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 (See Below)
-Latin America & the Caribbean

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)

ASIA: Status and Trends of the Epidemic

Asia is the HIV/AIDS epidemic's last epidemiologic frontier, and the virus' rapid spread throughout areas of the continent has shifted the epicenter from Africa to Asia. Although rates of infection in Asia are estimated to be increasing faster than anywhere in the world, country epidemiologic profiles are dramatically different, and governmental responses are equally varied -- from proactive and serious engagement against the epidemic to continued denial and blame on foreigners. Likewise, the past 6 years -- from the beginning of the AIDSCAP Project to its conclusion -- have witnessed areas of dramatic improvements in HIV control in Asia, as well as continuing challenges.

Thailand: Asia's Leader in HIV/AIDS Control

Evidence that extensive HIV transmission was occurring in Thailand began accumulating in 1988. By 1993, an estimated 500,000 to 750,000 cumulative HIV infections had occurred among a population of 58 million. HIV surveillance indicated that an initial HIV epidemic occurred among injecting drug users; another epidemic of separate origin erupted among female commercial sex workers (CSWs), sexually active heterosexual men, and most recently, the wives and sexual partners of these men. Serosurveys conducted among army recruits at conscription showed an increase from 0.5 percent in 1989 to 3.7 percent in 1994, providing yet more evidence of the epidemic's rapid spread.

In late 1994, however, the overall prevalence of the HIV epidemic among army conscripts decreased to 3.0 percent. An even greater decrease was reported among men from the upper northern part of the country (from 12.4 percent in 1992 to 7.9 percent in 1994), where the prevalence had been highest. Furthermore, new cases of five major sexually transmitted infections (STIs) -- syphilis, gonorrhea, nongonoccocal urethritis, lymphogranuloma venereum, and chancroid -- seen in government hospitals and STI clinics also decreased by 79 percent from 1989 to 1993.

Reductions in sexual risk taking measured by AIDSCAP/FHI's pioneering behavioral surveillance surveys (BSS) in Bangkok helped identify one of the factors responsible for the reductions in HIV and STIs. The five-wave survey, conducted from 1993 to 1996, illustrated that three groups of males (vocational students, STI clinic attendees, and factory workers) reduced their patronage of CSWs by an overall average of 48 percent. This rate mirrors national surveys showing similar declines in commercial sex. Furthermore, in recent survey waves of the Bangkok BSS, the percentage of CSWs reporting condom use during the most recent sexual intercourse was consistently more than 90 percent.

Thailand's 100 Percent Condom Program, which AIDSCAP/FHI helped to design and document (see articles in AIDS and the International Journal of AIDS and STDs), has been identified as a major contributor to the observed declines in HIV and other STIs. Future challenges in Thailand's HIV/AIDS prevention and control program include maintaining high levels of condom use in commercial sex as relapse to nonuse emerges, and increasing condom use among casual, noncommercial sex partners.

Asia's Continuing Challenges

Apart from Thailand, which experienced the earliest HIV/AIDS epidemic in Asia, there has been substantial variation in the timing and growth of the epidemic in Asia. Cambodia, India, Burma, and Vietnam have documented the most severe epidemics thus far, and Cambodia may surpass Thailand in having Asia's most heavily infected population. HIV surveillance in Cambodia in 1996 indicated that 1.7 percent of urban pregnant women were infected compared with Thailand's 1.8 percent; prevalence rate among CSWs was twice as high as Thailand's. Although condom use in commercial sex has increased significantly during recent years in Cambodia, the current levels are still inadequate to prevent secondary epidemics among wives and casual partners of infected men.

In India, HIV seroprevalence is high in the south and west. For example, surveys of CSWs in Mumbai (Bombay) showed HIV rates rising from 40 percent in 1992 to 51 percent in 1995 and among STI clients from 2 to 3 percent before 1990 to 36 percent in 1994. Studies among CSWs in Calcutta have shown a clear and consistently low prevalence rate of 1.2 percent. In Vellore, Tamil Nadu state, in South India, rates among women attending antenatal clinics have been steady at 0.1 percent, although STI clinic rates grew from 4 percent in 1993 to 15 percent in 1995. The geographic variability and the size of the country have made estimation of the actual number of infections difficult. Evidence suggests that more than 2.5 million individuals were infected with HIV in India by 1997.

The epidemic in Burma is also severe, with an estimated 500,000 people infected with HIV in 1996. HIV prevalence among CSWs increased from 4.3 percent in 1992 to 18 percent in 1995. There is substantial geographic variability in Burma, with infection rates in pregnant women ranging from 0 to 12 percent in different regions.

In Vietnam, there is some evidence that the HIV/AIDS epidemic is primed to accelerate. Higher levels of infection among CSWs are concentrated in the southern half of the country, near the Cambodian border. How rapidly rates of HIV infection increase may be determined by the speed and effectiveness of prevention program implementation in 1997 and 1998.

Opportunities for Early Intervention

In other developing countries of Asia -- Indonesia, Nepal, the Lao People's Democratic Republic (Lao PDR), Bangladesh, Sri Lanka, and the Philippines -- high levels of sexual risk taking have been reported and correspondingly high rates of STIs other than HIV documented. However, HIV surveillance has not yet shown an advancing epidemic, as seen in other countries. These six countries, therefore, offer an excellent opportunity for primary prevention to forestall pending epidemics, as well as research opportunities to investigate why HIV has not yet progressed to epidemic levels.

An example of primary prevention at work may be seen in Nepal, where low levels of HIV prevalence have continued to be documented over the past several years. Although weaknesses in the country's HIV surveillance system may be inaccurately capturing existing levels, HIV prevalence rates among STI clients in five different sites around the country have remained less than 2 percent for the past 5 years. Based on these and other ad hoc prevalence surveys, 1997 projections of the number of HIV infections in the country were at approximately 15,000, with most new cases hypothesized to be returning CSWs from India. This number was actually lower than the number of cases predicted for 1997 during a similar exercise in 1993.

It is highly likely that AIDSCAP/FHI's efforts in Nepal have contributed to the continuing low prevalence of HIV. Because the country faces numerous public health challenges with few resources, AIDSCAP/FHI has been a major partner of the Ministry of Health's HIV/AIDS prevention efforts during the past 4 years, and its program was one of the few operating in the key Central region and border areas with India, where much of the country's commercial sex is believed to occur. AIDSCAP/FHI's activities led to increases in reported condom use during most recent sexual contact from 35 to 61 percent among CSWs, whereas a comparable control area reported no change (48 versus 47 percent).

Accomplishments and Results

The Asia regional program of AIDSCAP/FHI had the opportunity to implement and support interventions in the region primarily as part of the global AIDSCAP Project, but with significant augmentation by the Asia Near East Bureau (ANE) of USAID. Country-level programs in Thailand, Nepal, and Indonesia were able to demonstrate significant population-level improvements in risk-behavior reduction when compared with areas and time periods without AIDSCAP programs. In implementing ANE's regional strategy, AIDSCAP was able to do ground-breaking work in conceptualizing the special risks of mobile populations and implementing innovative interventions for these populations as part of the Area of Affinity Initiative. In addition, the ANE resources enabled the regional program to develop extensive training, epidemiology, and policy activities that made a valuable contribution to mobilizing Asian nations and communities to respond to the challenges of HIV/AIDS.

Table 11. Asia Regional Process Data 1991-1997
.	Cumulative
Total People Educated:	2,086,786
Total People Trained:	43,353
Total Condoms Distributed:	15,828,851
Free:	1,976,566
Sold:	13,852,285
Total Materials Distributed:	1,630,996
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.

Responded to Contextual Factors Affecting HIV Prevention

The following five characteristics of the Asia region shaped the planning of AIDSCAP/FHI programs and activities in 1992:

• the regions large population;
• the relative immaturity of the epidemic and the resultant low prevalence rates;
• the presence of risk factor and risk behaviors in most countries in the region;
• significant seasonal and multiyear migration of workers; and
• the emergence of newly industrialized nations.

Population Size

It was evident that the international community could not muster the resources to fund prevention interventions on a scale necessary to have a significant impact on the huge populations in the region. Therefore, influencing policies at all levels of society in the target countries and capacity building of local public and private organizations became priorities. This demographic context required a strategy that would convince policymakers that the epidemiological situation in their country required the indigenous public and private sectors to collaborate with each other and to mobilize their resources to address the emerging epidemic. Concurrently, AIDSCAP/FHI developed intervention models that could be replicated, and strengthened the capacity of both the public and private sectors to design and manage such programs.

Policy activities sought to mobilize indigenous resources by exposing policymakers to the reality and the potential of the epidemic, by demonstrating the critical need for timely prevention interventions, and by developing analytical and communication skills among key groups.

• A policy workshop in December 1993 helped participants from six countries interpret epidemiologic data for policy advocacy.
• Regional and country journalist workshops provided basic knowledge of HIV/AIDS and the context of the epidemic to improve reporting on HIV/AIDS for a more informed readership.
• Epidemiology workshops in Nepal, India, and Cambodia assisted in improving existing surveillance systems and projecting trends in the epidemic among population groups for policy applications.
• Six policy study tours of public and private sector leaders from Indonesia resulted in heightened awareness of both the program and policy issues that need to be confronted. The Indonesian National HIV/AIDS Plan was subsequently drafted by alumni of the policy tours who called themselves the "Bangkok Group."
• National counseling and testing guidelines were developed and implemented in Cambodia.
• National STI treatment guidelines were developed and implemented in the Philippines and Cambodia.
• AIDSCAP/FHI steered the national response to focus on targeted intervention in Nepal, Lao PDR, and Bangladesh.

AIDSCAP's large country programs in Asia focused only on specific geographical areas. Through these demonstration areas, AIDSCAP sought to influence larger national programs in the public and private sectors. Although the demonstration model approach is difficult to assess, anecdotal evidence suggests that AIDSCAP/FHI has had a positive influence on the design of national programs in the region.

• The Bangkok Fights AIDS program in Thailand's capital was developed by AIDSCAP/FHI in collaboration with the Bangkok Metropolitan Administration, which continues to manage the program. The national program has adopted portions of the AIDSCAP/FHI surveillance methodology.
• The AIDSCAP/FHI program in Tamil Nadu state, India, was designed to influence other state governments in their response to the epidemic. Tamil Nadu is now recognized as the leading state in India for dealing progressively with HIV/AIDS, partly because of its collaboration with the USAID AIDS Prevention and Control Project (APAC), supported by AIDSCAP/FHI.
• AIDSCAP's strategic and implementation plan for HIV/AIDS prevention in Nepal's Terai region was approved by the National AIDS Program (NAP) in 1993; the NAP manager served on the steering committee. Public statements made by government officials indicate that they consider the AIDSCAP/FHI activities to be part of their national program.
• The USAID HIV/AIDS Prevention (HAP) Project, implemented by AIDSCAP and now by Family Health International, is working in North Jakarta, Surabaya, and Manado in collaboration with both the national and the provincial AIDS committees. A primary purpose of this new project is to demonstrate the effectiveness of policies and interventions.

The Asia Regional AIDS Training and Education Program focused on human resource development for HIV/AIDS prevention through training and education in behavior change communication, training skills, sexually transmitted infections, and policy. Centers of excellence were developed by strengthening the institutional capacity of three organizations so that they could continue their contributions, even after AIDSCAP/FHI support was terminated. The centers were the Institute of Population and Social Research of Mahidol University, the Asia-Pacific Development Communication Center of Dhurakijpundit University, and the Women's Studies Center of Chiang Mai University. The Asia-Pacific Development Communication Center continues to offer the courses developed with assistance from AIDSCAP, charging a fee to sustain the service.

Relative Immaturity of the Epidemic

The relative immaturity of the HIV/AIDS epidemic in Asia and the resulting low HIV prevalence rates had implications both for the design of the interventions and for fitting the interventions into the local framework of what was feasible and acceptable. AIDSCAP adopted an early epidemic model of interventions targeting groups at greatest risk of infection. This model also emphasized reducing all STIs and improving surveillance to track the spread of the infection among diverse groups in the population.

In each of the country and area of affinity programs (area of affinity programs address the cross-border spread of HIV/AIDS by way of mobile populations), interventions were designed following an assessment of the most prevalent risk behaviors contributing to the transmission of HIV. Program resources were then targeted on the population groups engaging in those behaviors. In the Bangkok Fights AIDS program, the target population was low-income young adults. In Nepal, the focus was on transport workers and the CSWs who serve them. In Indonesia the target populations were CSWs and their clients, partners of clients, and youth.

Evaluation data from Nepal indicate that the targeted interventions in the areas covered by AIDSCAP/FHI had a marked effect in reducing risk behaviors. Surveys in Bangkok document a reduction in risk behaviors as part of a national trend; this reduction cannot be attributed to the efforts of any one prevention program or project, but most likely reflects the combined effects of many prevention efforts.

The strategy of focusing on all STIs was chosen for the following reasons: (1) most governments in the region were reluctant to acknowledge the reality of HIV in their populations; (2) most nations in the region had unacceptably high STI rates; (3) the behaviors that put one at risk of the other STIs will also put one at risk of HIV infection; and (4) infection with other STIs increases the risk of HIV infection. By initiating interventions that reduce STI risk (including condom use and limiting high-risk sexual contacts), AIDSCAP/FHI sought to facilitate behavior changes that reduce HIV risk even before governments were prepared to recognize the magnitude of their problem and initiate HIV/AIDS control measures.

AIDSCAP's plan for the Asia region called for research on "etiologies of common STI clinical presentations and drug sensitivity patterns to allow development of treatment guidelines." This plan was implemented in four stages: (1) assess epidemiologic and antimicrobial sensitivity patterns of STIs in major urban centers in the region; (2) recognize common patterns of STIs among countries in the region; (3) develop standard treatment protocols, based on World Health Organization protocols, according to epidemiologic findings, as well as local laboratory and therapeutic circumstances; and (4) validate these protocols as needed in the field.

In Thailand, AIDSCAP assessed STI prevalence in Bangkok, national trends, and the role of STI therapies. In Papua New Guinea an assessment examined STI prevalence, risk behaviors, and program needs. Program needs identified by assessments in Mongolia and Sri Lanka were addressed by training health care providers, and microbial resistance studies resulted in modifications of national STI management protocols in the Philippines and Cambodia.

Activities conducted to strengthen surveillance activities in the region included an epidemiology roundtable discussion in India, consultations by an AIDSCAP/FHI advisor to Cambodia, Nepal, and India, and funding of the Cambodia Sentinel Surveillance Initiative. Epidemiology workshops in Nepal, India, Cambodia, and Indonesia modified national projections and working estimates of HIV prevalence.

BSS: Tracking Trends in Sexual Behavior The BSS were used in Bangkok among blue collar workers from a variety of occupations throughout the city during 1993 to 1996. A typical interview lasted no longer than 30 minutes. Like epidemiologic surveillance, the BSS can serve as an early warning system, alerting policymakers and program managers to increases in risk behavior. They also can help guide prevention programs by identifying groups whose behavior makes them particularly vulnerable to HIV infection and the specific behaviors that need to be changed. For evaluation, the BSS provides a baseline for measuring the impact of prevention efforts and a series of cross-sectional snapshots of behavioral trends among vulnerable groups. In the Bangkok BSS, interviews were conducted with 3,000 individuals every 6 months. (One-year intervals are now considered more appropriate to monitor behavior change trends.) The results helped document substantial increases in condom use and declines in male patronage of commercial sex. Data from the BSS convinced project managers of the need to direct prevention interventions to single, non-CSWs, sexually active women. AIDSCAP/FHI believes the BSS fill two gaps in evaluation information by identifying the short-term effect of prevention interventions as well as the trends in risk behaviors among vulnerable groups. Even though the BSS cannot dissect the impact of different interventions, the tool can give an indication of whether a combination of interventions are working together to change risk behaviors. In Bangkok, the surveys enabled program managers to say that behaviors were changing for the better.

Risk Factors and Risk Behaviors

Behaviors that put one at risk of STI, including HIV, were identified in most Asian countries, portending high HIV infection rates. Given this high level of risk, even in the face of low HIV prevalence, AIDSCAP focused on behavior change and developed BSS methodology to measure that change.

Behavior change interventions were designed for specific communities, and were intended to be mutually reinforcing and supported by messages and influences from other sources. In the AIDSCAP-sponsored Bangkok Fights AIDS program, the behavior change communication (BCC) interventions encompassed workplace and other interpersonal outreach initiatives, mass communications, and public relations. These interventions were reinforced by community mobilization through the district AIDS committees and collaboration with NAP through the Bangkok Metropolitan Administration.

AIDSCAP developed the behavioral surveillance surveys for the Bangkok Fights AIDS program to directly track behavior change, the focus of the interventions. These innovative surveys tracked behavior change over time among key risk groups in Bangkok. They were also incorporated into AIDSCAP programs in Nepal, Indonesia, and Senegal, and the national AIDS programs of Thailand and the Philippines incorporated modified versions of AIDSCAP/FHI's BSS into their national surveillance methodologies.

Migration Within Countries and Across National Borders

Significant seasonal and multiyear migration of male and female workers is common in the Asia region. Targeting populations for AIDSCAP/FHI interventions frequently required accommodating the reality of this mobility. Thus, it was decided that geographical targeting would need to be more precise to ensure that interventions would be absorbed by mobile populations. Assessments and pilot interventions, therefore, were conducted in strategic cross-border areas in many parts of the region.

• The initial assessment of risk along the Thai-Lao border in December 1993 resulted in the design of the Lao PDR program. The assessment revealed that most HIV/AIDS cases were found in returnees and refugees from Thailand and in bar workersthe majority of them from provinces bordering Thailand.
• AIDSCAP/FHI commissioned an assessment along the Thai-Cambodian border in June 1994 that revealed the presence of a substantial number of Vietnamese CSWs, demonstrating the mobility in this regional industry.
• AIDSCAP/FHI commissioned an assessment of five provinces in Indonesia, which resulted in the selection of Manado as the third demonstration area of the HAP Project. The two other demonstration areas are North Jakarta and Surabaya.
• AIDSCAP/FHI staff rode trucks from Calcutta north to the Nepal border as part of the assessment that lead to the Bhoruka AIDS Prevention (BAP) Project, which serves truckers in India and complements the AIDSCAP/FHI/Nepal truckers' interventions.
• AIDSCAP/FHI pioneered the conceptualization of cross-border interventions. Other donors, such as Joint United Nations Programme on HIV/AIDS, UNICEF, and USAID, are now promoting a regional approach. Partner agencies are now using this approach for their own interventions (e.g., World Vision and CARE).

A Logo for Both Sides of the Border Cross-border HIV/AIDS interventions aim to maintain a seamless environment for those who cross the border and linger in check-post towns. Exposing travelers to the same messages as they move from one country to another shows them that HIV/AIDS is not a foreign disease and that a sincere effort is being made in both countries to prevent it. The staff of two HIV/AIDS prevention projects, sponsored by AIDSCAP/FHI on either side of the India-Nepal border, believed it was important to maintain consistency not only in the prevention messages but also in the image and tone of those messages. Thus, BAP adopted the project logo developed by AIDSCAP's program in Nepal to use on posters, leaflets, stickers, and counter displays. A few changes were necessary to make the Nepal program's logo culturally acceptable to Indian sensibilities. The logo shows a condom named Dhaaley Dai fighting the HIV virus with a shield. (The program markets condoms under the brand name Dhaal [shield].) Focus group discussions held with Indian truck drivers to pretest the image revealed that the drivers could not identify with the shield, which is a symbol of Nepal's legendary Gurkhas. The condom figure's muscular arms and legs also were not appealing to the Indian men. After revisions were made based on the pretesting, the logo designed for the BAP Project was similar to the Nepali-animated condom but without the shield and the muscular limbs. The eyes and nose on the animated condom figure were modified to appeal to Indian audiences. The messages, translated into Hindi, remained the same. The pretesting and adaptation of the AIDSCAP/FHI/Nepal program logo for use in the BAP Project in India is one of many examples of the collaboration between the two projects. This collaboration enables project staff to communicate consistent, yet culturally appropriate, HIV/AIDS prevention messages to mobile populations along the border.

Newly Industrialized Nations

High levels of education in the Asia region had implications for communications initiatives as well as skilled staff availability for public and private STI/HIV/AIDS control activities. The relatively high levels of economic development also meant that certain critical commodities (e.g., condoms, lubricants, and STI drugs) were available in commercial markets. In addition, public resources were potentially available in many countries to support STI/HIV control initiatives that had demonstrated their value to policymakers.

The AIDSCAP/FHI strategy took into account the reality that the newly industrialized nations in the region (e.g., Thailand and India) could potentially bring more resources to bear on the epidemic than less developed nations (e.g., Nepal and Cambodia) and that different levels of development and preferences of national governments required different organizational configurations.

• Supplies of Condoms and STI Drugs: In Thailand and India, condoms and STI drugs have been readily available in the commercial markets and in public clinics and hospitals. Therefore, AIDSCAP/FHI built on these resources in mounting interventions in these countries. In poorer countries like Nepal and Cambodia, either AIDSCAP/FHI or colleague agencies were required to augment these essential commodities. Condom supplies were made available in Cambodia by Population Services International through a mission-funded contract. In Nepal, AIDSCAP/FHI supported a local agency, Contraceptive Retail Sales, and arranged for technical assistance from the Futures Group.
• Models Relating to NAP: AIDSCAP/FHI's organizational structure adapted to the requirements of the national government and its programmatic demands, with guidance from the USAID Mission. In all cases, the AIDSCAP/FHI interventions were designed to support the NAP and were approved by the NAP manager. The following organizational models were adopted:
• Free Standing Program: In Nepal, NAP agreed that the AIDSCAP/FHI interventions would be managed as an autonomous program, supporting NAP staff through training and coordinating closely with agencies of His Majesty's Government. The NAP manager served on the AIDSCAP/FHI/Nepal steering committee.
• Technical Assistance Only: The APAC Project in the Tamil Nadu state of India is funded directly by USAID/India. The head of the state AIDS cell is also chairman of the APAC management committee. AIDSCAP/FHI was not directly involved in management and provided technical assistance only.
• Integrated into NAP: The HAP Project in Indonesia is part of the Ministry of Health (MOH); the project director is the director general of the MOH, Communicable Disease Control/Environmental Health. The AIDSCAP/FHI chief of party reports to the project manager, who is a civil servant within the MOH.

Reduced Risk Behaviors Among Target Populations

Thailand

Results from the BSS in Bangkok provide an aggregate view of trends in the target population of the AIDSCAP country program in Thailand. Five rounds of surveys were conducted from 1993 to 1996 and involved more than 20,000 interviews with lower-income women and men aged 15 to 29. Highlights of the BSS determined by comparing round 1 data (1993) to round 5 data (mid-1996), follow. All responses are based on self-reports during personal interviews and from self-administered questionnaires.

Single and married men

• The percentage of men who had had commercial sex in the past year decreased from 21 to 13 percent for blue collar workers and from 13 to 4 percent for vocational students.
• The percentage of men who had used a condom in their last commercial sex contact increased from 89 to 94 percent among blue collar workers and from 92 to 94 percent among vocational students.
• The percentage of men who had had more than one noncommercial sex partner in the past year declined from 15 to 11 percent for blue collar men, but remained the same (13 percent) for vocational students.

Female CSWs

• The percentage of CSWs who had used condoms with every paying client increased from 87 to 97 percent for brothel-based CSWs and from 56 to 89 percent for indirect CSWs, who work out of cocktail lounges and night clubs.
• The percentage of CSWs who had had sex with nonpaying partners increased from 38 to 42 percent for brothel workers and remained at 51 percent for indirect CSWs.
• The percentage of CSWs who had used condoms with nonpaying partners was low, but it increased from 20 to 32 percent for brothel-based CSWs and from 23 to 28 percent for indirect CSWs over the project period.
• The percentage of CSWs who sought medical treatment for STIs remained high at 94 percent for brothel-based CSWs and increased from 91 percent to 96 percent for indirect CSWs.

Single and married women (non-CSWs)

• The percentage of single women who had had sex in the past year declined slightly: from 8 to 6 percent for blue collar workers and from 4 to 2 percent among vocational students.
• The percentage of sexually active single women who had used a condom during the last sexual contact remained low and constant at 19 percent.
• The percentage of married women who had used a condom during the last sexual contact increased slightly from 5 to 8 percent.

Nepal

• Among CSWs in the project area, 61 percent reported using a condom with their most recent client, compared with only 35 percent prior to the start-up of outreach activities.
• The percentage of CSW clients seeking services for urethral discharge who received advice from trained chemists on partner notification increased from 5 percent prior to intervention to 21.2 percent by the end of project.
• The percentage of CSW clients seeking services for urethral discharge who received advice from trained chemists on condom use increased from 13.7 percent prior to intervention to 23.1 percent by the end of project.
• The percentage of CSWs and the percentage of CSW clients from the Central region who reported perceptions of risk by the end of project were 92.3 and 77 percent, respectively.
• Extensive training of STI program managers and communication specialists from governmental and nongovernmental organizations (NGOs) resulted in a network of trained professionals in the region.
• The BSS was designed by the Bangkok Fights AIDS staff and collaborators, and was modified for other countries in the region and is now recognized by the international community as the state of the art in behavioral measurement.

Lessons Learned and Recommendations

Regional

• There continues to be a need for a unified regional program that complements bilateral support. The program should include a combined strategy of borderless activities linked to region-wide capacity building and coordinated with bilateral work.
• AIDSCAP/FHI, as AIDSTECH did before, moved from targeting CSWs to targeting the clients. Now is the time to aggressively reach out with prevention interventions to the spouses and partners of the clients. More work is needed on developing the messages and support networks for these groups.
• Although many countries in Asia have low prevalence rates, organizations of people living with HIV/AIDS can play a valuable role in speaking out on the human rights issues and raising the consciousness of the public and leaders regarding STI/HIV/AIDS.

India

• In India, it was found that an extremely large amount of work can be accomplished with small amounts of funds if the funds are channeled to the appropriate organizations. Some of the AIDSCAP rapid-response grant achievements (activities with a budget of less than U.S. $5,000) were extraordinarily cost-effective.

Indonesia

• In Indonesia, it was determined that the most productive role for donors in implementing politically sensitive activities and programs is that of a facilitator responsible for accessing technical expertise on relevant policy options. Smaller scale financial assistance directed to an expressed government need and carried out in a timely manner can be the most effective way to influence policy outcomes as well as to increase ownership.
• NGOs frequently focus on field activities rather than management needs and skills. Day-to-day planning and activity management are important areas for capacity building, and management skills focusing on sustainability are essential for implementing agencies. The donor agency must assist NGOs' practical skill development and capacity building.

Nepal

• In Nepal, the integration of STI services at established, respected, quality family planning and family health care service delivery sites proved successful in Nepal's Central region. STI services should be further integrated at family planning and other health care delivery sites.
• BCC interventions are further strengthened when coordinated with other HIV intervention programming, such as community-based condom social marketing and STI service delivery initiatives. Condom promotion and complementary STI initiatives can be integrated to further strengthen BCC efforts.

Thailand

• There was considerable resistance to the syndromic management of STIs by government and private physicians in Bangkok. Also, it was considered unethical to send false patients to clinics to assess physician practices. Other programs need to anticipate this resistance and find constructive ways of encouraging the influential STI practitioners to support program strategies. For the Thailand program, AIDSCAP/FHI established a technical working group made up of AIDSCAP and local STI experts. Yet, this was not enough to overcome resistance to some of the STI strategies and policies promoted by AIDSCAP. Therefore, alternative mechanisms of leveraging support need to be sought.
• In Thailand, the behavioral surveillance methodology was the appropriate tool for evaluating the combined effects of linked interventions rather than the sum of individual subproject interventions. The disadvantage of the BSS methodology is that it is not possible to attribute improvements to AIDSCAP-supported subprojects directly. Inferences must be made about the contributions of the AIDSCAP activities recorded in process indicator reports to measured changes in risk behavior. Other comprehensive programs should use BSS for overall evaluation but should strive to locate a control area to enable more conclusive evaluation judgments.

 

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