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 (See Below)
- Brazil
- Dominican Republic
- Haiti
- Honduras
- Jamaica

Associate Countries
- Bolivia
- Colombia
- Costa Rica
- Ecuador
- El Salvador
- Guatemala
- Nicaragua
- Peru
- Regional Activities

Volume 1

Latin America/Caribbean, Major Countries: Brazil

Epidemiology

Brazil has the largest HIV/AIDS epidemic in South America. The country is home to 50 percent of the population of South America but has 75 percent of the region's AIDS cases. The first AIDS case was reported to the Ministry of Health (MOH) in 1982; several earlier cases were retrospectively identified. By May 1997, 110,845 AIDS cases had been reported to the Pan American Health Organization. While many countries have higher per capita AIDS incidences, only the United States has reported more cumulative AIDS cases. The HIV/AIDS epidemic in Brazil is concentrated in highly populated urban areas, such as São Paulo, Rio de Janeiro, Pôrto Alegre, Santos, and Belo Horizonte.

Men who have sex with men (MWM) have experienced high rates of infection since the beginning of the Brazilian epidemic. In 1994, HIV seroprevalence among MWM was 24 percent in Rio de Janeiro and 28 percent in Pôrto Alegre. While seroprevalence remains high among MWM, the proportion of AIDS cases occurring among this population decreased from 50 percent in 1988 to 23 percent in 1996. The proportion of cases due to heterosexual transmission increased from 5 percent in 1988 to 31 percent in 1996. Consequently, the male to female case ratio has decreased from 9:1 in 1987 to 3:1 in 1996.

Sentinel surveillance has documented high HIV prevalence among other at-risk populations. Studies completed in the early 1990s show that 6 percent of commercial sex workers (CSWs) serving upper-income clients in São Paulo were infected with HIV. Among CSWs serving low-income clients, seroprevalence ranged from 12 percent in São Paulo to 27 percent in Santos, a major port. Sexually transmitted infection (STI) clinic attendees also have high rates of infection. Seroprevalence among STI patients was 15 percent in São Paulo and 23 percent in Rio de Janeiro. Studies of STI patients in smaller cities have found lower rates of infection, ranging from 1 percent in Aracaju to 9 percent in Salvador. Injecting drug use also accounts for a substantial proportion of HIV infections in Brazil. Approximately 19 percent of cumulative AIDS cases have occurred among injecting drug users (IDUs). Sentinel surveillance has found HIV prevalence as high as 65 percent among IDUs in several cities.

While seroprevalence is higher among those groups considered at-risk, rates of HIV infection are increasing among the general population. Seroprevalence among pregnant women, often used as a proxy for sero- prevalence among the general population, ranges from 0 percent in rural states to nearly 3 percent in the city of Pôrto Alegre. As the number of infected women has increased, the proportion of AIDS cases due to vertical transmission has also increased, from 0.5 percent in 1985 to more than 3 percent in 1996. The MOH estimates an HIV seroprevalence of 1 percent among men and women aged 15 to 49 in the states of São Paulo and Rio de Janeiro .

In Brazil, the only STIs subject to epidemiologic surveillance are congenital syphilis and AIDS. As a result, little is known about the prevalence of other STIs, such as gonorrhea, chlamydia, or primary and secondary syphilis. As in many settings, asymptomatic infection among women and self-treatment by men contribute to high STI prevalence in Brazil. Studies on STIs in CSWs found point prevalence of 66 percent in São Paulo and 69 percent in Santos. These rates are worrisome because they indicate high-risk behavior among CSWs and because concomitant STI infection can greatly increase HIV transmissibility.

Country Overview

Brazil is the largest and most populous country in Latin America and the fifth largest and most populous country in the world. Seventy-seven percent of Brazil's population of 160 million live in urban areas. The cities São Paulo and Rio de Janeiro rank third and ninth, respectively, among the world's largest cities. Since independence, Brazil has often experienced political instability and has been subject to several military dictatorships. Although Brazil has relatively low rates of unemployment, the disparity between the upper and lower socioeconomic groups is among the largest in the world.

Cultural factors influencing the HIV/AIDS epidemic include the extreme alienation of the gay community, which often leads to low self-esteem, fatalistic attitudes about HIV/AIDS, and sexual risk taking among this population; traditional gender roles that often limit communication about STI/HIV prevention and impede women's ability to negotiate condom use; the acceptance of multiple sexual partners for men; abuse of alcohol and other drugs; rapid urbanization; and the marginalization of Brazil's poor. In addition, economic necessity forces many women and girls into commercial sex work.

USAID identified Brazil as a priority country for HIV/AIDS prevention in 1992, after completion of the AIDSCOM and AIDSTECH projects. The goal of the AIDSCAP program was to reduce the incidence of sexually transmitted HIV infection in Brazil. AIDSCAP/Brazil identified three strategies to achieve this goal:

• reduce sexually transmitted infection prevalence by improving STI clinical services, expanding services to new clinics, and increasing use of new and existing STI clinics by creating a referral system.
• reduce high-risk sexual behavior among the target groups through behavior change communication (BCC).
• increase condom use by improving accessibility, availability, and affordability of condoms.

AIDSCAP/Brazil targeted male and female CSWs, MWM, STI patients and their partners, men away from home , women, and youth. The states of São Paulo and Rio de Janeiro were the geographic focus of the interventions; however, during the final year of the project, AIDSCAP expanded its interventions into the impoverished northeast, which has a rapidly growing HIV/AIDS epidemic.

Accomplishments

Strengthening STI Services

The STI component of AIDSCAP/Brazil employed several strategies to decrease STI prevalence. Recognizing the importance of surveillance to STI control efforts, AIDSCAP supported the development of a health information system in Santos and Rio de Janeiro. Second, AIDSCAP worked to improve STI diagnosis and treatment by training clinic staff in the syndromic management of STI. AIDSCAP/Brazil translated an STI manual entitled Control of Sexually Transmitted Diseases: A Handbook for the Design and Management of Programs, and published nearly 10,000 copies in Portuguese. This manual is intended for use in Portuguese-speaking Africa as well as in Brazil. In addition, AIDSCAP supported the development of a newsletter on STIs for health professionals.

Approximately 2,000 health care professionals from Rio de Janeiro, Santos, Ceará, and Bahia were trained in syndromic management and gender sensitivity. AIDSCAP also supported the decentralization of STI services and the creation of new clinics. In Santos, the number of STI treatment facilities increased from 1 to 22 over the life of the project. STI treatment is now available at every public health clinic in the city. BCC campaigns emphasized appropriate treatment-seeking behaviors among target audiences, increasing demand for STI services. Finally, AIDSCAP worked with the MOH to improve STI drug logistics.

Condom Promotion and Distribution

The condom promotion component of AIDSCAP/Brazil exceeded its goals for distribution and sales. During the life of the AIDSCAP program, 14.8 million condoms were given away free-of-charge and 72 million were sold through condom social marketing programs. AIDSCAP/Brazil contracted with DKT do Brazil to develop and market a new brand of condom, called Prudence. Prudence condoms were advertised on television, radio, and billboards and promoted by AIDSCAP's other implementing agencies. This affordably priced and well-advertised condom created competition in the condom market, which forced other condom manufacturers to aggressively market condoms. As a result, annual condom consumption increased from 50 million to 200 million between 1992 and 1996. Prudence is now the third largest brand in Brazil.

Behavior Change Communication

The BCC component of the AIDSCAP/Brazil was characterized by innovative approaches to educational interventions. BCC activities used a variety of media, such as videos, brochures, posters, radio programs, and street theater to communicate messages about STI/HIV/AIDS prevention to the target audiences. Behavior change messages included partner reduction, consistent and correct condom use, and appropriate and timely treatment for suspected STIs. During the life of the project more than 16,000 people were trained and more than 1.3 million people were educated. In addition, 7.8 million educational materials were distributed.

Capacity Building

AIDSCAP's provision of technical assistance and resources to implementing agencies engaged in HIV prevention in Brazil resulted in significant organizational and institutional development. Specifically, AIDSCAP noted the following trends in a study of organizational development conducted in December 1996:

• Increased demand for technical services from AIDSCAP implementing agencies.
• Increased use of monitoring and evaluation information for project planning and implementation.
• More effective financial management and systems in implementing agencies.
• Improved coalitions, involving stakeholders and counterpart organizations, for program implementation and policy development.

Conclusions about the sustainability of initiatives is premature. However, the institutionalization of AIDSCAP's strategies and techniques, the scaling up of AIDSCAP pilot projects and reproduction and adaptation of its materials, and the improved funding environment for HIV/AIDS prevention in terms of both public and private sector support are promising for future interventions. Encouragingly, Associação Saúde da Família (ASF), the NGO that served as the AIDSCAP office in Brazil, has received funding from the Brazilian government, U.S.-based private foundations, and the private sector to continue its prevention activities. ASF has implemented a high-profile HIV/AIDS fund-raising campaign targeting the Brazilian general population.

Key Outcome Data

In order to evaluate the effectiveness of AIDSCAP interventions, surveys on STI/HIV/AIDS knowledge, attitudes, beliefs, and practices (KABP) were conducted with several target groups before and after the interventions. In the preintervention surveys, awareness of HIV/AIDS was nearly universal among all target groups, but knowledge of specific means of prevention and perception of personal risk was much lower. Qualitative data from in-depth interviews and focus group discussions were also collected.

Postintervention surveys showed improved KABP among the target groups. Among MWM in Rio, knowledge that condoms can prevent HIV transmission increased from 71 to 93 percent. While few MWM reported reducing their number of partners, many reported increased condom use or avoiding penetrative sex with casual partners. The proportion of MWM reporting consistent condom use increased from 60 percent in 1993 to 89 percent in 1995. Among CSWs, knowledge that HIV can be transmitted through vaginal intercourse increased from 79 to 95 percent, and reported consistent condom use with clients increased from 57 percent in 1991 to 93 percent in 1997. More than 96 percent of CSWs interviewed had condoms with them at the time of the interview. Reported condom use with regular partners also increased substantially, from 12 to 22 percent, though it remains low. Many CSWs reported that alcohol use sometimes interfered with their ability to enforce condom use with clients.

Adolescents reported fewer misconceptions about HIV/AIDS in the postintervention surveys. Awareness of the asymptomatic nature of HIV infection increased from 76 to 90 percent among this population, although knowledge that other STIs can be asymptomatic was much lower. Reported consistent condom use increased from 25 to 40 percent among adolescent females and from 40 to 77 percent among males in this age group. This is a significant increase over control areas: the most recent Demographic and Health Survey notes that only 20 percent of Brazilian women aged 15 to 19 use condoms. Men away from home reported a decrease in sex with casual partners, from 20 to 14 percent, and increased condom use with casual partners.

Special Features

The AIDSCAP/Brazil program was characterized by innovative approaches to potential constraints. A position paper written by DKT do Brazil is credited with the Brazilian president's decision to decree a yearlong tax holiday on the 60 percent duty levied on imported condoms. The duty was reimposed after one year, but at a much lower rate of 10 percent.

AIDSCAP/Brazil leveraged approximately $4 million in private sector investments, which greatly increased the sustainability of project activities. DKT International provided nearly $2 million worth of condoms to condom promotion projects. A number of companies, including Levi-Strauss, Unilever, publicity agencies, and several fashion magazines, provided in-kind contributions that furthered prevention activities. With support from the Brazilian postal service and the MOH, an AIDS awareness postal stamp was created showing the red ribbon symbol superimposed on a condom. A T-shirt, "Wear for a Cure," also raised awareness of HIV/AIDS among the general population. The popular women's magazine Claudia collaborated with AIDSCAP by publishing a series of monthly articles about HIV/AIDS. This contribution allowed HIV prevention messages to reach Claudia's 700,000 readers.

Formative research and program evaluation were also key components of the AIDSCAP program in Brazil. An important study on the acceptability of the female condom concluded that this method increased the chances of successful condom negotiation and safer sex, and offered an alternative contraceptive option for women wishing to prevent pregnancy. Study participants were motivated not only to use the female condoms, which were provided free of charge during the study, but also to purchase the device after the study's completion.

Implementing Partners

Associação Brasileira Interdisciplinary de AIDS (ABIA)

Appropriate Health Resources and Technologies Action Group Ltd. (AHRTAG)

Association for the Prevention and Treatment of AIDS (APTA)

Center for AIDS Prevention Studies, University of California at San Francisco (CAPS)

Childhope

DKT do Brazil/Population Services International (PSI)

Implementing Agency for Cooperation and Training (IMPACT)

Instituto de Estudos da Religião (ISER)

John Snow, Inc. (JSI)

Organização de Apio ao Portador do Virus da AIDS (OASIS)

State University of New York (SUNY)

União Brasileira Contra as DST

Women, Children, Citizenship & Health

Latin America/Caribbean, Major Countries: Dominican Republic

Epidemiology

HIV/AIDS has been well established in the Dominican Republic since the mid-1980s. Between 1983 and 1996, 3,289 cases of AIDS were reported to the national AIDS control program, Programa de Control de Enfermedades de Transmisión Sexual y SIDA (PROCETS). PROCETS estimates the actual number of AIDS cases to be as much as 70 percent higher. While men who have sex with men (MWM) have experienced high rates of infection, heterosexual contact is the most common mode of transmission in the country, accounting for more than 80 percent of infections. Seroprevalence among pregnant women, often a harbinger of an epidemic in the general population, has increased steadily from 0.7 percent in 1991 to 2.2 percent in 1996. Certain areas of the country have been more affected than others; in 1996, the Puerto Plata region reported HIV seroprevalence of 8 percent among women seeking antenatal care. High rates of HIV infection have also been found among those groups traditionally considered at-risk, such as MWM (12 percent), commercial sex workers (CSWs) (7 percent), and sexually transmitted infection (STI) clinic attendees (7 percent ) The male to female case ratio has dropped from 7:1 in 1984 to 2:1 in 1996, suggesting an increasingly heterosexual epidemic.

Country Overview

Located in the western Caribbean, Hispaniola is the second-largest island in the Antilles. The Dominican Republic (DR) occupies the eastern two-thirds of the island, while Haiti occupies the remainder. The country has 8.2 million inhabitants, most of whom are of mixed Spanish and African ancestry, although a minority predominantly of European descent comprises the country's political and economic elite. Tourism has become increasingly important to the Dominican economy, and agricultural production is reliant on Haitian labor, as large numbers of Dominicans move from rural to urban areas and to the United States.

Several structural factors contribute to the spread of HIV/AIDS in the Dominican Republic. Urbanization, Haitian immigration, and seasonal migration to the United States have led to increased sexual risk taking and increased contact with high-prevalence populations. The marginalization of poor neighborhoods has also increased sexual risk taking, especially among youth. Alcohol abuse also plays an important role. Limited economic opportunities for women lead many to engage in commercial sex, and social and religious barriers to condom use hinder the widespread adoption of safer sex practice.

The Dominican Republic became an AIDSCAP associate country in 1992, following completion of the AIDSTECH and AIDSCOM projects. Epidemiological projections that year estimated that by the year 2000 as many as 5 percent of the adult population, or 300,000 persons, would be infected with HIV. In 1992, USAID changed the status of the Dominican Republic from an associate to a priority country, greatly increasing both funding and technical support for HIV/AIDS prevention.

The goal of the AIDSCAP program was to reduce the incidence of sexually transmitted HIV infection in the Dominican Republic. AIDSCAP/DR identified three strategies to achieve this goal:

• To decrease the prevalence of sexually transmitted infections (STIs) through improved diagnosis, treatment, and prevention.
• To increase condom use among target groups and the general population by expanding access, availability, and acceptability.
• To reduce sexual risk taking among target groups through behavior change communication (BCC).

AIDSCAP/DR targeted MWM, CSWs, adolescents and young adults, people in the workplace, and family planning clients as groups at risk of HIV infection.

Accomplishments

The AIDSCAP/DR program provided financial support and technical assistance to 15 nongovernmental organizations (NGOs). These NGOs conducted behavioral research, implemented educational interventions, promoted condom use, and worked to improve STI services. Support of governmental agencies, including the national laboratory and PROCETS, strengthened epidemiological surveillance, improved the government's ability to respond to the HIV/AIDS epidemic, and led to the promulgation of a national AIDS law.

AIDSCAP/DR implemented BCC subprojects ranging from person-to-person educational interventions to a mass media campaign targeting youth that aired on Dominican television and radio. These subprojects trained 21,000 people, educated nearly 930,000, and distributed approximately 1.5 million educational materials. The mass media campaign aired nearly 500,000 TV and radio spots.

The STI component of the AIDSCAP program worked to decrease the prevalence of STIs by upgrading clinic and laboratory facilities, improving drug logistics, and developing STI treatment protocols. Recognizing that the Dominican health system had limited resources, AIDSCAP/DR developed an algorithm for the syndromic management of STIs. Evaluation showed the algorithm to be effective, and 854 service providers were trained in syndromic management.

Six implementing agencies worked to develop condom distribution networks in the regions where educational interventions had been implemented. In an effort to improve quality and increase affordability, AIDSCAP developed and marketed a new condom, called Pantera. During the life of the program, over 2 million Pantera condoms were distributed free-of-charge and 4.6 million were sold.

Key Outcome Data

Evaluation research shows that the AIDSCAP program helped reduce high-risk sexual behavior in the Dominican Republic. During the program, both awareness of HIV and knowledge of how to prevent the infection increased among all the target groups. Men from the general population reported reducing the number of partners, avoiding sex with CSWs, and using condoms more frequently. Both male and female youth in Santo Domingo reported delaying sexual debut and decreasing their involvement in commercial sex. Condom use increased, and self-reported STIs decreased across the target groups. Most significant, HIV seroprevalence appears to have remained stable in most of the sentinel populations.

Over the course of the program, sexual risk taking decreased among both target groups and the general population. In 1992, 73 percent of youth in poor neighborhoods of Santo Domingo reported that they were sexually active; in 1996, only 30 percent reported sexual activity. Among this same population the proportion reporting that they engaged in transactional sex decreased from 27 to 7 percent among males and from 9 to 6 percent among females. In the general population, 85 percent of men and 26 percent of women report having changed their sexual behavior to avoid HIV infection.

Condom use increased significantly during the AIDSCAP program. Condom use at last sexual encounter increased from 80 to 98 percent among brothel-based CSWs and from 38 to 63 percent among MWM. In the Puerto Plata region, the percentage of hotel employees who use condoms during sexual encounters with tourists increased from 86 to 95 percent.

Inconsistent reporting of STIs limits the conclusions that can be made about trends in STI prevalence. However, rates of self-reported STIs have decreased among the target groups. In Puerto Plata, self-reported STIs dropped from 11 to 7 percent among CSWs and from 15 to 1 percent among hotel employees. The proportion of CSWs reporting that brothel owners require regular gynecological exams increased from 89 to 98 percent. Knowledge of STI treatment locations increased strikingly among target groups.

Most significant, HIV seroprevalence appears to be stabilizing in several sentinel populations, including STI clinic attendees, where prevalence has averaged about 7.5 percent since 1992. Preliminary data suggest that the rate of HIV infection declined slightly among pregnant women from 1995 to 1996 -- from 2 to 1.2 percent in Santo Domingo and from 1.2 to 0.3 percent in San Francisco -- although continued surveillance is necessary to confirm this trend. HIV appears to be spreading rapidly in the tourist region of Puerto Plata, where seroprevalence increased among pregnant women from 4.1 percent in 1995 to 7.9 percent in 1996.

Special Features

A highlight of the AIDSCAP/Dominican Republic program was the extraordinary success of its mass media campaign. The campaign received unprecedented private sector support from radio and television stations, which donated more than U.S. $9 million worth of free air time to broadcast HIV/AIDS prevention messages. Given the current climate of decreased donor funding, the private sector will be called on to play an increasingly prominent role in HIV/AIDS prevention efforts. The active involvement of the national media in HIV/AIDS prevention is an important example of private sector/NGO collaboration.

Building capacity and sustainability was a key focus of the AIDSCAP/Dominican Republic program. AIDSCAP conducted an institutional development workshop for representatives from NGOs working in HIV/AIDS prevention and worked to develop partnerships between these NGOs, which had previously seen themselves as competing for funding and recognition. As a result of this emphasis on collaboration, several subprojects were implemented by two Dominican NGOs working cooperatively. At the end of AIDSCAP funding, the five central NGOs had developed institutional sustainability plans, and all had secured funding from other donors for additional HIV/AIDS prevention projects.

Implementing Partners

Agencia Latinoamericana de Expertos en Planificación H. (ALEPH)

Amigos Siempre Amigos (ASA)

Coordinadora de Animación Socio Cultural (CASCO)

Centro de Enfermedades de Transmisión Sexual y SIDA (CETS)

Centro de Orientación e Investigación Integral (COIN)

Comité de Vigilancia y Control de SIDA (COVICOSIDA)

Fundación Cultural y Educativa (FUCES)

Instituto Dominicano de Desarrollo Integral (IDDI)

Instituto Nacional de Salud (INSALUD)

Laboroto Rio de Janeiro Nacional de Salud

Patronato de Lucha Contra el SIDA (PLUS)

Programa de Control de Enfermedades de Transmisión Sexual y SIDA (PROCETS)

Technicmarketing

University of Washington

Latin America/Caribbean, Major Countries: Haiti

Epidemiology

HIV prevalence in Haiti is estimated to be 10 percent in urban adult populations and 4 percent in rural areas. The female to male ratio of HIV/AIDS-infected persons is close to 1:1. Of all HIV infections reported in the country, 80 percent occur in young adults aged 20 to 44, many of whom contracted the infection during adolescence. The prevalence of non-HIV sexually transmitted infections (STIs) is also high. An AIDSCAP-funded study of 1,000 women attending an urban antenatal clinic in an impoverished area found that 46.9 percent of women in the sample were infected with at least one STI. Overall, STI/HIV/AIDS epidemiology in Haiti parallels high-prevalence patterns found in parts of sub-Saharan Africa.

Country Overview

USAID/Haiti began supporting HIV/AIDS prevention in Haiti in June 1989 through Family Health International's AIDSTECH Project. In April 1991, the USAID project was expanded and renamed Aba SIDA (Haitian Creole for "Down with AIDS"). Shortly after the initiation of the expanded Aba SIDA Project, a military coup deposed Haiti's democratically elected government and ignited a severe political and economic crisis that lasted almost 4 years. Although the United States withdrew development assistance to Haiti in protest of the military government, HIV/AIDS prevention in the private and nongovernmental sector was exempted, allowing for a continuation of Aba SIDA activities. The Aba SIDA Project was the only nationwide response to the HIV/AIDS epidemic during this period. Under a new cooperative agreement with Family Health International (FHI) that began in October 1992, technical assistance responsibility for Aba SIDA was transferred to FHI's AIDSCAP Project. Aba SIDA ended in June 1996.

AIDSCAP/Haiti was designed to respond to an advanced HIV/AIDS epidemic and pronounced prevalence rates for other STIs. Therefore, its target populations were broad: adolescents and sexually active adults. Other behavior change interventions were tailored to meet the particular needs and perspectives of smaller, well-defined target populations, including commercial sex workers and their clients, women and men in the workplace, adolescents in schools and communities, and patients with symptoms of sexually transmitted infections. The communication strategy for targeted interventions was based on a variety of behavior change messages to accommodate individual variability both within and among target audiences.

AIDSCAP/Haiti's behavior change interventions with specific target audiences were multifaceted projects. While behavior change communication (BCC) was the centerpiece of the interventions, distributing condoms, facilitating access to STI care, and engaging the support of influential persons in target communities were also important components.

Accomplishments

Twenty Haitian institutions received technical and financial assistance to conduct key interventions to reduce the sexual transmission of HIV/AIDS and STIs. During the life of AIDSCAP, Haitian communities and grassroots organizations made remarkable progress in raising awareness about STI/HIV/AIDS and encouraging behavior change. More than 800,000 people were educated on how to protect themselves from HIV/AIDS, and more than 400,000 educational materials were distributed. More than 6,000 health workers, nongovernmental organization (NGO) personnel, and community volunteers were trained in the skills needed to sustain HIV/AIDS prevention programs, and more than 16 million condoms were sold or distributed through condom social marketing activities.

Strengthening STI Services

After an elected government was installed in Haiti, national guidelines for STI case management were developed and adopted by the new Haitian Ministry of Health. These national STI management guidelines were disseminated in June 1996 after extensive research, training, and institutional development had built a consensus with public and private sector practitioners on STI diagnosis and treatment. Although no measurement of STI treatment according to the national guidelines was feasible, a measurement of the percentage of clinicians in an AIDSCAP-funded project correctly treating the most common STI syndrome increased from 10 percent in 1993 to 69 percent in 1995.

Policy Dialogue

In addition to the development of national STI policy, other activities were undertaken to improve the policy environment in support of HIV/AIDS prevention. The first forums on women and HIV/AIDS in Haiti were sponsored, and a dialogue was initiated to ensure that women's concerns were addressed in Haiti's new plan of action for HIV/AIDS prevention. AIDSCAP also sponsored a mass media campaign, with special events aimed at increasing the awareness of the public of the HIV/AIDS epidemic and increasing social support of prevention projects.

Improving Care and Management

Through the AIDSCAP AIDS Care and Management Small Grants Initiative, three hospitals in Haiti received financial support to improve hospital and home-based care for AIDS patients and social support for people living with HIV/AIDS and their families, to provide economic assistance to affected families through income-generation activities, and to integrate prevention services into their care activities.

Capacity Building

Evidence of increased managerial and technical capacity of the AIDSCAP/Haiti implementing agencies was documented through a rapid assessment survey and in-depth interviews. Program managers reported increased staff skills in a range of technical areas, including BCC, condom social marketing, evaluation research, and STIs. Improvements in program management were reported in the areas of report writing, financial management, and strategic planning. In addition to improved staff skills, program managers reported improved management systems for finance, monitoring, and evaluation. Finally, all program managers cited improved networking with private and public sector organizations and developing coalitions.

Key Outcome Data

AIDSCAP/Haiti programs led to a significantly increased understanding of HIV/AIDS transmission and prevention methods in both high-risk target populations and the Haitian population in general. Behavioral changes were also reported. Three significant outcomes of the AIDSCAP program, evident from an analysis of baseline and postintervention research in AIDSCAP target audiences, are that the knowledge of HIV/AIDS has substantially increased, personal risk assessment skills have improved, and a high percentage of the population report behavioral change to reduce the risk of HIV/AIDS infection.

Documented Outcomes for the General Population in Haiti  

Aware of the sexual transmission of HIV
	1990	1995
	60%	90%
Knew of at least one prevention method
	1990	1995
		95%
Unable to assess personal risk for HIV/AIDS
	1990	1995
	18%	1%
Knew of condoms
	1990	1995
men	69%	95%
women	54%	95%
Knew of one or more sources for condoms
	1990	1995
		>90%
Ever used condoms
	1990	1995
men	16%	32%
women	6%	12%

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