Dominican Republic decided to reduce its support for PROCETS, the government's national STI control program, and to shift those resources to projects carried out by NGOs and other private sector institutions.

Nevertheless, AIDSCAP's challenge during the 1992-93 fiscal year was to prepare the NGOs for the possibility that USAID would no longer be their primary source of income and technical assistance. The series of activities AIDSCAP created to deal with that prospect assisted many Dominican organizations in developing new skills and perspectives and creating successful alliances with other groups sharing the same HIV/AIDS prevention goals.

"These NGOs represented nearly the entire core of organizations working in AIDS prevention with primary target groups in the Dominican Republic," said Dr. Martha Butler de Lister, AIDSCAP's resident advisor in the country. "We recognized that it takes time for field outreach people to acquire technical and methodological skills, and therefore we were determined to bring them farther along this road before we had to leave them."

AIDSCAP worked with NGO staff members to assess the technical, managerial and administrative needs of the organizations. What they found were creative people who had developed thoughtful, innovative projects. Yet many NGO personnel lacked administrative experience and had difficulty managing, evaluating and documenting their activities. In addition, many of the groups were reluctant to share ideas and work with each other, since they expected they would later be competing for the same limited USAID funds.

"These groups weren't being collaborative with us or each other," Dr. Butler said. "They had forgotten about what they were supposed to be doing -- fighting AIDS. We knew that we needed to try something drastic and nontraditional to get them focused, or all our efforts would be lost."

The NGOs recognized the problem as well. "Personality problems, economic problems and professional difficulties were tearing us apart," Elizardo Puello of CASCO recalled. "It was very clear that we were headed in the wrong direction."

Enter Dr. Josefina Romero, who had conducted a number of human and institutional development workshops for AIDSCAP and other private and governmental organizations. Dr. Romero begins by identifying the personal as well as professional needs of people in the workplace. "I've discovered that people who work with people need first to understand themselves, express their needs, understand how they exchange information and determine what is most important to them in life," she explained.

Dr. Romero's "STOP" workshop engages participants in a personal review of the actions, beliefs and spiritual values that are often overlooked when people work in large groups. She calls it "STOP" because participants are asked to stop and examine the lessons they learn about themselves and their colleagues during each activity.

Dr. Butler thought this approach could guide NGO personnel toward greater cooperation. "I felt that if they were able to identify what motivated them to work in the AIDS field, they would be able to move beyond the difficulties we were experiencing," she said.

Participants received assertiveness training and discussed how to hold on to strong moral beliefs without imposing them on others. Through role-playing exercises, participants gained a better understanding of how they might react under stressful conditions. They also learned to devise strategies for preventing misunderstandings. Perhaps most important, participants were asked to put themselves in the roles of their target audiences and other NGOs.

Dr. Romero described a "watershed moment" that occurred during one of the workshop activities. Participants were asked to choose a partner from another NGO, and one person in each pair was blindfolded. The person without a blindfold had to guide the other through "the path of life," a set of difficult obstacles. After the activity, participants were asked to discuss their experiences during the exercise.

"Many of the blindfolded participants reported they began the exercise not being able to trust the person who was leading them," said Dr. Romero. However, with each successfully negotiated obstacle, they gained trust in their partners. "Several people were able to make a link between their feeling of helplessness during this exercise and the feelings of abandonment they were experiencing as the project was at a turning point."

Those who had served as leaders also drew parallels between the responsibility they felt as they guided their partners and their approach to HIV/AIDS prevention work.

"I understand now the tremendous responsibility I have put on myself by feeling that my way is the only way to help stop the spread of AIDS," recalled one participant. "There are many paths to achieve our objectives, just like there were many ways to approach the obstacle course. I need to be more tolerant and open to the different paths my colleagues have chosen."

After the STOP workshop, NGO project managers and staff participated in AIDSCAP workshops on project design, financial management, and monitoring and evaluation. In addition, AIDSCAP staff gave many NGO personnel individual training in office procedures and proposal writing as they worked together to develop projects.

In late spring 1993, USAID decided to continue funding HIV/AIDS prevention activities in the Dominican Republic. Although this decision was unrelated to the success of the STOP and capacity building workshops, AIDSCAP staff took advantage of the momentum from these efforts and of the funding extension to meet with the NGOs and discuss ways they could work together.

Productive Partnerships

One collaboration that grew out of AIDSCAP's efforts was the Acuario Project, a joint undertaking of CASCO and IDDI that focused on young people in four low-income neighborhoods of Santo Domingo. Acuario merged CASCO's expertise in working with youth and IDDI's community development approach that had made it a credible source of advice and assistance for young adults in the community. Those complementary skills and experience engendered innovative, constantly improving methods and materials over the life of the project.

"It was hard at the beginning, but we worked things out," said CASCO's Betances, who heads the group's department of education. "We exceeded the project's goals, and we achieved things that we couldn't have done separately."

Several other AIDSCAP-supported activities teamed up NGOs of diverse backgrounds to reach thousands more Dominicans with HIV/AIDS prevention information. The Avancemos Project linked COIN, a Santo Domingo-based group, with COVICOSIDA, a Puerto Plata organization, to reach sex workers and their clients and other men involved in the sex industry in a number of cities (see Empowering Core Groups). "It's basically the same audience and the same methods," said Tanya Medrano, program coordinator of the AIDSCAP Dominican Republic office. "The two groups share their lessons and expertise with each other."

Another type of collaboration took place in the AIDSCAP-supported Triunfadores Project, which brought together COIN and ASA to communicate behavior change messages to men who have sex with men . The COIN/ASA collaboration focused on project management rather than exchange of technical skills and knowledge. ASA had years of experience working with the target audience members "but didn't have such a strong administrative structure," explained Mar�a del Carmen Weise, a field officer with the AIDSCAP program in the Dominican Republic. "COIN provided that. What ASA is today has much to do with that coordination with COIN."

AIDSCAP made alliance-building and the development of standardized HIV/AIDS prevention messages a key element of its mass media campaign targeting adolescents (see Reaching Youth). A February 1996 workshop convened representatives from various youth organizations to discuss what they had learned from their work with young people and suggest models for effective education and counseling services on HIV/AIDS and STIs. Using that information, AIDSCAP compiled a manual and held training sessions for some 100 groups in four cities during the spring of 1996.

In another outgrowth of the interinstitutional collaboration and networking AIDSCAP promoted, five of the NGOs that had received AIDSCAP funding formed a coalition in March 1997 to continue coordinating HIV/AIDS program planning and advocacy for appropriate HIV/AIDS policies. As it was closing down, AIDSCAP's Dominican Republic office even donated some of its equipment of modest value -- such as a slide projector and overhead transparency projector -- to the coalition on the condition that the group keep them in a central location and lend them out to the coalition members.

While proud of the successes NGOs achieved through collaboration, AIDSCAP and its partner NGOs also learned to be objective about how much progress could be made and how quickly. "It isn't easy to consolidate methodologies and policies that are similar but not the same," Betances said of the Acuario Project. "Many preconceived ideas have to be abandoned. But the results of this unification are successful in terms of quality, organization and effective strategies."

Building NGOs' Skills

The NGOs involved in the AIDSCAP-supported partnerships and coalitions learned from each other on a daily basis. Following the intensive training given during the 1992-93 transition year, AIDSCAP used a variety of other techniques to further build the capabilities of its partner NGOs and other groups to carry out prevention programs and to move toward financial self-sustainability. "We tried to systematize things, such as monitoring and the validation of communications materials," said Dr. Butler. "These things must become a habit, something totally familiar."

Some of the skills development occurred informally, through the project staff members' daily interaction with NGO personnel and the monitoring of their projects. Other instruction, however, was more structured. For example, AIDSCAP sponsored 44 consultancies, using local and international experts, for some 20 different groups. Generally working with one or several individuals from an organization, the consultants provided technical assistance in data analysis, communication materials development, project evaluation and other subjects. AIDSCAP also organized 45 courses and workshops, through which more than 1,300 persons were trained in technical and programmatic areas, including behavior change communication, strategic planning and project design.

The most in-depth skills building was done with five NGOs that implemented AIDSCAP projects: CASCO, ASA, COVICOSIDA, IDDI and COIN. During 1995 and 1996 AIDSCAP funded a consulting firm, the Agencia Latinoamericana de Expertos en Planificaci�n H. (ALEPH), to assist those groups in institutional strengthening and sustainability. ALEPH began with a situational analysis that included collecting qualitative and quantitative data through interviews and site visits. The consulting firm then helped each NGO create a plan for capacity building and financial self-reliance, as well as an evaluation system to measure progress toward its objectives.

In the work that ALEPH did and in all the other capacity-building activities, AIDSCAP staff members found that mutual trust and open communication between the project and the NGOs was essential. This encouraged a fruitful discussion of the groups' weaknesses and needs, without fear that AIDSCAP would cut the organizations' funding because they lacked certain skills.

Once training needs were identified, providing the appropriate instruction was far from a simple matter. Many NGO employees found it hard to take time away from their demanding project implementation duties in order to participate in the skill building activities. Careful schedule coordination with the organizations was essential so employees could dedicate sufficient time and attention to the training sessions.

The lack of a tradition of continuing education in the Dominican Republic made it difficult to update the skills of some NGO employees who already considered themselves experts in a particular subject area. Groups also needed to choose trainees whose improved skills would have the greatest impact on their organizations. However, some NGOs thought of the training as a prize to be awarded to dedicated individuals rather than to the employees most likely to apply their new knowledge to their organizations' benefit. (See 6.3. Lessons and Recommendations.)

Employee training was an ongoing process due to the high staff turnover in many NGOs. Some organizations created incentives for trained employees to stay in their jobs. Even where groups had limited financial resources, such inducements could include public praise or opportunities to participate in raffles of donated items.

Organizations that worked with AIDSCAP varied in their initial skill levels and in their abilities to absorb new knowledge and then take on more complicated tasks. In some instances, Dr. Butler said, NGOs with more expertise could be matched with universities and carry out sophisticated research. Groups with less capacity, however, could still make a contribution. "You can have people do what they're good at," said Dr. Butler. "For example, persons who talk to sex workers can have input to evaluation, but they don't have to do the evaluation themselves."

A critical element of the NGO capacity building was helping the organizations diversify their funding sources. In 1997 AIDSCAP worked with its NGO partners in creating promotional strategies and marketing pieces in English and Spanish. A number of the groups distributed those brochures to business, government and donor representatives who attended a late-July open house event AIDSCAP hosted to express appreciation to its partners and allow them to highlight the lessons learned in their projects.

AIDSCAP's workplace prevention projects, with hotel employees in the Puerto Plata area and with industrial zone workers in and around Santo Domingo, have had some initial successes in their fund-raising efforts. For example, by the fall of 1997, COVICOSIDA had persuaded four hotels to help finance the costs of the group's prevention program for hotel workers.

Raising money for projects outside the workplace, however, has proved to be more difficult. "The private sector will probably support workplace projects," Dr. Butler said, "but programs with sex workers will always need donor support." The key difference, she noted, is the greater social acceptability of programs targeting employees. One solution might be to convince business owners to finance prevention programs for the brothels their workers patronize.

National Policy Efforts

While AIDSCAP was building the capabilities of its NGO partners, the program was also working to establish an overall national environment promoting sustained prevention efforts. From the beginning, AIDSCAP staff members recognized that one of their priorities would be providing key decision makers with the information and motivation to support HIV/AIDS prevention programs.

One of the essential elements for a national consensus was adequate epidemiological information showing the seriousness of the epidemic. AIDSCAP supported the epidemiological surveillance department of the Dominican government's national AIDS program, PROCETS, in monitoring HIV/AIDS trends in the Dominican Republic. The data were used to influence important public and private sector policy makers as well as the general population, through such special events as forums, conferences, workshops, TV interviews and talk shows, and press announcements. In 1993 AIDSCAP developed two documents projecting estimates of the epidemic until the year 2000, one for technical audiences and another for the general public. PROCETS and other organizations continue using those materials in their awareness building activities.

National AIDS legislation for the Dominican Republic was signed into law in 1993 partly as a result of a presentation on trends in the epidemic that AIDSCAP held in October of that year for high-level government, business and church officials. To build wider awareness of the new statute, AIDSCAP supported the Instituto Nacional de Salud (INSALUD), a national membership group for public health professionals, to work with PROCETS. INSALUD held informational meetings with physicians, nurses, laboratory technicians, medical school professors and other health personnel; members of women's groups; and lawyers, judges, legislators and human rights activists. To reinforce those efforts and reach additional audiences, INSALUD participated in numerous radio and TV programs focusing on the new legislation.

AIDSCAP conducted detailed socioeconomic impact studies to promote involvement in HIV/AIDS prevention among businesses in some of the country's most important economic sectors. In early 1996, the program used a study of HIV/AIDS in the industrial zones of the Dominican Republic to increase awareness among the business community of the epidemic's dimensions and its present and future financial impact on their industries. Results of a similar investigation of the tourism sector in 1997 motivated tourism ministry officials to push hotel owners and managers to include HIV/AIDS educational sessions in their training programs for new hotel workers and to make condoms more accessible to hotel guests.

Another important contribution to the policy environment for HIV/AIDS prevention in the Dominican Republic was the national HIV/AIDS prevention strategies and plans AIDSCAP helped develop. One of the first was a national strategy on communication for the prevention of HIV/AIDS and STIs. That plan influenced a subsequent strategy for young people, as well as AIDSCAP's mass media campaign targeting adolescents. AIDSCAP also collaborated with government agencies, NGOs and other groups in creating the first national strategies for preventing the spread of HIV/AIDS among women.

"To get people together and write things down does provide structure," Dr. Butler explained. "It gives them 'roots' for their activities."

The plans are one of AIDSCAP's most important legacies in the Dominican Republic. Together with the legislative and social changes the program helped bring about and the local organizations it strengthened, they will provide a foundation for an effective response to the country's evolving HIV/AIDS epidemic.

6.1. All-Volunteer Organization Mounts Sustainable Response to HIV/AIDS
In countries around the world, government resources fall far short of the needs for HIV/AIDS prevention and control, and the Dominican Republic is no exception. One organization that has worked creatively to overcome that limitation is the Patronato de Solidaridad (PASO), or Solidarity Council, a nonprofit group based in Puerto Plata.

Established in September 1994 to expand HIV/AIDS prevention activities in the northern part of the Dominican Republic, PASO has organized major conferences, held workshops and other training sessions, counseled persons living with HIV/AIDS, and helped establish a grassroots network of self-sustaining local HIV/AIDS prevention organizations. All this has been achieved through the efforts of an unpaid staff and other volunteers, with a bare minimum of funding from AIDSCAP and other outside sources.

PASO grew out of the work that COVICOSIDA, another AIDSCAP-supported NGO, had been doing in Puerto Plata and other nearby communities in the province of the same name. "We decided to create an independent support group," said PASO President Alexandra Lister, "not just to look for money for COVICOSIDA, but to do other things as well."

Rather than restricting its work to the Puerto Plata region, PASO has promoted HIV/AIDS prevention activities in all 14 of the Dominican Republic's northern provinces. That region makes up about one-third of the country's territory and has a little over a quarter of its population.

COVICOSIDA has concentrated primarily on prevention and education, while PASO has given more attention to care and support for HIV-positive persons.

PASO -- and the new local groups it has helped establish -- also differ from COVICOSIDA in terms of their revenue sources and staffing. COVICOSIDA has mainly depended on USAID and other donors for its funding, and it has a staff of paid employees. PASO and its local "offspring" are intended to be financially self-sustaining from local community resources and to rely exclusively on volunteers.

One of PASO's first major activities was organizing a two-day congress on HIV/AIDS and other STIs. The first major AIDS conference held in the northern region, the congress took place in Santiago in mid-July 1995. Some of the meeting's costs were covered by a $5,000 rapid-response grant from AIDSCAP. During 1994 and 1995 AIDSCAP used those small, targeted grants to fund seven community-based HIV/AIDS prevention activities in the Dominican Republic.

PASO had expected some 200 persons to attend the congress, but more than 300 showed up. While presenting up-to-date scientific information about the HIV/AIDS epidemic, the meeting concentrated just as much on sensitizing and motivating the participants, who included both medical professionals and laypersons interested in helping slow the epidemic's spread.

"It wasn't just a 'show and tell' conference," said AIDSCAP Resident Advisor Dr. Martha Butler de Lister. "It was a 'feelings' conference, to make people feel the mission they have. They remain committed today."

Before the congress, Lister and other PASO volunteers visited all 14 of the northern provinces to persuade individuals to attend the conference. The visits also furthered PASO's goal of establishing independent, self-sustaining HIV/AIDS prevention organizations in all the northern provinces. By the spring of 1997, 12 of those jurisdictions had set up local committees.

PASO has helped the provincial groups with advice and interinstitutional coordination and also helped arrange AIDSCAP support for training workshops for the organizations' members. Each of the local groups, however, directs its own activities, including choosing a name for itself, deciding where to work, and selecting which aspects of HIV/AIDS prevention and care on which to focus.

PASO has provided interest-free loans to some of the new organizations to help them hold local fund-raising events. In recent workshops for representatives from the provincial organizations, PASO has asked the local volunteers to cover the fees for renting the meeting space, in addition to their own transportation costs and other incidental expenses.

Foundation for Life

One of the strongest local groups to grow out of PASO's organizing work is based in Santiago. Called Fundaci�n por la Vida (FUNDAVI), or Foundation for Life, the organization was created in September 1995, just two months after PASO's congress on AIDS and STIs.

Many of the FUNDAVI volunteers are doctors, nurses and other medical personnel who have seen firsthand the impact of the HIV/AIDS epidemic. Others are commercial sex workers, and there are even economists and agronomists in the group. Many became involved after witnessing relatives, acquaintances and neighbors fall ill from HIV/AIDS. "I saw how AIDS was growing in the Dominican Republic," said Mar�a Alvarez, an economist, "and I had several friends die. I was looking for something to give to infected persons. FUNDAVI was like a light that came on inside me [saying] this is what I need to do."

FUNDAVI's volunteers have concentrated on educating persons on HIV/AIDS and other STIs by giving presentations in schools, clubs, neighborhoods, private companies and government agencies in and around Santiago. The group has targeted young people in particular, using one-on-one and group discussions, sociodramas and written materials.

FUNDAVI carried out a week-long series of events tied to World AIDS Day commemorations in 1995 and 1996. The group held marches that culminated in church masses. In a downtown park, FUNDAVI volunteers showed informational videos, posted photos of AIDS patients and distributed condoms. They also persuaded a local newspaper to devote a full page to articles on HIV/AIDS prevention.

A major challenge, however, has been convincing the business sector to contribute. While some enterprises have asked FUNDAVI volunteers to give presentations to their employees, the firms have been reluctant to provide any financial support. "They say it's the responsibility of the government," commented a FUNDAVI member. Like the other groups PASO helped establish, however, FUNDAVI has raised all of its funds from local sources.

6.2. Capacity Building Leads to New Dominican Foundation
Even though AIDSCAP's Dominican Republic program closed its operations in the summer of 1997, many of the program's special capacities will be maintained through a nonprofit group, the Fundaci�n G�nesis (Genesis Foundation). Established in January 1996, Genesis will continue to support HIV/AIDS and STI prevention, but will work on other areas of health and education as well.

Several former AIDSCAP staff members are now a part of the new organization, which was founded with assistance from the AIDSCAP NGO Partnership Initiative. Recognizing that the skills and experience of its field staff represented a valuable resource in each of the host countries, AIDSCAP and FHI launched the initiative to help its field offices establish indigenous NGOs.

AIDSCAP provided training to Genesis and the six other new NGOs in business planning, fund raising, proposal writing and financial management. These skills prepared the NGOs to raise funds from a variety of sources so they can continue to provide technical and financial support to other local organizations.

Building on relationships established during the years of the AIDSCAP program, Genesis staff may raise funds from international donors. Other potential funding sources are Dominican institutions, especially the private sector.

"Genesis staff know the insides and outs of international agencies, and they know the issues concerning local institutions," said Dr. Ricardo Calder�n, AIDSCAP's regional director for Latin America and the Caribbean. "They can open doors and provide advice to both parties."

6.3. Lessons and Recommendations
Lessons Learned

Collaboration by agencies with common concerns but differing areas of expertise can increase a project's effectiveness.
Capacity building plans must be defined jointly with all those involved in order to match those plans with an organization's specific needs and its stage of development.
Human relation workshops and other such unconventional methods and an emphasis on shared goals and common challenges can help organizations overcome inter- and intrainstitutional rivalries for effective collaboration.
Continuous staff training is essential for institutional growth when there is frequent employee turnover.
Sentinel surveillance data can promote policy reform, but the information must be made available in "user-friendly" language for decision makers as well as the general public.
Fund-raising to create self-sustaining prevention programs is easier with efforts that are more socially acceptable, such as workplace projects. Other types of interventions, such as those with sex workers, will likely need more ongoing donor support.

Recommendations

Interventions to encourage individual behavior change should be supported by structural and environmental interventions to build a more supportive environment for HIV/AIDS prevention. (See the Dominican Republic's experimentation with replicating such an intervention, Thailand's 100 percent condom policy for commercial sex establishments).
Efforts to build awareness and acceptance of the country's new AIDS law should continue through ongoing educational campaigns, use of the mass media, and the design of a law school curriculum component covering the legislation.
Programs to help Dominican NGOs diversify their revenue sources, such as additional training in proposal writing and fund-raising, should be continued. The NGOs should be encouraged to seek support from both domestic and international sources.

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