This report covers the FHI AIDS Control and Prevention (AIDSCAP) Project (1991-1997). Volume 1 covers regional program overviews, technical strategies, and program support strategies.

Table of Contents
Volume 1

Introduction

Regional Program Overviews
-Africa
-Asia
-Latin America & the Caribbean (See Below)

Technical Strategies
-Behavior Change Communication
-Condom Distribution
-STI Services
-Policy
-Behavioral Research

Program Support Strategies
-Program Evaluation
-Program Management
-Women's Initiative
-Information Dissemination

Appendixes

Volume 2

Regional Program (continued)

LATIN AMERICA AND CARIBBEAN: Status and Trends of the Epidemic

As of September 1997, Latin America and the Caribbean (LAC) had reported more than 200,000 cases of AIDS, 13 percent of the total number of cases reported worldwide. Of the 470 million people in the 44 countries that comprise the region, it is estimated that between 1.6 and 2 million people have already been infected with HIV.

In a region noted for its tremendous diversity in culture, ethnicity, geography, climate, and economic activity, seven subregions can be identified, allowing for a more meaningful review of the epidemic's impact: Mexico; the Central American Isthmus (Guatemala, Belize, El Salvador, Honduras, Nicaragua, Costa Rica, and Panama); the Latin Caribbean (Cuba, the Dominican Republic, Haiti, and Puerto Rico); the English-speaking Caribbean (Jamaica and 21 island nations); the Andean subregion (Bolivia, Colombia, Ecuador, Peru, and Venezuela); the Southern Cone (Argentina, Chile, Paraguay, and Uruguay); and Brazil.

The HIV/AIDS epidemic began in LAC in the late 1970s and early 1980s. Initially most infections occurred among men who have sex with men (MWM). Heterosexual transmission has since increased substantially, principally among bisexually active men and their female partners, and among female commercial sex workers (CSWs) and their clients. Injecting drug use has played a significant role in transmission in several South American countries, notably Brazil and Argentina, and is an increasing concern in Central American and Caribbean countries, principally Honduras and Jamaica. Nonetheless, sexual transmission of HIV accounts for 81 percent of overall transmission in the region, ranging from 66 percent in Brazil to 94 percent in the Andean subregion.

Four factors that contribute to the epidemic also explain the diversity of prevalence rates within the region:

• characteristics of sexual behavior (multipartnerism, bisexuality, and commercial sex),
• STI prevalence and treatment-seeking behaviors,
• demographic and economic factors (including migration, urban concentration, income, level of education, gender inequalities, and access to health care and prevention), and
• injecting drug use.

Patterns of sexual activity across the region reflect behaviors that place the population at risk for HIV. These behaviors include early onset of sexual behavior, cultural acceptability of multiple partners, especially for males, and low levels of condom use. National behavioral surveys in Haiti and the Dominican Republic, for example, have found average age of first sexual intercourse to be as low as 13. A relatively high proportion of men report having had sex with other men, and in many countries, a majority of men report having had multiple, concurrent sexual partners and paying for sex. Condom use has been historically very low and is generally opposed by religious institutions.

While the countries of LAC have established health care infrastructures, they are often plagued by inefficiencies and are inaccessible to low-income populations. Self-treatment of sexually transmitted infections (STIs) is common, and prevalence rates are high. In Haiti, for example, 47 percent of pregnant women in the Cité Soleil neighborhood of Port-au-Prince were found to have at least one STI. In a national survey in the Dominican Republic, 33 percent of women reported having had an STI in the past 12 months, and 48 percent of youth reported STI symptoms. Of Jamaican men reporting an STI in a national survey in 1996, only 54 percent sought appropriate treatment, and 33 percent did not seek any treatment at all. A study of Brazilian STI patients found that 70 percent had had symptoms for at least 1 month before seeking treatment.

The region's demographic and economic characteristics are conducive to the rapid spread of HIV infection. Migration, both among countries and to and from rural and urban areas, contributes to the spread of HIV/AIDS. Epidemiological evidence signals a rapid shift of new infections to younger ages, particularly toward individuals aged 15 to 24. Declining economic conditions, particularly in the Caribbean, have caused many women to become even more dependent on their male partners. Women's economic vulnerability has resulted in increased multipartnerism and commercial sex.

Injecting drug use is another important mode of transmission in South America, accounting for 26 percent of AIDS cases in Brazil and 29 percent of AIDS cases in the Southern Cone. Decreasing male to female ratios of AIDS cases and decreasing ages at diagnosis in these regions have been associated with this mode of transmission.

Mexico, the Central American Isthmus, and the Latin Caribbean

The number of new HIV infections and AIDS cases in Mexico, the Central American Isthmus, and the Latin Caribbean continues to rise. As of September 1997, 53,464 AIDS cases had been reported to the Pan American Health Organization from this region. Because of widespread underreporting, the true incidence of AIDS is estimated to be between 20 and 70 percent higher.

Although MWM continue to be the most affected group in Mexico, incidence in this population does not appear to be increasing as rapidly as it did in the 1980s. Transfusion-associated HIV infection and AIDS cases have been drastically reduced because of effective blood screening. Heterosexually transmitted HIV infection among women is slowly increasing. In Mexico, there are effectively two epidemics: (1) an urban epidemic, more mature and mainly affecting MWM; and (2) an emerging rural epidemic, spreading through heterosexual transmission.

In Central America, Honduras has only 17 percent of the region's population, yet it has 48 percent of AIDS cases. HIV seroprevalence levels among CSWs in Honduras have reached almost 40 percent. Sentinel surveillance of pregnant women in the city of San Pedro Sula has documented prevalence of up to 4 percent. Commerce, migration, and communication patterns within this subregion suggest that HIV is spreading within each country in well-established local epidemics, as well as across international borders. In contrast, Nicaragua, perhaps because of its relative isolation from tourism and trade in the 1980s, has very low documented rates of HIV prevalence. A study conducted in 1996 of Nicaraguan CSWs in three cities found an HIV prevalence of less than 1 percent. STI prevalence, however, was much higher.

In the Latin Caribbean, Haiti is of particular importance because it is the only country in the region with a relatively mature epidemic. Exacerbated by social, economic, and political instability, HIV prevalence rose from 2 percent in 1989 to an estimated 5 percent of the rural adult population in 1994. In urban areas, prevalence was estimated at 10 percent in 1994. HIV prevalence is particularly high among CSWs, STI clinic attendees, and tuberculosis patients. Although prevalence appears to have stabilized among the general population in the past 5 years, HIV incidence may be increasing. The Dominican Republic has seen a similar trend, with HIV prevalence appearing to have stabilized in the past 5 years between 1 and 2 percent among antenatal clinic attendees and between 7 and 8 percent among STI clinic attendees. HIV prevalence in the tourist zones of the north continues to increase, however, with rates rising from 3 to 8 percent among antenatal clinic attendees between 1994 and 1996.

Within this subregion, the structure and organization of commercial sex is very diverse, ranging from informal networks of individuals who engage in occasional commercial sex to established, thriving sex industries. Several countries import or export sex workers and organize sex tourism. International and intraregional travel, including tourism and employment seeking, also influence the dynamics of the Caribbean epidemic, increasing the potential for spread of HIV.

The English-Speaking Caribbean

The predominant mode of HIV transmission in the English-speaking Caribbean is heterosexual, but estimates suggest that homosexual transmission accounts for 14 percent of all new infections. Intercountry variation exists in AIDS incidence and prevalence, but in general, the number of cases is increasing in all countries. The doubling time for the annual number of new AIDS cases in this subregion is 4 to 5 years. Some Caribbean countries report AIDS incidence rates that are among the highest in the world. Among the many small countries of the Caribbean, the fact that some countries have very high incidence rates while others have very low rates demonstrates that there are many distinct HIV epidemics, rather than one regional pattern.

HIV is increasingly affecting individuals from marginalized groups, such as migrant workers, CSWs, and users of crack cocaine. AIDS has become the leading cause of death among young adult men in some Caribbean countries. On a more hopeful note, the extremely low incidence of HIV infection through contaminated blood represents a success story for the Caribbean countries.

Jamaica was identified in the late 1980s and early 1990s as a country on the verge of an explosive epidemic. With high rates of STIs, multipartnerism, migration, and poverty, it was believed that the 0.4 percent HIV prevalence found in 1992 among antenatal clinic attendees would quickly escalate. In 1995, however, HIV prevalence among this group was still less than 1 percent (0.9 percent). In Barbados, HIV prevalence among pregnant women has been documented between 1 and 2 percent.

South America: Andean Subregion, Southern Cone, and Brazil

The number of HIV infections and AIDS cases in South America is rising steadily. While Brazil has 75 percent of South America's AIDS cases, escalating prevalence in Argentina and Colombia will lower Brazil's percentage in the near future. As in other regions, sexual transmission is the most common mode of transmission of the 66 percent of all reported AIDS cases (42 percent homosexual and 24 percent heterosexual), with injecting drug use accounting for the remaining 34 percent.

Many countries in the Andean subregion and in the Southern Cone report low rates (below 0.5 percent) among the general population and higher rates (about 20 percent) among MWM, CSWs, and injecting drug users.

The HIV/AIDS epidemics in these subregions are at differing levels of maturity but are well established in most countries. Transition from epidemics centered in major urban areas to increasing involvement of smaller urban centers and rural areas is emerging. Epidemics are increasingly taking hold in specific population subsets, including adolescents, marginalized communities, and populations characterized by low socioeconomic status and lack of basic socioeconomic, educational, and health services.

Accomplishments and Results

Accomplishments

In the LAC region, AIDSCAP/FHI established comprehensive programs and fully staffed country offices in Brazil, the Dominican Republic, Haiti, Honduras, and Jamaica. AIDSCAP/FHI collaborated with other countries on a smaller scale, including Bolivia, Ecuador, Peru, Costa Rica, El Salvador, Guatemala, Nicaragua, and Mexico. The level of prevention and control conducted in these countries was determined by the local USAID Missions, and ranged from a single project to comprehensive national campaigns integrating the efforts of nongovernmental organizations (NGOs), the Ministry of Health (MOH), and the private sector.

During the 6 years of the project, achievements in the LAC region have been exciting and encouraging. AIDSCAP/FHI programs resulted in prize-winning advertising campaigns in the Dominican Republic, a national postage stamp in Brazil, a presidential commendation in Honduras, a world-touring theater troupe in Jamaica, promulgation of an AIDS law in Nicaragua, and continuing HIV/AIDS prevention efforts during political upheaval in Haiti. Activities expanded from a planned focus on five major country programs to include additional STI/HIV/AIDS prevention interventions in nine associate countries. In the overall region, where AIDS was once viewed as a homosexual disease and a disease of foreigners, governments are increasingly aware of the gravity and potential impact of the epidemic and of the importance of prevention in avoiding the level of crisis faced in other regions. The AIDSCAP Project, through its many local implementing agencies, has been largely responsible for this shift.

In addition to its high-profile achievements, the AIDSCAP Project has had numerous other successes. It conducted high-quality mass media campaigns for a wide range of target audiences and promoted syndromic management of STIs in the public and private sectors. In collaboration with subcontractors, AIDSCAP/FHI country offices initiated social marketing of condoms for STI/HIV/AIDS prevention. In several countries, gender-focused strategies were developed to respond to the shift in the pandemic to higher rates of infection among women. AIDSCAP/FHI effectively worked with the public and private sectors in the region, presenting impact analyses, mobilizing commitment, and leveraging resources. It also designed a rapid program implementation protocol for Honduras that jump started a national program in just 2 weeks.

Table 12. LAC Regional Process Data 1991-1997
.	Cumulative
Total People Educated:	5,282,195
Total People Trained:	46,751
Total Condoms Distributed:	125,104,164
Free:	28,705,274
Sold:	96,398,890
Total Materials Distributed:	9,574,321
Process indicators are used to track measurable data in a subproject. People educated includes number of people attending educational sessions or contacted through AIDSCAP interventions. People trained includes number of people attending training of trainers sessions. Condoms distributed indicates condoms sold through condom social marketing programs and condoms distributed for free. Materials distributed includes behavior change, condom promotion, and HIV/STI educational materials such as posters, pamphlets, handbooks, tapes, newsletters, and comic books.

Mass Media Campaigns

In the LAC region, sophisticated, high-quality media are an effective means of reaching the general populations, as most people have access to television, radio, and a variety of print media. AIDSCAP/FHI programs in Haiti, Jamaica, Brazil, and the Dominican Republic disseminated behavior change messages, making creative use of mass media channels. In Haiti, the jingle for Panther condoms was recited in the streets. The Jamaican program worked with a local public relations firm and succeeded in raising awareness and putting HIV/AIDS on the country's social agenda. The Brazilian magazine Claudia, with a monthly circulation of almost 700,000 copies, teamed up with AIDSCAP/FHI to educate its readership on HIV/AIDS through articles in each issue. Working with a Dominican advertising company, AIDSCAP/FHI crafted an award-winning ad campaign for adolescents. Not only did these campaigns reach a vast audience, but they created linkages with the private sector, resulting in millions of dollars worth of donated airtime and print space.

Dominican Republic: Just Once "Just one time I loved in my life, just one time and never again." This lyric from the popular and traditional Mexican ballad "Solamente Una Vez" was the backdrop of a three-part mass media campaign in the Dominican Republic that has won international acclaim. Since this high-quality production of TV and radio spots aimed at Dominican youth was launched in September 1995, the young actors have become minor celebrities, being approached frequently with questions about HIV/AIDS. "Just Once" is transformed from a heartfelt declaration of love to a warning to youth to protect themselves from infection. "Young people live in their own world," said Mr. Freddy Ginebra, president of the Dominican advertising company, Cumbre, that worked with AIDSCAP/FHI on the campaign. "They don't have fear; they take more risks; they're adventurous and rebellious. They don't think death exists, so we looked for a 'code' to challenge them and make them think." In four separate phases, the campaign urged adolescents to learn about HIV/AIDS and to protect themselves and exhorted parents to discuss STIs and HIV/AIDS with their children. It garnered extraordinary support from the media, with donated airtime for the advertisements valued at more than U.S. $9 million.

Syndromic Management of STIs

Another area of improvement in the region was in the diagnosis and treatment of STIs. Using guidelines developed by the World Health Organization for syndromic management, AIDSCAP/FHI focused on field testing and adapting them to local situations. As a result, new national guidelines were established in the five major LAC countries. Public and private sector medical professionals in these countries received training in syndromic management.

• In Haiti, the three main STI programs achieved consensus on standardized protocols, which were adopted by the MOH for national use. In addition, AIDSCAP funding to the Haitian Study Group for Kaposi Sarcoma and Opportunistic Infections (GHESKIO) supported the training of some 440 medical professionals in STI management.
• In Jamaica, training was provided through the MOH's Epidemiology Unit, the Medical Association of Jamaica, and the Nurse Practitioner Association of Jamaica. More than 1,700 medical professionals received training to strengthen STI services. In addition, the MOH produced and distributed more than 2,000 copies of a manual on STI case management and counseling.
• In Brazil, approximately 2,000 health care professionals were trained in syndromic management in Rio de Janeiro, Santos, Ceará, and Bahia. Approximately 10,000 copies of STI management guidelines and supporting materials, developed and translated into Portuguese with AIDSCAP/FHI funding, were distributed to polyclinics and medical professionals throughout the country.
• In the Dominican Republic, syndromic management course participants were directly involved in developing and validating instructional manuals. The STI training program was attended by more than 850 clinicians, bioanalysts, and health promoters nationwide.
• In Honduras, partially as a result of AIDSCAP/FHI-supported regional training for STI managers, word got out about syndromic management, and the medical establishment requested training before the MOH had completed preparations. By the end of the project, the guidelines had been published, and training had been initiated.

Condom Social Marketing

In 1992, lack of access to condoms was common in most of the countries of the LAC region. To address this constraint, AIDSCAP and its subcontractors initiated or strengthened condom social marketing programs in four of its major countries in the region. These interventions sometimes had dramatic results, not only on sales of the socially marketed product but also on commercial sales and government policy. For example, during a 4-year project in Brazil implemented by DKT do Brazil, an affiliate of Population Services International, sales of Prudence -- the DKT condom -- totaled more than 71.5 million. Of this number, approximately 45.8 million were sold in AIDSCAP target areas. Prudence is the third largest brand in Brazil. Prior to this program, Brazil had one of the lowest rates of condom use in the world, with nationwide sales of approximately 50 million condoms in 1991. By the end of 1996, sales had more than tripled. A DKT position paper is also credited with the president's 1995 decision to decree a yearlong tax holiday on the 60-percent duty charged on imported condoms. This holiday expired after a year, but the duty was lowered to 10 percent.

Gender Initiatives

Gender inequality is one of the greatest barriers to STI/HIV/AIDS prevention. The World Health Organization estimates that women are 10 times more vulnerable to STIs and HIV infection than men because of biological, social, cultural, and economic factors. The response of the LAC Regional Office to this critical need clearly evidenced the commitment of the regional programs to implementing gender-sensitive initiatives.

In addition to the major technical strategies of the global AIDSCAP Project, the AIDSCAP Women's Initiative worked with the project's LAC Regional Office to incorporate techniques to integrate gender into regional STI/HIV/AIDS prevention efforts. In Brazil, AIDSCAP conducted a study on the acceptability of the female condom. The study concluded that this method not only offered an alternative contraceptive for women but also increased the chances of safer sex and successful condom negotiation. Study participants liked the female condom, and they were sufficiently motivated to buy the device. In Haiti, an NGO used dialogue to get families and adolescent children talking about STI/AIDS in a gender-sensitive and constructive manner. Educational sessions created an open atmosphere in which sexual partners, mothers, fathers, and teenagers were able to share a basic understanding of sexual risk and the methods to prevent and control STIs and HIV, without the tension typical of such encounters.

One of the most significant steps taken toward institutionalizing gender in AIDSCAP/FHI programs was the development of a regional gender and STIs strategy. In this three-tiered strategy, each country office designed and implemented an STI research, intervention, or training pilot project; participated in gender-analysis training; and participated in a 2-day regional conference for partner countries. This workshop was attended by 25 participants, including AIDSCAP/FHI senior managers and implementing agency officials from the Dominican Republic, Honduras, Brazil, Bolivia, Peru, and Nicaragua. As a result, participants from AIDSCAP country offices who were establishing indigenous NGOs to carry on their work drafted value statements for their nascent organizations that communicated their beliefs about gender. Regional guidelines were also developed for implementing gender-oriented STI/HIV/AIDS prevention activities. Finally, partnerships were established between Brazil and Bolivia, and Honduras and Nicaragua.

Haiti: Don't Take a Hit Although a military coup in 1991 sent Haitian President Jean-Bertrand Aristide into exile, and subsequent embargoes virtually shut down foreign aid for several years, AIDSCAP/FHI continued its HIV/AIDS prevention programs. The Panté condom jingle, "Pa pran gol" (Don't take a hit), could be heard everywhere, and a news program sponsored by Panté kept the public informed about political developments. Yet, this high profile was not without its problems. Dr. Eddy Génécé, former AIDSCAP resident advisor, recalled an evening meeting with CSWs: "The police broke in and insisted that the meeting was political and subversive and that we had to disperse." In spite of harassment and fuel shortages, the program maintained a strong network among those working with the HIV/AIDS program. In fact, these adversities enhanced their resolve and cooperation. Dr. Génécé recounted, "We shared information: when one group found fuel for sale or discovered a district or town was blockaded, we let each other know. We learned to make each gallon go a long way by shipping several months' worth of condoms at one time." Another group turned long gas lines into an opportunity. Ms. Gessy Aubry, director of the NGO Groupe de Lutte Anti-SIDA, was only one example. "We took creative advantage of those hours spent in gasoline lines to talk to drivers about STI/HIV/AIDS prevention. We developed a portable presentation that could be delivered as we walked up and down the line, and even began to sell condoms to other customers."

Impact Analyses

The countries of the LAC region, unlike many of their counterparts in other regions, were able to intervene before HIV became a full-fledged epidemic. While HIV seroprevalence levels became epidemic in some urban areas, levels remained relatively low throughout most of the region. As a result, HIV prevention did not receive sufficient attention from either policymakers or the private sector in the early 1990s.

To provide policymakers with sufficient information about the potential impact of an HIV epidemic in the region, AIDSCAP/FHI conducted socioeconomic impact studies in the Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, and Peru. With funding from the Colombian MOH and SIDALAC/Mexico and technical support from AIDSCAP/FHI, Colombia and Costa Rica conducted similar studies. The MOH in each country assembled a team of epidemiologists and economists who used computer and mathematical models to simulate the trajectory of the epidemic from 1995 to 2000 for both high and low transmission rate estimates and to estimate the epidemic's economic impact. Every country projected that the incidence of HIV/AIDS would rise sharply between 1995 and 2000.

These impact analyses raised awareness of HIV as a multisectoral development issue, rather than merely a health issue. As a result of the impact assessment in Honduras, USAID decided to make Honduras a major country for prevention and control efforts under the AIDSCAP Project and secured a commitment from the Government of Honduras. In addition, a video production in Honduras was successfully used to initiate workplace prevention programs in the private sector. In both the Dominican Republic and Nicaragua, information from these studies contributed to the promulgation of new AIDS laws. The study in El Salvador led to increased funding for HIV prevention programs and to the creation of STI clinics in the workplace.

Private Sector Mobilization and Leveraging

Widespread support in mobilizing the private sector was obtained in the LAC region over the life of the project. Helping private sector companies understand the potential impact of HIV/AIDS on their workers was the key to leveraging financial support for prevention and care. In addition, considerable direct cash or in-kind contributions were made to support the prevention activities of governments and NGOs. Examples of these kinds of contributions included the following:

• AIDSCAP/Brazil leveraged approximately $4 million in investments to increase the sustainability of program activities. DKT International provided nearly $2 million worth of condoms to the AIDSCAP/Brazil project. Companies such as Levi Strauss and Unilever, publicity agencies, and several fashion magazines also provided in-kind contributions to further prevention activities.
• In the Dominican Republic, community-based distribution and private sector partnerships were negotiated to increase condom distribution nationwide. In addition, AIDSCAP/Dominican Republic also launched a national mass media campaign for youth that successfully leveraged approximately $9 million of both domestic and international free airtime for radio and television spots.
• A local public relations firm working with AIDSCAP/Jamaica and the MOH was able to leverage strong support from the private sector, evidenced by the more than U.S.$180,000 cash or in-kind contributions on behalf of the national AIDS control program. Furthermore, this firm secured free advertising time on television, on radio, and in newspapers valued at more than U.S.$1 million.

Results

AIDSCAP/FHI's HIV prevention programs in the LAC region have significant results to match their accomplishments. Results can be noted on several different levels, which are summarized in the following sections.

Strengthened Local Capacity to Respond to HIV/AIDS

The AIDSCAP Project provided support and training to local organizations, including NGOs, universities, and MOHs, through 180 subprojects with the objective of strengthening technical and management skills, management systems, physical resources, and interorganizational networks.

As a result of the project's effort, management systems (including financial, monitoring, and condom and STI logistic systems) were significantly strengthened in every organization. Program managers and staff reported a greater understanding and sophistication in the use of both technical skills (in peer education, behavior change communication materials development, evaluation methodologies, condom logistics, social marketing, and STI clinic upgrading) and management tools (strategic planning, financial management, monitoring, and reporting). Finally, by encouraging organizational cross-fertilization and multisectoral collaboration, AIDSCAP/FHI was able to improve information dissemination and exchange of experiences. The project created informal and formal coalitions that were able to exercise political leverage and generate increased resources.

AIDSCAP/FHI capacity building efforts resulted in a significant number of local organizations managing sustainable interventions, which will continue to respond to target population needs beyond the initial geographic area and period of AIDSCAP funding. With AIDSCAP/FHI's support, many effective intervention models were developed and replicated in other contexts. In São Paulo, Brazil, for example, an intervention targeting adolescents attending evening remedial and high school classes developed a curriculum on HIV/AIDS that was accepted by the Ministry of Education and reproduced throughout the state, reaching more than 1 million youth. Successful intervention approaches with CSWs in the port of Santos, Brazil, were presented to local health officials and NGOs in the northeastern state of Bahia for replication. Worksite prevention programs in Haitian factories received ongoing funding from local factory owners and were able to expand coverage to additional sites. STI case management training, funded by AIDSCAP/FHI and offered in Jamaican public hospitals and clinics, is being expanded to include private sector practitioners.

AIDSCAP/LAC country offices led the effort to ensure the organizational sustainability of implementing agencies. They also ensured their own sustainability by becoming independent NGOs with diversified funding sources.

• In Honduras, the Fundación Fomento en Salud competed for and won a USAID/Honduras contract to continue interventions started under AIDSCAP.
• In Brazil, the Associação Saúde da Família received funding from the government, U.S.-based private foundations, and the private sector to continue its activities and implemented a high-profile HIV/AIDS fund-raising campaign targeting the Brazilian general population.
• In the Dominican Republic, Fundación Genesis is currently in contact with U.S. and European donors, designing intervention projects targeting youth and women.
• In Haiti, Prometeurs Objectif Zerosida is working to organize an active coalition of local NGOs and has received a grant from Plan International to incorporate HIV/AIDS prevention into Plan's projects in four areas of the country.

Jamaica: The First Face of Aids Teri Ann was 25 years old when her life fell apart. She was diagnosed with AIDS. Her husband, who had infected her, deserted the family. Her young son was sent to live with relatives in New York. Fearing violence and ostracism in her community, she sought the help of the Jamaican AIDS Support (JAS), a nonprofit organization offering prevention services and hospice care for people living with HIV/AIDS. A beautiful woman with a model's cheekbones and a dazzling smile, Teri Ann became a gentle crusader, the first to publicly discuss her illness. She wanted to help others, to reach other Jamaicans with her story. Together with filmmaker Pat Lazarus and the supportive encouragement of JAS, Teri Ann chronicled her last 6 months with the hope that her message of prevention and protection could save lives. Her other most fervent wish, which she spoke of passionately on tape, was to see her son one last time. JAS Executive Director Ian McKnight recalls the power of this story: "People could relate to Teri Ann. It impacted everyone, especially women. It was a real wake-up call!" Teri Ann died in September 1994 at the age of 28. She never did see her son. The "Teri Ann" video continues to be widely used. JAS shows it in schools and churches, and TV stations have rebroadcast the story many times. "Tuesday Forum" hostess Elaine Wint-Leslie -- the Jamaican Oprah Winfrey -- credits Teri Ann with "single-handedly doing the most for HIV/AIDS education in Jamaica."

Reduced Risk Behaviors Among Targeted Populations

AIDSCAP/FHI programs in the LAC region targeted diverse populations, including male and female CSWs, MWM, hotel workers, STI clinic attendees, residents of impoverished and marginalized communities, adolescents, factory and agricultural workers, college students, and general population adults. In every population, increased knowledge of HIV/AIDS transmission and prevention methods has been recorded. In addition, some positive measure of protective behaviors, such as increased condom use or decreased number of partners, has been noted.

Knowledge of two or more methods of preventing HIV transmission is nearly universal among both high- and low-risk target populations in many of the AIDSCAP major countries. Table 13 shows changes in knowledge of HIV prevention methods among various target groups in selected LAC countries.

Table 13. Changes in Knowledge of Two or More Methods of HIV/AIDS Prevention

Country	Target Population	Percentage Able to State Two or More HIV/AIDS Prevention Methods
		Baseline	Follow-up
Brazil	CSWs	74% (1991)	93% (1996)
	MWM	71% (1993)	91% (1995)
DR1	Youth (15-19)	45% (1993)	100% (1996)
	MWM	94% (1992)	100% (1996)
	CSWs	91% (1992)	100% (1996)
Haiti	General population	71% (1990)	97% (1995)
Jamaica	General population	91% (1994)	95% (1996)
	Youth (12-14)	70% (1994)	95% (1996)
	MWM	85% (1993)	95% (1996)

1Dominican Republic

Unfortunately, while knowledge of HIV transmission and prevention is high in most populations, deficiencies remain in terms of specific knowledge and belief in inaccurate means of HIV transmission (such as mosquitoes and social contact with HIV-positive individuals). Forty percent of adults in Jamaica named an incorrect means of HIV prevention in 1996. In the Dominican Republic, rates were even higher, with 26 percent of men reporting that a good diet could prevent HIV infection, 39 percent reporting not touching a person with HIV, and 63 percent reporting avoiding mosquito bites. Adolescents often report even higher levels of belief in incorrect transmission methods, poor knowledge of STI symptoms, and lack of understanding of the transmission of HIV by asymptomatic individuals. While target populations have accepted and understood information on HIV/AIDS conveyed to them by mass media campaigns, peer educators, and outreach workers, they have been slow to reject the persistent rumors, gossip, and sensationalistic news that convey misinformation.

In addition to improved knowledge, condom use has increased in every AIDSCAP LAC country, as shown in Table 14. While condoms have been accepted only moderately well among men and women over the age of 30 and in the context of regular relationships, 100 percent condom use is becoming a norm among female CSWs and, to a lesser degree, among MWM.

Table 14. Reported Condom Use During Last Sexual Intercourse by Target Population

Country	Target	Population Baseline	Condom Use Follow-up
Brazil	CSWs	57% (1991)	97% (1996)
	MWM	21% (1993)	76% (1995)
DR	CSWs	65% (1992)	98% (1996)
	MWM	38% (1992)	63% (1996)
Honduras	CSWs Tegucigalpa	N/A	94% (1995)
	CSWs Comayagua	N/A	100% (1995)
Haiti	CSWs	N/A	92% (1995)
Jamaica	CSWs	N/A	95% (1996)
	MWM	51% (1993)	78% (1995)

The high levels of condom use in these populations reflect the success of the AIDSCAP/FHI peer education efforts and the impact of condom social marketing programs. CSWs and MWM now universally report that low-cost condoms are available in a myriad of outlets, including pharmacies, supermarkets, bars, hotels, kiosks, and beauty salons.

In general populations targeted by AIDSCAP, significant increases have been noted in individuals' ability to discuss HIV/AIDS and negotiate condom use. For example, in 1994, 45 percent of urban youth in Haiti stated that they were able to discuss HIV/AIDS with their partners, and 23 percent reported that they were able to negotiate condom use. One year later, 75 percent reported that they were able to discuss HIV/AIDS, and 63 percent said that they were able to negotiate condom use. Despite these improvements, condom use with nonregular partners is much lower than it is for high-risk populations and has shown little change since baseline, as shown in Table 15.

Table 15. Reported Condom Use with Nonregular Partners During Last Sexual Intercourse by Target Population

Country	Target Population	Condom Use
		Baseline		Follow-up
		Male	Female	Male	Female
Brazil	Youth (18-25)	4%1 (1994)		2%1 (1995)
DR	Youth (15-19)	24%	10% (1992)	47%	17% (1996)
Haiti	Youth (15-19)	40%	21% (1996)
	General Population	16%	6%2 (1990)	32%	12%2 (1995)
Jamaica	Youth (12-14)	16%	21%3 (1994)	29%	35%3 (1996)

1 Use of condoms with casual partner in the past 6 months, no gender specified
2 Ever used condoms
3 Consistent (every time) condom use in the past 12 months

The lower levels of behavior change in condom use among general populations may be due to their lower perceptions of risk of HIV infection. Another explanation may be that the more intensive interventions targeting high-risk populations were simply more effective.

One exception to low rates of condom use in the general population is Jamaica, where HIV/AIDS prevention campaigns have benefited from long-running family planning campaigns. Seventy-five percent of men in the general population with nonregular partners reported condom use during their most recent sexual intercourse. This high figure was unchanged between 1992 and 1996.

Throughout the LAC region, a high percentage of men in the general population report having changed their sexual behavior to reduce their risk of HIV infection (see Table 16). The most common steps taken by these men include having fewer partners, avoiding commercial sex, and selecting sexual partners more carefully. The extent to which these changes in sexual behavior have occurred, as well as the protective effect of this incremental behavior modification, is difficult to assess, but undoubtedly provides some degree of reduced exposure to and risk for HIV infection. A smaller percentage of women report changed behavior, primarily because of their lower rates of high-risk behaviors.

Behavior change strategies adopted by the general population varied greatly by age. For example, among men in Haiti citing behavior change, the strategy of having one partner was adopted by only 20 percent of men aged 15 to 19 versus 77 percent of men aged 50 to 59. In the same study, condom use was cited by 30 percent of men aged 15 to 19, 40 percent of men aged 20 to 24, and only 3 percent of men aged 50 to 59. Among women in Haiti, abstinence was cited by 57 percent of women aged 15 to 19 versus 8 percent of women aged 25 to 29.

Table 16. Rates of Behavior Change

Country	General Population	Behavior Change (1995-96)
		Change	Specific Strategies Cited
DR	Male	85%	Have one partner (29%)
			Avoid sex with CSWs (26%)
			Reduce number of partners (25%)
			Use condoms (23%)
	Female	26%	Have a steady partner (23%)
			Have one sex partner (11%)
			Abstain (4%)
Haiti	Male	68%	Have one partner/be faithful (48%)
			Avoid occasional partners (36%)
			Avoid CSWs (35%)
			Use condoms (25%)
	Female	31%	Have one partner/be faithful (71%)
			Use condoms (11%)
Jamaica	Male	59%	N/A
	Female	47%	N/A

Improved Policies and Changed Social Norms

Another result of the efforts of the AIDSCAP/LAC regional office has been an improved political and social environment for HIV/AIDS prevention. Governments' recognition of the costs of the HIV/AIDS epidemic and their commitment to providing resources to fund programs have increased, partly because of the socioeconomic impact studies sponsored by AIDSCAP. As mentioned earlier, model interventions with documented impact have been scaled up and supported by government resources. Important policy changes have improved the efficiency of HIV/AIDS prevention projects as well as the human rights environment for individuals at risk of, or already infected with, HIV.

Examples of the improved policies include the lowering of duties on condom imports in Brazil, passage of AIDS laws in the Dominican Republic and Nicaragua, adoption of national STI guidelines in Honduras and Haiti, and development of a national HIV/AIDS 5-year plan (1995) in Haiti.

Many countries in the LAC region also have seen widespread changes in social norms. For example, the Catholic Church in Haiti has reached out to HIV/AIDS prevention organizations and has taken an active role in providing care and support for HIV-positive individuals. Today, individuals who die from AIDS may be buried in Catholic Church cemeteries; 5 years ago they were not allowed.

While these results in building capacity, reducing risk, and improving policies and changing social norms validate AIDSCAP/FHI's approach and attest to its persistent efforts, they do not provide justification for complacency. Many of these results represent only the initial steps toward completely sustainable organizations, fully protective behaviors, effective policies, and supportive social, economic, and political settings.

Lessons Learned and Recommendations

Behavior Change Communication

• Many members of high-risk populations are no longer considered to be at high risk because of their adoption of risk-reduction strategies. Therefore, the emphasis should be on reaching individuals within these groups who continue to practice high-risk behaviors, including low-income, occasional CSWs, subsets of MWM (for example, cross-dressers in the Dominican Republic), and migrant workers. Emphasis also should be put on improving the environmental and structural conditions that can sustain behavior change among those who have adopted lower-risk behaviors.
• The HIV/AIDS epidemic can be understood as a series of overlapping epidemics involving different populations at different times. Intensive efforts aimed at targeted populations in which the epidemic is spreading most rapidly are most cost effective and efficient over the long term for slowing the overall epidemic. However, these efforts also initially require more costly formative research and labor-intensive intervention strategies. At the same time, broad general population campaigns can increase public awareness of HIV, social acceptance of people living with HIV/AIDS, and support for resources for HIV prevention. General population programs also reach individuals who do not identify themselves as members of one of the targeted populations, as well as partners of those being targeted.
• Adolescents represent an increasing percentage of HIV infections in the LAC region. As they become sexually active, sustained education interventions must be available to address their concerns. Reaching this group requires substantial support from a wide range of gatekeepers (for example, parents, schoolteachers, and religious officials) and frank recognition that ignoring adolescent sexuality is a deadly proposition.
• It is important to integrate all institutions, both governmental and nongovernmental, from the outset in developing, planning, and implementing a behavior change communication strategy. This coordination creates a homogeneous team and a spirit of cooperation and collaboration that ensures consistency and enhances the effectiveness of the campaigns. In addition, working as a team can eliminate competition and duplication of efforts and increase cost effectiveness.
• In the LAC region, it is particularly important to produce professional-quality messages because most audiences have wide exposure to mass media. Polished productions are also better accepted by TV and radio stations and are more likely to generate donated airtime at highly visible times of the day.
• Peer education, while effective among some groups, was ineffective and impractical for street-based CSWs and some youth groups. Because of the transient life-style of street-based CSWs, training them in peer education was not an efficient use of resources. Turnover was high, and monitoring was difficult. In addition, other CSWs resisted the counseling and education from peers. They were suspicious of the advice given and feared losing customers if they followed it. These CSWs responded better to the intervention of professionals. Similarly, youth groups in Jamaica reported feeling more confidence in education provided by professionals rather than by their peers. Sexually Transmitted Infection
• In the LAC region, STIs are still highly prevalent and can increase HIV transmission potential up to 40 percent. STI treatment-seeking behavior is poor, with a high percentage of individuals either treating themselves or not treating their STIs at all. Contact-tracing and partner-referral rates are low as well. Medical establishments have resisted implementing syndromic management protocols. Further interventions are needed to increase the use of syndromic management and to reinforce STI counseling, particularly among private sector practitioners, who treat up to 60 percent of STI patients in some countries.
• The ultimate sustainability of STI prevention activities depends on their integration into reproductive health programs. Given the high level of STI prevalence and the low level of treatment, a demonstrated need exists for improved screening capabilities in primary health care centers. Without this integration, the impact of STI campaigns will be limited.
• A large percentage of symptomatic men continue to seek STI treatment outside clinics. This population is an important target group for future service delivery efforts.

Condoms

• In Latin America, overcoming religious and social barriers to condom distribution and sales has been a challenge. Use of mass media and celebrity endorsements emphasizing the benefits of condoms have been an effective solution.
• Social marketing programs have been successful in the region; however, a number of issues must be considered when initiating programs of this kind.
• The move from obtaining free-of-charge condoms to purchasing condoms may not be easily achieved.
• Using existing distribution channels for social marketing of condoms is desirable; however, the willingness of private sector companies to be associated with a controversial product should be explored indepth before investing time negotiating agreements.
• Good logistics management and inventory controls are necessary to preclude leakage of donated condoms meant for free-of-charge distribution into the black market, where they are then sold.

Program Management

• To be responsive to changing needs in the field, programs should decentralize decision making. Subprojects of country programs suffered from delays in disbursements of funds and approval of amendments.
• The demands of submitting monthly and quarterly reports diverted staff from other program management tasks. New programs should strive to simplify reporting requirements, and reports should focus more on results than process.
• Larger subprojects are more cost effective and demand no more time from country and regional office staff than small projects. Therefore, where feasible, larger (perhaps umbrella) projects should be encouraged.

Evaluation

• Cross-sectional studies are still vital in sentinel and population-based surveys, but more emphasis should be placed on younger age groups and finer age stratification to identify risk-reduction strategies adopted. Coordinated and repeated behavioral surveys of multiple target populations -- such as those conducted in Jamaica -- provide an essential overview of trends. They can also establish the long-term effectiveness of intervention efforts and identify emerging risk groups or behaviors.
• The process of triangulating evaluation results (such as biological data with quantitative and qualitative outcome and process data) in annual evaluation reviews with program managers and evaluation researchers can lead not only to improved, more insightful findings, but also to an improved understanding of and appreciation for the evaluation process and the means of applying evaluation results.
• A comprehensive evaluation framework should include the measurement of project coverage rates, such as the percentage of target audiences recognizing campaign slogans or materials on behavior change communication, and the percentage of target audiences contacted by peer educators or accessing outreach facilities. These kinds of surveys can be conducted with minimal questions, rapid training of interviewers, and limited analysis to ensure low-cost and rapid completion. The target population's access to condoms can also be measured to assess condom promotion and social marketing projects. Results from coverage surveys improve the triangulation of evaluation results and make it possible to attribute results to program efforts, complementing the information on trends uncovered by the behavioral studies.
• As our response to the HIV/AIDS epidemic continues to evolve, new program areas (e.g., care, counseling, and testing) demand new indicators. Additional indicators should also be identified to measure sustained behavior change.

 

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