FHI - Introduction

Table of Contents

I. Introduction (See Below)

II. Empowering Core Groups

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

I. Introduction

Funded by the U.S. Agency for International Development (USAID), the AIDS Control and Prevention (AIDSCAP) Project was implemented by Family Health International (FHI) in more than 45 countries around the world. As the AIDSCAP program was getting underway in one of those countries, the Dominican Republic, in 1992, it faced a less "mature" HIV/AIDS epidemic than the ones in some Asian and sub-Saharan nations.

For AIDSCAP, the early stage of the epidemic represented an opportunity to apply lessons learned from other countries' experiences to help slow the spread of HIV before the virus had dispersed as widely as in some other nations. It also presented a challenge: the need to persuade public officials, other opinion leaders and the general public that the epidemic was serious and that the country needed to take meaningful measures to contain it.

During the five years that AIDSCAP worked in the Dominican Republic, the epidemic evolved and so did the program's activities. Following a pattern seen in a number of countries, HIV/AIDS in the Dominican Republic moved from affecting mainly persons in such "core groups" as sex workers and men who have sex with men, to reaching a much broader segment of the Dominican population, including adolescents and monogamous women.

AIDSCAP's response was broad and comprehensive. The AIDSCAP program in the Dominican Republic funded 23 projects, as well as more than a dozen smaller initiatives, carried out by local partner nongovernmental organizations (NGOs) and other Dominican institutions. AIDSCAP provided those groups with technical assistance that increased the effectiveness and reach of their interventions. The AIDSCAP program also collaborated with NGOs, government agencies and other institutions in creating national strategies and plans that guided prevention efforts with such key groups as women, teenagers and young adults. And it supported the development of 50 behavior change communications pieces, ranging from comic books for sex workers and their clients to TV and radio ads carried for free thousands of times by local television, radio and cable broadcasters. Throughout the life of the program, AIDSCAP's efforts were guided -- and improved -- by ongoing research and evaluation activities.

AIDSCAP and its partners focused on four primary target groups: people in the workplace, adolescents and young adults, family planning clients, and such core group members as sex workers and men who have sex with men. These target groups were chosen because of their epidemiological and social characteristics and because working with them offered the best prospects for slowing the spread of HIV/AIDS.

While women were not specifically identified as a target group in the strategic and implementation plan developed in the fall of 1993 to guide the efforts of the Dominican Republic program, AIDSCAP increasingly focused on gender concerns as the program advanced. Research by AIDSCAP and its partners showed that in many cases women were slower than men to reduce their risk behavior, and it described the underlying social and economic causes of women's inability to protect themselves. AIDSCAP responded by creating a major mass media campaign and other materials and activities to encourage greater social support for women's adoption of safer sexual practices.

AIDSCAP applied a comprehensive, resourceful combination of mutually reinforcing interventions. Behavior change communication (BCC) activities and the improvement and expansion of services for the treatment and prevention of sexually transmitted infections (STIs) focused on individuals and their need to reduce risky conduct. To make the overall political and cultural environment more supportive of HIV/AIDS prevention efforts, AIDSCAP also promoted policy reform, HIV/STI surveillance, program-related research and private sector resource leveraging.

Thousands of persons became more aware of the HIV/AIDS threat and altered their behavior during the AIDSCAP program, evaluation research showed. For example, surveys among hotel employees reached by a project in the northern coastal resort area of Puerto Plata showed that by 1996, 100 percent of the workers could identify two HIV prevention behaviors. Hotel employees who reported having only one sexual partner during the previous year rose from 37 to 59 percent. In another AIDSCAP workplace intervention, conducted in the industrial zones in and around the capital city of Santo Domingo, the percentage of employees who said an infected colleague should be kept on the job more than doubled, from 27 percent to 71 percent. By 1996, more than 97 percent of sex workers targeted by the program reported that they had used a condom with their most recent client. Equally impressive changes occurred in other populations, including young people and men who have sex with men.

With AIDSCAP's assistance, some individuals transformed their lives far beyond just their sexual conduct. Dozens of sex workers who served as peer educators developed new-found confidence and self-respect that helped them leave the sex industry and find new ways to earn a living. One such woman is Nancy G�mez, who went into sex work in 1987 to support herself and her three children. Impressed by the way a Puerto Plata NGO reached out to her and other women, she began working for the group as an unpaid volunteer health messenger. As her skills and experience grew, she began receiving a small stipend from the NGO. In 1993, G�mez left sex work entirely to become a full-time health educator.

Reinforcing the efforts to promote individual behavior change were AIDSCAP interventions to create broader political and societal support for HIV/AIDS control and prevention. After helping gain passage of new national AIDS legislation, the program worked to build broad public awareness and acceptance of the law and its protections for individuals living with HIV and for other persons, such as workers whose employers were illegally requiring them to take HIV tests.

AIDSCAP used epidemiological data, socioeconomic studies and other tools to persuade government officials and private sector owners and managers to increase their support for HIV/AIDS prevention efforts. One of the most dramatic results was the more than U.S.$9 million in advertising space that Dominican broadcasters contributed to carry TV and radio advertisements for an AIDSCAP campaign directed at adolescents and their parents.

With help from AIDSCAP, Dominican NGOs put aside earlier rivalries and implemented highly successful collaborative projects targeting young people, sex workers and their clients, men who have sex with men, and other key audiences. Through capacity building workshops and other training, the program increased the skills and accomplishments of its NGO partners and moved the groups toward the financial self-sustainability they would need once AIDSCAP funding ended.

Throughout the program, behavioral research was used to improve the quality of strategies, methods and materials and to identify new avenues for intervention, such as a mass media campaign targeting women.

The program in the Dominican Republic learned from AIDSCAP country programs elsewhere and shared its new knowledge with many other nations. Contributions to other countries ranged from comic books that sex workers took with them when moving to work outside the Dominican Republic to the award-winning adolescent mass media program, which drew attention and recognition across Latin America. Materials and strategies AIDSCAP applied from elsewhere have been as small in scale as a Brazilian comic book on condom negotiation and as broad as an effort to replicate Thailand's highly successful 100 percent condom policy for sex establishments. These cross-fertilizations even involved linkages between NGOs in the Dominican Republic and counterpart groups in the United States that work with Dominican immigrants and their children.

It is hoped that this "Special Report" will help other countries to benefit similarly from AIDSCAP's experience in the Dominican Republic, leading to stronger, more effective, more enduring HIV/AIDS prevention programs.

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