This report covers the FHI AIDS Control and Prevention (AIDSCAP) Project (1991-1997). Volume 2 contains brief summaries of each FHI/AIDSCAP country program or activity.
Table of Contents
Volume 2
Introduction
Africa
Major Countries
- Cameroon
- Ethiopia
- Kenya
- Nigeria
- Rwanda
- Senegal
- South Africa
- Tanzania
- Zimbabwe
Associate Countries
- Côte d'Ivoire
- Lesotho
- Mali
- Mozambique
- Niger
- West Africa
- Zambia
Asia
Major Countries
- India
- Indonesia
- Nepal
- Thailand
Associate Countries
- Bangladesh
- Egypt
- Mongolia
- Morocco
- Philippine
- Sri Lanka
Areas of Affinity
- Indian Subcontinent
- Indonesia/Philippines
- South Pacific Island Nations
- Thai/Cambodia/ Vietnam
- Thai/Lao PDR/Burma
Latin America/ Caribbean
Major Countries
- Brazil
- Dominican Republic
- Haiti
- Honduras
- Jamaica
Associate Countries (See Below)
- Bolivia
- Colombia
- Costa Rica
- Ecuador
- El Salvador
- Guatemala
- Nicaragua
- Peru
- Regional Activities
Volume 1
Latin America/Caribbean, Associate Countries: Bolivia
Epidemiology
Bolivia has a low incidence of HIV/AIDS and is in an excellent position to institute a sustainable STI/HIV/AIDS prevention program that will ensure continued low incidence. The reviewed project had established an ambitious program, using baseline research, the integration of sexually transmitted infection (STI) case management, a behavior change communication (BCC) component, and condom promotion and distribution. A strong basis for expansion of the program is now in place.
Country Overview
In 1991, a comprehensive effort was initiated by USAID/Bolivia to control and prevent the spread of STI/HIV/AIDS. Project activities were originally focused on targeted interventions with high-risk behavior groups in selected cities in the country. In October 1993, an AIDSCAP team conducted a midterm evaluation of this project. The evaluation team interviewed staff of the project, the USAID Mission, the former Secretariat of Health, and nongovernmental organizations to assess the issues and challenges of each component of the project. General findings and recommendations were issued in a final report, which was used to improve the project during its last 15 months.
Accomplishments
The team visited the project sites and conducted extensive interviews with local and international staff from the Ministry of Health, the Centers for Disease Control and Prevention, and the USAID Mission, among others.
The specific areas reviewed included
- STI case management and prevention practices,
- STI and HIV/AIDS sentinel surveillance systems,
- information, education, and counseling components,
- project management and institutionalization,
- condom promotion and distribution, and
- financial management.
The team concluded that the project's strength was in its STI services to registered commercial sex workers. It also concluded, however, that the project lacked a strong communication component, had limited condom promotion coverage, and was reaching a small percentage of the target population. There were also concerns regarding the financial management system and the sustainability of the project due to its limited integration with local institutions. The team produced a report with recommendations to improve the project's different program areas.
Latin America/Caribbean, Associate Countries: Colombia
Epidemiology
Of all South American countries, Colombia ranks third behind Brazil and Argentina in the number of cumulative AIDS cases. The capital, Bogotá, is the geographic center of the Colombian epidemic and home to 39 percent of the country's reported AIDS cases. Nearly two-thirds of cases are among people aged 25 to 44, and more than 90 percent of infections are sexually transmitted. Early in the epidemic, the majority of AIDS cases occurred in men who have sex with men (MWM). In 1990, the male to female ratio of cumulative AIDS cases was 11:1. However, the increasing number of AIDS cases among women indicates that heterosexual transmission is increasing rapidly. By 1995, the male to female ratio among new AIDS cases had decreased to 3.8:1.
Seroprevalence studies in Colombia suggest that the HIV/AIDS epidemic is well-established, particularly among groups engaging in high-risk behaviors. By the year 2000, the number of people living with HIV could reach between 65,000 and 190,000. There may be between 9,000 and 26,000 new AIDS cases by 2000, with as many as 170 AIDS deaths a week.
While core groups such as MWM's and commercial sex workers continue to be at high risk of infection, many female members of the general population are at risk because of the behavior of their regular partners. Of the 13 female AIDS cases treated at one Bogotá hospital in 1996, nine attributed their HIV infection to their husbands (Fundación Forjar, 1996).
Country Overview
At the request of the USAID/Colombia, a team of behavior change communication experts from AIDSCAP traveled to Colombia in May 1992 to conduct an HIV/AIDS needs assessment in order to program USAID mission funds set aside to support HIV prevention activities.
Accomplishments
AIDSCAP conducted an analysis of the national response to HIV/AIDS in order to develop a prevention and control strategy for Colombia. The needs assessment suggested that Colombian decision makers have insufficient knowledge about AIDS, and the knowledge of the general population is often medically inaccurate. Despite public education campaigns, the creation of a National AIDS Program in the Ministry of Health, and the passage of appropriate legislation to protect the rights of people living with HIV/AIDS, there was little awareness of the gravity of the epidemic among policymakers. The lack of public sector commitment was reflected in the minimal resources allocated to prevent the spread of HIV. AIDSCAP determined that a stronger commitment from decision makers in the public and private sectors was crucial to control the rapidly growing HIV/AIDS epidemic in Colombia.
As a result of these findings, AIDSCAP recommended a two-part strategy to initiate HIV/AIDS control and prevention efforts in Colombia. The first component was to develop an AIDS Impact Model to provide key decision makers with accurate information on the extent of the epidemic and the potential socioeconomic impact on Colombia. The second component was to design and implement a public opinion awareness campaign to create an environment conducive to increased funding for HIV prevention on the part of both the private and public sectors.
The public opinion campaign began in October 1992 and continued until March 1993. The campaign published 205,000 newspaper supplements, each with a condom attached, which were included in the December 1 issue of El Espectador, a national daily newspaper. A publicity launch on the eve of the supplement's appearance drew prominent political and journalistic personalities and received extensive media coverage. Other activities included the creation of posters targeting both policymakers and groups at high risk of infection, as well as a Human Rights Day program promoting the rights of people living with HIV/AIDS. It is estimated that 16 million people were reached either directly or indirectly as a result of the campaign.
In 1996, AIDSCAP, in collaboration with the consulting firm Consultores Internacionales en Seguridad Social y Salud, conducted an assessment of the socioeconomic impact of the HIV/AIDS epidemic in Colombia. A team of experts developed and implemented the study. Local staff were trained in modeling techniques and computer programs to obtain economic and epidemiologic projections of the impact of the epidemic. The socioeconomic impact assessment is being used to raise awareness of the need for HIV prevention among public and private sector policymakers.
In addition to these projects, AIDSCAP sponsored the participation of three Colombians at the 1995 USAID HIV/AIDS Prevention Conference in Washington, D.C.
Implementing Partners
- Apoyemonos
- Consultores Internacionales en Seguridad Social y Salud Ltd. (CINSSA)
Latin America/Caribbean, Associate Countries: Costa Rica
Epidemiology
A national study of reproductive health conducted among youth aged 15 to 24 indicated that 31.4 percent of the males and 15 percent of the females aged 15 to 17 engaged in premarital sexual relationships. The first national AIDS survey, prepared in 1991, reported that 94.9 percent of the males interviewed (n=1,671) and 74.6 percent of the females (n=1,584) had initiated sexual activity before they were 20. In their first sexual act, 76.7 percent of the males and 81.6 percent of the females did not use any contraception. While more than 70 percent of the males aged 15 to 19 reported having between 2 and 10 sexual partners, less than 20 percent of the female respondents reported more than one partner.
Country Overview
The Costa Rican government began its National Adolescent Program (NAP) in 1989. NAP's goal is to respond to the needs of Costa Rican adolescents and to help protect them from biological and psychosocial trauma through the efforts of interdisciplinary teams. Despite the high level of knowledge of HIV/AIDS among the adolescent population, further programs are required to change attitudes toward HIV/AIDS as a necessary phase in the adoption of recommended prevention behaviors.
AIDSCAP collaborated with NAP to contribute to the long-term reduction in the incidence of sexually transmitted infection (STI) and HIV/AIDS among this population. The project enabled NAP to develop a model for training and supervising a network of adolescent peer health educators in selected regions of Costa Rica.
Accomplishments
Four workshops were conducted with the goal of increasing knowledge and changing attitudes, beliefs, and practices that place youth at risk of infection. In turn, some of the participants became peer health educators in their communities. A total of 128 adolescents between the ages of 15 and 19 (65 females and 63 males; 60 students and 68 employed) received educational training during the three-day workshops. Approximately 2,060 informative pamphlets on STI/HIV/AIDS, condoms, and self-esteem were distributed directly to adolescents and 6,735 were distributed by peer health educators. A total of 289 activities (video presentations, lectures, group meetings, plays, and one-to-one dialogue) reached 2,970 adolescents during the project.
Two methodological guides were developed, one targeting adolescents and the other targeting adults. The guides stress the importance of a participatory methodology, or a combination of lecture and small-group discussion, in training. A total of 3,000 condoms were distributed through the Adolescent Clinics of Programa Integral del Adolescente. A postworkshop questionnaire was completed by 253 adolescents (50 percent male and 50 percent female). The questionnaire revealed an increased level of knowledge of STI/HIV/AIDS and correct condom use and increased tolerance of people living with HIV/AIDS and of homosexuality.
The experience gained in this project formed the basis for a nationwide program to be undertaken by NAP.
Implementing Partner
- FUNDESIDA/MOH (Departamento de Control de SIDA, Ministerio de Salud)
Latin America/Caribbean, Associate Countries: Ecuador
Epidemiology
Ecuador, like many countries in the region, lacks adequate epidemiologic HIV/AIDS surveillance. As of 1991, only 141 AIDS cases had been reported to the Ministry of Health (MOH), but public health authorities estimate that the actual number of AIDS cases is at least 10 times higher. While the majority of early cases were among men who have sex with men, increasing numbers of female AIDS cases suggest that heterosexual transmission is increasing, in large part because of unprotected commercial sex.
The MOH requires that commercial sex workers (CSWs) be tested for sexually transmitted infections (STIs) and HIV bimonthly in order to obtain and retain legal status. Data obtained from the MOH STI Prevention Unit in Guayas Province indicate that 12 percent of CSWs test positive for syphilis and 60 to 70 percent test positive for gonorrhea. Although HIV seroprevalence has been relatively low, the high prevalence of STIs indicates the potential for a rapid spread of HIV among CSWs and their clients. Many CSWs are unregistered and are not tested for STI/HIV on a regular basis. These unregistered CSWs are at high risk of HIV infection.
Country Overview
As of September 1996, the Pan American Health Organization had recorded 569 cases of AIDS in Ecuador, placing the country in the low-to-middle range of South American nations affected by the HIV/AIDS epidemic. AIDSCAP's aim in Ecuador, therefore, was to maintain the country's relatively low prevalence of HIV/AIDS. With this goal in mind, AIDSCAP assisted the Ecuadorian Red Cross to improve laboratory procedures to improve blood screening and worked with Fundación Futura on a behavior change communication (BCC) project that targeted CSWs. AIDSCAP's most recent intervention in Ecuador consisted of an educational program for CSWs implemented by a family planning association that operates in Guayaquil, the country's commercial center.
Accomplishments
AIDSCAP supported the Asociación Pro-Bienestar de la Familia Ecuatoriana (APROFE), a private, nonprofit affiliate of the International Planned Parenthood Federation (IPPF), Western Hemisphere Region, to implement a project focused on BCC for CSWs and brothel owners. The strategy was to recruit CSWs as peer educators and to obtain support for condom use from brothel owners. A technical team comprised of STI and BCC specialists, a nurse, and an evaluator, conducted 24 risk-reduction workshops with groups of CSWs. The brothel owners also participated in four workshops on STI/HIV/AIDS. In addition, APROFE trained five CSWs as peer educators and 48 CSWs to provide follow-up in the field. APROFE worked closely with the CSW union Primero de Agosto, which represents 3,000 legally registered CSWs, to identify workshop participants and peer educators. An estimated 15,000 unregistered or clandestine CSWs are working in Guayas Province. The project activities took place in three cities where commercial sex is prevalent-Guayaquil, which is Ecuador's main commercial center and largest port, and Milagros and Naranjal, which are cities located in the sugar cane, pineapple, and rice producing regions. These cities are centers of seasonal migration and transport.
APROFE developed a team of peer health educators who held weekly meetings with CSWs and recruited volunteer promoters. The Hermanas Adoratrices, an order of Catholic nuns, supported the project by arranging meetings between APROFE and the CSWs and by providing space for the meetings. The project has trained at least 100 educators; produced and distributed 12,000 printed materials; and reached more than 1,800 CSWs, brothel owners, and clients.
AIDSCAP also supported a project targeting CSWs, their clients, and brothel owners in Quito. The project, titled AIDS Prevention Pilot Program with HighRisk Groups, was implemented by Fundación Futura. This Ecuadorian nongovernmental organization promotes family planning and STI prevention, and has considerable experience in condom social marketing. With backing from the National AIDS Control Program and USAID/Ecuador, Fundación Futura had previously established a pilot project in Guayaquil targeting female CSWs and their clients, brothel owners, and pharmacy workers. The project, based in an MOH clinic serving CSWs, provided BCC and promoted and marketed condoms. With AIDSCAP support, it was replicated at two MOH clinics in Quito and at MOH clinics in Santo Domingo de los Colorados, Milagro, and Quevedo. At least 800 peer educators and bar and brothel owners were trained. During the project, 4,400 CSWs were reached with HIV/AIDS awareness and prevention messages, 10,000 educational materials were distributed, and 74,000 condoms were sold.
The Red Cross of Ecuador implemented a project under AIDSCAP to develop a long-term national program for quality assurance in HIV testing, and the Red Cross worked with every laboratory performing HIV testing in Ecuador. The project established ongoing laboratory inspection and proficiency testing programs, improved data management and reporting capabilities, and trained laboratory inspectors in identifying the technical needs of laboratories.
AIDSCAP also funded activities that developed materials for World AIDS Day.
Implementing Partners
- Asociación Pro-Bienestar de la Familia Ecuatoriana (APROFE)
- Fundación Futura
- Ecuadorian Red Cross
Latin America/Caribbean, Associate Countries: El Salvador
Epidemiology
The first case of AIDS in El Salvador was identified in 1984. By 1996, nearly 1,800 cases of AIDS had been reported to the Ministry of Health (MOH), although it is believed that the actual number of cases is significantly higher. El Salvador has many of the social conditions conducive to a serious epidemic, such as widespread commercial sex, significant migration, and post-civil war social disruption. Inaccurate knowledge of transmission and discrimination against people living with HIV/AIDS impede prevention efforts. In 1995, a socioeconomic impact study conducted by AIDSCAP found that, in the absence of interventions, El Salvador would soon experience a substantial number of infections, which would have a negative impact on both the health sector and the national economy. With sexual transmission the predominant mode of transmission, the epidemic was expected to affect the young, the working population, and housewives.
Country Overview
In 1995, USAID/El Salvador requested the assistance of AIDSCAP to support the Educational Program in AIDS Prevention strategy developed by the Pan American Health Organization. The AIDSCAP project, implemented by the nongovernmental organization Fundación Nacional de Prevención, Educación y Control del VIH/SIDA, developed materials and trained health educators from the Instituto Salvadoreño de Seguro Social (ISSS) and the MOH to conduct behavior change communication interventions in the workplace. The goal of this project was to increase knowledge of HIV/AIDS and reduce high-risk behavior among factory workers in San Salvador.
Accomplishments
AIDSCAP/El Salvador trained 25 health educators from the ISSS in data collection, interviewing techniques, group and participatory education techniques, and in the use of the new educational materials. In addition, a baseline study was conducted with 499 participants from 50 factories, as well as a qualitative study with 47 focus groups, to develop messages and educational materials.
Based on the findings of these studies, the project produced 500,000 pamphlets, 600,000 flyers, 20,000 posters, 500 flipcharts with instruction manuals, 500 copies of a manual on educational methodology, 5,000 copies of a promotional calendar, 25,000 notebooks, and 500 T-shirts for the facilitators.
Key Outcome Data
Knowledge, attitudes, beliefs, and practices surveys conducted at the beginning and end of the project indicated that
- knowledge of means of infection increased from 70 to 94 percent.
- knowledge of two means of protection increased from 24 to 37 percent.
- knowledge that healthy looking people can be carriers of HIV/AIDS increased from 62 to 81 percent.
- condom use increased from 18 to 30 percent.
Implementing Partner
- Fundación Nacional de Prevención, Educación y Control del VIH/SIDA (FUNDASIDA)
Latin America/Caribbean, Associate Countries: Guatemala
Epidemiology
HIV/AIDS prevalence in Guatemala has increased dramatically since the first AIDS case was reported in 1984. As of July 1994, 1,280 cases had been reported to the National AIDS Prevention and Control Program of the Ministry of Health. As in many developing countries, underreporting by physicians and a deficient surveillance system make existing data unreliable. Conservative figures estimate that there are between 4,000 and 7,000 AIDS cases in Guatemala. The first cases were reported among men who have sex with men (MWM). While MWM continue to experience high rates of infection, more recent data suggest that heterosexual transmission is increasing rapidly, as heterosexuals now account for approximately 65 percent of cases. As the epidemic has evolved, a greater number of cases have been reported among women. Women aged 15 to 19 now account for more cases than men in that age group. As greater numbers of women of reproductive age have become infected, the number of cases of vertical transmission have also increased.
Country Overview
HIV/AIDS is not perceived as a serious threat to the overall well-being of Guatemala because its spread there has been much slower than in other countries. As the epidemic is still at an early stage, prompt action can help avoid an escalation in prevalence. Therefore, using a rapid assessment approach, an exploration of the demographic, sociocultural, political, and economic effects of the epidemic in Guatemala was undertaken to mobilize policymakers to make informed decisions about preventing HIV/AIDS.
Accomplishments
The assessment identified many weaknesses in the current response to the epidemic. In the area of epidemiology, Guatemala lacks national guidelines for the diagnosis of HIV/AIDS, standards for the diagnosis and treatment of sexually transmitted infections (STIs), and a national STI control program. In addition, the health system's list of essential drugs is outdated and does not include many basic STI treatment drugs. To date, HIV/AIDS education efforts have been inadequate. Behavior change communication activities have emphasized information dissemination rather than behavior change, and existing educational materials are inappropriate for illiterate audiences.
Based on the results of this assessment, AIDSCAP recommended the development of a multidisciplinary and multisectoral national strategy. An important component of this strategy is integrating HIV/AIDS prevention messages into secondary school curricula, as well as integrating HIV/AIDS and STI control and prevention with maternal and child health services. AIDSCAP recommended the development of a surveillance system based on anonymous case reporting and sentinel surveillance. The study's authors hope that Guatemala's HIV/AIDS strategy will employ prevention and control activities that have proven effective in curbing sexual transmission of HIV.
In February 1995, USAID and AIDSCAP conducted a 3-week workshop for epidemiologists, physicians, and economists from Guatemala, El Salvador, and Nicaragua. The workshop trained participants in the use of computer models and indirect costing methodologies to estimate the impact of the epidemic. Workshop participants were also trained in techniques of effective presentation of study findings to policymakers in both the public and private sectors.
Implementing Partner
- PANOS Institute
Latin America/Caribbean, Associate Countries: Nicaragua
Epidemiology
The first AIDS case in Nicaragua was reported in 1987. To date, with approximately 300 cumulative AIDS cases recorded, Nicaragua's epidemic may seem minor. However, like many other countries in Central America, Nicaraguan records suggest considerable underreporting of cases. A 1993 Pan American Health Organization report estimates that the number of HIV/AIDS cases in Nicaragua may be as high as 5,000. A more recent assessment by the Ministry of Health (MOH) estimated the potential number of infected individuals closer to 15,000.
The HIV/AIDS epidemic in Nicaragua is comparable to the epidemic in other Central American nations. Eighty percent of the reported cases are contracted through sexual transmission, 19 percent through the exchange of infected syringes between drug addicts, and 1 percent through the transfusion of infected blood. Fifty-four percent of the people affected were heterosexual, 40 percent were men who have sex with men, and the remaining 6 percent were children. The male to female ratio for these cases was 6:1. However, it should be noted that the ratio was 2:1 for the 30 cases reported during the first semester of 1995.
Country Overview
Nicaragua is located between Costa Rica and Honduras, and has a population of 4.2 million. Approximately 45 percent of the population are under 15 years of age. The country and its economy were devastated by civil war and mismanagement in the late 1970s and early 1980s. Recovery has been slow, and unemployment is a continuing problem. Although reported AIDS cases in Nicaragua are low, many factors, including migration, poverty, and increasing levels of commercial sex, could lead to an explosive epidemic by the end of the century. Public reaction to HIV/AIDS is often discriminatory or indifferent.
At the beginning of 1995, the USAID Mission in Nicaragua requested AIDSCAP to develop HIV/AIDS prevention and control activities in the country. The first stage of the activities was a qualitative study to support a national strategy for the prevention of HIV/AIDS. The results of the investigation indicated that misinformation about transmission and prevention was a major problem. In general, condom use was very low. The ineffectiveness of the traditional epidemiological focus on high-risk groups was also revealed by the study; therefore, a greater range of groups should have been considered to be at high risk of HIV/AIDS infection and included in education and prevention interventions. Based on this study, a behavior change communication (BCC) strategy was initiated.
AIDSCAP/Nicaragua consisted of four program components, each one designed to reach specific audiences. The objectives of the components were the following:
- Influence the social environment through BCC in order to create the necessary support for changes in high-risk sexual behavior leading to the prevention of HIV/AIDS.
- Develop, organize, and support local HIV/AIDS prevention programs.
- Build the capacity of local institutions to develop and implement HIV/AIDS control and prevention activities.
- Establish, through BCC, the concept of vulnerability to HIV/AIDS among targeted audiences, eventually changing attitudes and practices to reducing sexual risk taking.
Accomplishments
The major accomplishments of AIDSCAP were in the areas of research, policy, and BCC. The project supported sentinel surveillance and qualitative behavioral research, which were the foundation for the national strategy. The BCC activities conducted by the project included rallies, a music video, seminars, beachfront education, video drama, and cultural events to raise awareness and promote the human rights of people living with HIV/AIDS.
AIDSCAP also contracted a nongovernmental organization (NGO) owned by professional songwriters, singers, and musicians widely recognized in the Hispanic world, to develop a music video aimed at counteracting the stigma against people living with HIV/AIDS.
The AIDSCAP-supported projects trained more than 1,000 persons, educated approximately 900,000 persons, and distributed nearly 60,000 pieces of BCC material in approximately 6 months. AIDSCAP supported efforts to promulgate a new law relating to the human rights of people living with AIDS. More than 60,000 condoms were distributed during the project.
AIDSCAP also supported a coalition of NGOs working to pass a law that would protect the human rights of people living with HIV/AIDS. The law was approved by a majority of the Senate and signed into law by the president of Nicaragua in December 1996.
Implementing Partners
- Casa de la Mujer "Mercedes Rosales" AMNLAE-Estelí
- Casa de la Mujer "Sonia Bello" AMNLAE-Rivas
- Centro de Asesorías y Servicios Mujer y Familia
- Centro de Intercambio Cultural y Técnico (CICUTEC)
- Cruz Roja Nicaragüense
- Fundación Mejía Godoy
- Fundación Nimehuatzín
- Pro-bienestar de la Familia Nicaragüense (PROFAMILIA)
- Socio-Medical Research Associates, Inc.
Latin America/Caribbean, Associate Countries: Peru
Epidemiology
The first case of AIDS in Peru was identified in 1983. Since 1983, cases have been reported in all regions of the country, and the number of AIDS cases reported is increasing exponentially. The cumulative number of cases reported increased from 878 in 1993 to 3,697 in 1995, a four-fold increase. While this increase reflects an improved case reporting system, it also indicates that the number of AIDS cases is considerable and that the epidemic is growing steadily. Seroprevalence studies suggest that the HIV epidemic is well-established in Peru, particularly among high-risk populations. Although only 3,697 AIDS cases had been reported as of 1995, there may be as many as 7,000 persons living with AIDS and up to 77,000 people living with HIV in the country. In other words, for every reported AIDS case in Peru, there may be one unreported AIDS case and up to 21 unreported HIV infections.
Data gathered by the Sexually Transmitted Disease and AIDS Control Program (PROCETS) of the Ministry of Health indicate that metropolitan Lima-Callao is home to 86 percent of the country's reported AIDS cases. The vast majority (83 percent) of Peru's AIDS cases have occurred among the economically active 20-to-49 age group. The prevalence of AIDS cases among people in this group suggests that many Peruvians are infected during adolescence. Almost 95 percent of HIV/AIDS infections are due to sexual transmission; blood transfusions or perinatal transmission account for the remainder. While men who have sex with men have experienced high rates of infection, increasing numbers of AIDS cases among women suggest that heterosexual transmission is becoming more common. The current male to female ratio of HIV/AIDS cases, based on cumulative reported HIV/AIDS cases, is 6:1.
Country Overview
Peru has one of the weakest public health infrastructures in Latin America. Access to health care is extremely limited and the health reporting system is poor. Reliable epidemiologic and economic data are also limited. Despite the limitations of available data, however, Peru's HIV/AIDS epidemic is rising steadily and has become established among a cross section of Peruvian society.
As part of an effort to contain the growth of the HIV/AIDS epidemic in Peru, USAID/Peru is designing the SIDAYUDA results package. The goal of the package is to raise the awareness and commitment of Peruvian political leadership to encourage a coordinated, multisectoral response to the epidemic. AIDSCAP was requested to assist in the design of this prevention effort.
Accomplishments
AIDSCAP completed an epidemiological computer modeling of the HIV/AIDS epidemic, as well as a rapid assessment of its socioeconomic impact of the epidemic. This assessment was based on a review of existing epidemiologic, demographic, and economic data.
The projections of the study estimate that between 50,000 and 77,000 Peruvians were infected with HIV as of 1995. By the year 2000, this number could reach 180,000, and there may be as many as 230 new AIDS cases and 144 AIDS deaths per week in the country. By the year 2005, projections suggest that a total of 65,000 to 100,000 individuals will have died of HIV/AIDS. Because the epidemic is prevalent among individuals aged 20 to 49, many of whom have young children, the impact on the work force will be devastating both to the national economy and to individual families. Growing numbers of AIDS orphans will need to be cared for by grandparents or other family members. Orphans without families will place a burden on already strained public services.
The AIDSCAP report's primary recommendation is to strengthen Peru's national HIV/AIDS prevention effort by developing and increasing awareness of the magnitude and impact of the epidemic, in order to generate more support and resources for HIV/AIDS programming. The socioeconomic impact study data can be an effective tool for raising policymakers' awareness of HIV/AIDS and to develop and sustain support for comprehensive prevention interventions. This approach relies on the strategic dissemination of study findings and the presentation of reliable data. Using the HIV/AIDS impact assessment to develop a short- and long-term policy strategy can strengthen the commitment of policymakers and others who influence policy to increase resources for HIV/AIDS prevention and control.
Coordinated and comprehensive HIV/AIDS prevention interventions provide an opportunity to slow the growth of Peru's epidemic. The material and political commitment of Peruvian leaders to a comprehensive and multisectoral prevention strategy will contribute not only to slowing the growth of the epidemic, but also to reducing the negative impact of HIV/AIDS on families and communities throughout the country.
Latin America/Caribbean, Associate Countries: Regional Activities
Epidemiology
El Salvador, Nicaragua, and Costa Rica all share a border with Honduras, one of the countries with the highest incidence of HIV/AIDS in Latin America. Rapid increases in commercial traffic traveling the regional highways has resulted in a sharp rise in commercial sex work in towns close to the highways. This situation has, in turn, increased the risk of the epidemic spreading from Honduras into the other countries' border towns, then continuing on to the inner cities. Therefore, it was of utmost importance to raise awareness among policymakers of the possible consequences of an unchecked and ignored epidemic in order to stimulate the development of national policies in support of HIV/AIDS prevention programs.
Accomplishments
Socioeconomic Impact Studies
At the request of the USAID missions in the three countries, AIDSCAP conducted a series of socioeconomic impact studies in El Salvador, Guatemala, Honduras, and Nicaragua in collaboration with representatives from governmental and nongovernmental organizations (NGOs). The main purpose of the assessments was to prepare an overview of findings on the epidemiological profile of HIV/AIDS in the region. They also analyzed the response of the public and private sectors, NGOs, and international donors in confronting the epidemic. The results provided policymakers with concrete information about the potential impact of an HIV/AIDS epidemic in the region.
AIDSCAP's impact analyses raised awareness of HIV/AIDS as a multisectoral development issue, rather than merely a health issue. As a result of the impact assessment, USAID decided to make Honduras a priority country for prevention and control efforts under the AIDSCAP Project and secured commitment from the Government of Honduras. In addition, a video production in Honduras was used to initiate workplace prevention programs in the private sector. The study in El Salvador led to increased funding for HIV/AIDS prevention programs and to the creation of new workplace sexually transmitted infection (STI) clinics.
Regional Workshops
AIDSCAP sponsored several satellite meetings of the X Latin American Congress on STIs and the IV Pan-American Conference on AIDS in Santiago, Chile, during November 1995. These included an international media seminar implemented by the PANOS Institute and the Corporación Chilena de Prevención del SIDA (CChPS) and two workshops conducted by the Civil-Military Alliance to Combat HIV/AIDS and AIDS.
Journalists' Training
The objective of the one-day media seminar held by the PANOS Institute/CChPS was to promote accurate reporting of HIV/AIDS issues and to facilitate future contacts between the media and key individuals attending the conference. Twenty-three journalists from print and broadcast media representing 11 countries participated in the seminar.
Civil-Military Collaboration
The Civil-Military Alliance implemented two workshops in connection with the STD/AIDS conference. The first session's objective was to disseminate information on regional models that demonstrate the types of prevention activities possible through civil-military collaboration. The second meeting, Planning Session for Latin America and the Caribbean: Military and Civil-Military Possibilities, was attended by high-ranking representatives from seven nations' military and for civil institutions. The purpose of this session was to develop a strategy and work agenda for civil-military collaboration on HIV/AIDS prevention in Latin America and the Caribbean.
As a sequel to the Chile conference, the Civil-Military Alliance drafted a policy and strategy paper, titled "HIV/AIDS Strategy in Latin America and Africa: Military and Civil-Military Policies and Issues," to develop a framework for a collaborative civil-military HIV/AIDS agenda and to improve strategies for the operationalization of this agenda. The paper, which also examined the important role women play in the civil-military collaboration, was presented in Honduras at a July 1997 regional policy and strategy seminar on gender issues. It was disseminated to all participants in the Chile conference, all ministries of health and defense in the region, and leading NGOs, and was published in the Civil-Military Alliance newsletter.
Gender Initiatives
Perhaps the most significant step taken toward institutionalizing gender in AIDSCAP programs was the regional gender and STI strategy. In this three-tiered strategy, each AIDSCAP program in the region developed and implemented a high-impact STI research, intervention, or training pilot project, participated in gender training for senior managers to enhance gender analysis skills building, and ultimately participated in a 2-day regional conference for partner countries. This workshop was attended by 25 participants, including AIDSCAP senior management and implementing agency officials from the Dominican Republic, Honduras, Brazil, Bolivia, Peru, and Nicaragua. As a result, AIDSCAP staff who were establishing their own indigenous NGOs drafted gender value statements for these nascent organizations that communicated their organizational beliefs about gender. Regional guidelines were also developed for the implementation of gender-oriented STI/HIV/AIDS prevention activities. Finally, partnerships were established between Brazil and Bolivia, and between Honduras and Nicaragua to share lessons learned in gender-sensitive HIV/AIDS programming.
Gender and STIs
As a part of the AIDSCAP Women's Initiative, the Centre for Development and Population Activities (CEDPA) trained the project's senior managers in the region with the knowledge and skills needed to facilitate incorporation of gender into STI/HIV/AIDS prevention activities. The three AIDSCAP resident advisors and three senior program officers participated in the 2-day gender and STI training in January 1997. The training focused on gender sensitization, analysis, and skill building, and on increasing technical knowledge, with particular emphasis placed on the implications of gender on STI awareness, treatment, and care.
Gender and STIs: A Participatory Approach
The principal goal of the AIDSCAP-supported project implemented by the Asociación de Municipios de Honduras (AMHON) was to increase women's power to make decisions about their reproductive health, especially with regard to STI/HIV/AIDS prevention, by training 50 women in leadership and reproductive health. A central component of this empowerment was to strengthen women's knowledge, attitudes, beliefs, and practices (KABP) surrounding STI/HIV/AIDS. Projecto Mujer also sought to raise awareness of gender issues in STI/HIV/AIDS prevention among the staff at nearby health clinics.
This project succeeded in integrating STI/HIV/AIDS education with AMHON's other leadership and training activities. In order to design the training, AMHON carried out a qualitative study examining sexual decision making, access to and perceptions of reproductive health services, and KABP regarding STI/HIV/AIDS. The researchers conducted focus groups with a total of 55 women. Seven indepth interviews with key informants provided more detailed information on these issues. In addition, AMHON conducted a survey of 260 women attending MOH clinics.
The qualitative data provided valuable insights into some of the constraints facing women as they seek access to reproductive health care services and try to protect themselves from STI/HIV/AIDS. Data indicated a relatively low level of knowledge regarding many reproductive health issues. Participants and their male partners had little knowledge, not only of STI/HIV/AIDS, but also of reproductive events such as the menstrual cycle, contraception, pregnancy, and menopause. The survey data also provided feedback on the perceived quality of local reproductive health services and suggested ways to improve them. Many women surveyed felt that obstetrical care was particularly inadequate.
Workplace Prevention
AIDSCAP supported the Mexican Federation of Private Health and Community Development Associations (FEMAP) to improve HIV/AIDS prevention services for maquiladora workers in the Mexican border city of Juárez. In a previous phase of the project, peer health educators had been trained in five maquiladoras. At the end of the first year, labor problems required FEMAP to withdraw activities from one of these maquiladoras and initiated activities in another maquiladora. The renewal of the project focused on consolidating the network of 60 peer health educators, which reached 3,515 workers at any one time. Activities were aimed at increasing peer health educators condom sales and prevention communication skills. During the project, 19,930 condoms were distributed
