Final Report for the
AIDSCAP Program in Brazil: Country Program Description

This report comprehensively summarizes the FHI/AIDSCAP program in Brazil (1992-1997). The report discusses program accomplishments and constraints, as well as providing behavioral outcome data.

Implementation and Management Issues

In January 1992, AIDSCAP, AIDSTECH and USAID staff members and consultants met in Brazil to develop strategies, identify target populations, and select geographic areas for program implementation. In August of the same year, a ten-member team embarked on a three-week implementation visit to Brazil. Included in the team were a BCC specialist, a private sector officer, and epidemiologist/evaluation officer, and the AIDSCAP Regional Director. These members joined AIDSCAP Resident Advisor, the AIDSCAP Project Advisor in Rio de Janeiro, a local STI consultant, the mission's AIDS Project Coordinator, and an experienced public health consultant.

1. Implementation

The development process of the strategies and implementation plans included program design, technical review and approval by AIDSCAP, USAID/Washington and USAID/Brazil, which took 11 months. Selection criteria for the two geographic regions chosen to be models for replication in other regions included: incidence and prevalence of HIV infection; potential for impact; governmental and non-governmental infrastructure, resources and potential for collaboration; previous USAID experience in selected regions; compatibility with other donor activities; and cost. The strategic planning team recommended that the AIDSCAP project focus on municipalities in São Paulo (Greater São Paulo), Santos and in the greater Rio de Janeiro.

The goal of the Brazil program was to reduce the incidence of sexually transmitted HIV infection among targeted populations in the two focus geographic areas. The primary program objectives were to reduce high-risk behaviors among target populations and reduce the incidence of STIs, including HIV. Initially, five target populations were selected to accomplish the goal and objectives: male and female CSWs, including transvestites; men who have sex with men (MWM) inclusive of self-identifying homosexuals and bisexuals who many not self-identify as gay or homosexual; men away from home (MAFH), targeted through workplaces and social settings; people with STI and their sex partners targeted in health care settings and through outreach programs; and adolescents at schools or living on the streets.

The Brazil program focused on reaching individuals at risk of HIV infection by improving the treatments of STI, minimizing high-risk behaviors, and increasing access to and use of condoms. This focus was reflected in the design of the major program, with specific interventions for target populations.

STI prevention and control was strengthened through local capacity to provide treatment and prevention. This included in-service training for clinic staff and other personnel, basic equipment for STI diagnosis, assistance with materials to improve client education, establishment of STI services in public health centers, development of information and training for public and private sector health care providers.

BCC was conducted through the distribution of information, education, and communication (IEC) materials using various types of media to increase the demand for STI treatment, reduce the number of sex partners, and increase the demand for and use of condoms among those at high risk of HIV infection.

Condom distribution, through condom social marketing and through the public sector sales, focused on target groups within the designated geographic areas.

In order to enhance these major program areas the Brazil program included four supporting interventions:

• AIDSCAP logistics management established state logistics units in target areas, to provide training and recommendations for the improvement of logistics cycles in the public sector.
• Private sector leveraging was conducted with the local media, through publicity companies and within the fashion industry. AIDSCAP implementation in Brazil was registered on more than 6.8 million USD free media publications and announcements.
• PVO/NGO/MOH support activities complemented the overall program. Through a competitive process Childhood was awarded funds to implement a project for poor adolescents in Rio de Janeiro.
• Furthermore, 39 small-grant projects were implemented through the Rapid Response Fund by NGOs in BCC materials development, interventions, research and innovative approaches. Several activities were developed to respond to the MOH request for technical assistance in STI, logistics, condom social marketing, private sector, training, and program design.

Condom Social Marketing (CSM), an aggressive and innovative program, was supported by AIDSCAP through PSI/DKT in Brazil. During the life of the project more than 71 million condoms were sold through traditional and non-traditional outlets, substantially increasing the access of low-price condoms.

Additional interventions integrated into the overall program were:

• IA support to build capacity to implement effective HIV/AIDS prevention programs. During the project, ongoing technical assistance was provided to IAs through program design, management, coordination, monitoring, evaluation, training establishment of health information systems, report preparation and writing.
• Behavioral studies were conducted through the Center for AIDS Prevention Study Group of the University of California San Francisco, which provided technical assistance to the Nucleus for AIDS Prevention at University of São Paulo (NEPAIDS) and the Santos Association for Research and Intervention (ASSPE) in developing studies of sexual behavior among young adults, harbor workers and truck drivers.
• AIDSCAP Brazil developed several activities to mobilize politicians, opinion leaders, NGO and the media to address the taxation on condoms. Two petitions were organized, one with 7,000 signatures and the other with 5,309 signatures. In October 1997, 18 percent state taxation was lifted from condoms in 27 Brazilian states. The local market responded immediately, reducing prices on condoms.
• Evaluation and monitoring were part of the design of major programs. A total of 35 quantitative and 10 qualitative studies were performed during the life of the project.

A key element of the Brazil program was a well-designed, comprehensive approach to AIDS prevention. All planned program components were implemented achieving planned and unplanned results. The major projects created model programs and through Rapid Response Funds the AIDSCAP Project was able to test innovative approaches and reach women through a multifaceted approach.

The implementation of the AIDSCAP Project in Brazil had an important association with the National Program NACP/MOH/World Bank, especially at the project implementation level. The procurement of STI drugs by MOH/NACP was key for the implementation of the STI component. Furthermore, all AIDSCAP projects distributed several BCC materials produced by NACP/MOH under the World Bank loan. This fact generated an important diversity of IEC materials that were distributed during the project. Strategies developed by AIDSCAP were used as models and replicated by MOH under the World Bank loan. The constant support of USAID was key for dissemination of the project which was facilitated by the participation of IAs in several national and international meetings, conferences, training and workshops.

2. Management

In order to legally implement the AIDSCAP project in Brazil, a local NGO was established called Associação Saúde da Família (ASF). ASF is a Brazilian NGO with the immunities established by Brazilian laws, and as such it is a separate entity from Family Health International (FHI) and from the AIDSCAP project. The establishment of ASF had the technical assistance of a group of Brazilian lawyers who acted as consultants to the US Embassy and the US Consulates in Brazil. To implement the AIDSCAP project in Brazil, ASF signed an agreement with FHI to monitor and manage the overall implementation of the AIDSCAP project in Brazil. To ensure that the ASF retained the status of a Brazilian NGO, it has only Brazilian citizens domiciled in the country as members. Since 1992 ASF was affiliated to FHI through the AIDSCAP project, and in order to implement the AIDSCAP project according to the norms and regulations established under the cooperative agreement and contract signed between USAID and FHI; ASF signed an agreement with FHI to implementation and manage the AIDSCAP Brazil program, thus ASF was the formal AIDSCAP/Brazil country office.

The mission of ASF, as a non profit organization, is to improve the quality of human life through the promotion of scientific, charitable, educational and literary activities -- especially for the prevention and control of the dissemination of the HIV/AIDS, including divulging the means of Prevention and Control of the HIV/AIDS epidemic best practices. The other major mission of ASF is to work in the area of reproductive health matters. The AIDSCAP resident advisor was also the president of ASF, who was recruited and hired according to USAID/regulations. All staff from ASF were recruited and selected through a competitive process, with positions posted in local newspapers, at universities, and within public and private institutions. Selection criteria and job descriptions were established for all positions.

In order to financially manage the AIDSCAP/Project in Brazil, ASF translated the AIDSCAP/Washington finance manual into Portuguese and adapted the contents to meet the needs of a highly inflationary economy (inflation rates increased from 1 percent to 1.5 percent per day from 1992 until July 1994). During the inflationary economy period, USAID approved the investment of all resources into interest accounts so that ASF and IAs would not lose a total of 30 percent to 40 percent of resources monthly. Thus, this procedure was a measure to protect the resources donated by USAID through the AIDSCAP program in Brazil. All IAs were trained to use the financial resources given directly to the NGOs or channeled through NGOs for project implementation in collaboration with the public sector. This procedure, on one hand, was essential to guarantee dynamic, flexible and non-bureaucratic management of resources. and on the other allowed AIDSCAP/Brazil to control the resources committed by USAID to IAs from the Brazilian public and NGO sectors.

Based upon lessons learned a new automated computerized financial system was created and all IAs were trained in its use. IAs considered this procedure a major accomplishment of the AIDSCAP project in Brazil. During the life of the project, ASF and IAs were financially audited each year by Ernst Young and technical area audits were conducted through a country review team (January 94), a mid-term evaluation (November 94) and a USAID review visit (May 96). The auditing procedures were important to the AIDSCAP Brazil program. The systematic technical auditing provided constant input and feedback important for refinement of overall program management. Constant FHI technical assistance through headquarters and LAC regional office were key for the quality of the program. Continuous advice assured that all USAID norms and regulations were followed during the life of the project. Initially FHI had to adjust to the fact that AIDSCAP/Brazil country office was a legal locally established NGO, but this model was soon used to create FHI-affiliated NGOs in several countries such as Haiti, Dominican Republic, and Honduras. Based upon its Brazil experience, FHI developed NGO partnership initiatives, which were an important step towards future sustainability of HIV/AIDS prevention programs in several countries.

In 1995, USAID/Brazil took the initiative to support ASF by seeking funds from the private sector and through other donors. The USAID/Brazil initiative was the vanguard towards the development of sustainable HIV/AIDS prevention programs in Brazil. ASF responded to this support by seeking funds from the Overseas Development Agency (ODA) and Ford and Levi-Strauss Foundations, and through US $82,000 grants from other donors. In addition, ASF was able to raise approximately US $400,000 in collaboration with the Brazilian fashion industry. As a result of the USAID/Brazil support, ASF was able to maintain their office and team in a less expensive infrastructure supported in part by funds from the private sector. The major outcome of this support was the development of actions that sustain effective USAID response to HIV/AIDS in Brazil. Thus, this initiative may be considered a model for other USAID missions in new USAID-funded programs worldwide.

During the life of the project, the major constraints were:

• Inflationary economy and currency changes from 1992-1994 which generated additional administrative work.
• Devaluation of the US Dollar in relationship to the real plan and the inflation on the real itself. From July 1994 until September 1997, the inflation rate was more than 64 percent. These factors had a major impact on project implementation.
• Payment of unexpected taxes such as IPMF and CPMF, which are taxation on the value of all monetary and financial transactions, which varied from 0.025 to 0.20 percent.
• Country office level salaries were not competitive with the local market after July 94. Furthermore, complex labor laws required the payment of several taxes and benefits versus limited budgets which were not adjusted according to inflation, decreasing the buying-power for the AIDSCAP/Brazil staff.
• Delays on sub-agreement approvals, which took an average of 6 months. Delays were due to long reviews and comments at the regional and HQ offices. Delays on amendment approvals were also verified.
• Re-negotiation and rewrites of the same sub-project after the first year of implementation generated a burden at IA and country office levels. Future programs should design and budget resources for the life of the project.
• Behavioral research and PVO/Grants did not benefit long-term capacity building because the project was being funded through the University of California at San Francisco and through Childhope, New York. This factor generated country-level monitoring and assisting difficulties.
• Year-extensions generated an increase of administrative and technical work.
• In 1995, AIDSCAP/USAID suffered relevant budget cuts.
• All final reports from IAs were written and prepared at the country office level, generating an unexpected task at the end of the project.

3. Capacity Building

The capacity building activities initiated by AIDSCAP have unquestionably improved the organizational sustainability of its partners, and encouraged the sustainable impact of its goals. While the future holds numerous challenges for the design and implementation of HIV/AIDS prevention programs, AIDSCAP efforts will enable organizations to more effectively and dynamically respond to these challenges.

Technical skills in every area have increased due to the AIDSCAP project. Organizations cited an average of 15 technical skills acquired during the project. The high level of expertise in policy dialogue reflects the overall confidence in the technical skills of the organizations and a willingness to apply this knowledge.

AIDSCAP had an important role in the implementation of Syndromic Management in the states of Rio de Janeiro and São Paulo. Every category of management skills improved due to AIDSCAP activities. The four largest improvements in specific management skills were evenly divided by category: strategic planning, financial management, personnel management and quality control. All categories showed significant increases.

Personnel management represents the lowest overall level of achievement and remains a challenge for the future. In the uncertain environment of funded programs, managers must learn to motivate staff to overcome the obstacles of this emotionally draining work. The relevancy of quality control for service organizations, as well as STI/condom logistics organizations, should be better recognized and emphasized. The institutionalization of administrative, financial, and monitoring systems by the majority of organizations represent significant evidence of strategic planning to aid organizational development. The financial management software provided by the AIDSCAP project allowed significant improvements in financial management systematization.

The expansion of management systems from AIDSCAP projects to other projects represents evidence of impact sustainability. The PIF monitoring system, while succeeding in satisfying AIDSCAP reporting requirements to USAID, should be improved in order to be more useful and effective to monitor IA activities. AIDSCAP has supported the development of an extensive array of national and international contacts and professional networks among HIV/AIDS prevention organizations. Representatives of AIDSCAP funded organizations have participated actively in coalitions at the grass roots, regional, national and international levels. While some organizations have established extensive community ties, and have incorporated community member's insight into program design and decision making, others have not yet developed these ties. The lack of improvement in overall management systems by two organizations represents an obstacle to their growth and sustainability.

Capacity Building Activities Developed at AIDSCAP/Brazil

• Participated in the Global Orientation Program of AIDSCAP in Arlington, VA, USA, during February 1992.
• Participated in the Resident Advisor Orientation in Arlington, VA, USA, in March 1993.
• Three AIDSCAP country office staff members participated in the MIS training course funded by the Italian Agency for International Development during March 1993.
• Three representatives of the State AIDS Coordination from São Paulo and Rio de Janeiro in conjunction with SUNY (State University of New York) were cosponsored to attend the "Primer Curso Internacional de Planificación y Administración de Programas de ETS en Latino America" in Santo Domingo, October 1993.
• Participated in the evaluation orientation in Arlington, VA, USA, March 1994.
• Planned, organized and conducted the First National AIDSCAP Meeting in São Lourenço, MG, on September 12-16, 1994, with the participation of USAID/Brazil, FHI Washington (Headquarters and Latin America/Caribbean Regional Office), Brazilian implementing agencies and subcontractors (JSI, DKT do Brasil), September 1994.
• In liaison with SUNY (State University of New York), selected and supported 3 participants from AIDSCAP sub-projects in Brazil to attend a course: Implementing AIDS Prevention and Care Programs organized by International Health Programs Western Consortium for Public Health in Santa Cruz, CA, USA, August-September 1994.
• Conducted an EPI-INFO training course in São Paulo for 12 participants from governmental and non-governmental institutions working in collaboration with AIDSCAP/Brazil from São Paulo and Santos, August 1994.
• Conducted 3 training courses on Logistics and Management of condoms and pharmaceutical supplies to 80 HCPs in the State Department of Health in Rio de Janeiro, August-September 1994.
• In conjunction with SUNY (State University of New York) sponsored participation of São Paulo State logistics coordinator for the STI/AIDS Division to participate in JSI/FPLM Logistics Management Training.
• Organized two STI workshops (one in Santos and one in Rio de Janeiro) in order to discuss better data collection in target AIDSCAP/geographical areas on the number of STI patients being followed by the Health system in January, 1995.
• Participated at the Management Skills And Techniques For Supervisors seminar at the American Management Association, March 1995.
• Conducted the Second National AIDSCAP/Brazil Meeting with implementing agencies in Caxambu from May 22 to 26, 1995. A total of 47 representatives from implementing agencies, States Department of Health (São Paulo and Rio de Janeiro), USAID, AIDSCAP Regional and Country Office participated in a five-day workshop. The purpose of these meetings was to brief participants on AIDSCAP and IA activities in Brazil, providing an worldwide overview of epidemiology trends in LAC/Region. Preliminary results of AIDSCAP/Brazil's quantitative, qualitative research protocols were also presented. IAs were also appraised of current funding situations and given budget constraints agreed to work with the Country Office to reprogram activities.
• Writing Report Workshop for all Implementing Agencies, October, 1995
• "The Female Condom as a Woman-Controlled Protective Method Workshop" conducted by the HIV Center in New York promoted by AIDSCAP Women's Initiative, October 1995.
• Training in Evaluation at AIDSCAP LAC/RO, April 1996.
• English Course Scholarship. ASF was awarded with an English Course Scholarship from the British Council (Cultura Inglesa) which has been used by several members from 1995 to 1997. It was given to Ruth Prata, Telma Toniolo and Jõao Batista F. Aguiar.
• English Course: As an institutional development policy, data clerk João Batista Fonseca Aguiar completed a 7-hour per week Basic I English Course during October 14-December 10, 1996. The course was held at SENAC in São Paulo. João has been working at ASF since 1994 and had an outstanding performance in his English classes passing with the average mark of 9.2.
• Rapid Response Fund Workshop conducted by AIDSCAP/country office in September and October 1996. The small grant competition was opened in September for NGOs located in the São Paulo and Rio de Janeiro target areas and in Northeast of Brazil. The subject chosen for the competition was again STI/AIDS Prevention in Women. A one-day workshop was developed in order to inform NGOs of small grant procedures and FHI/USAID regulations. Four workshops were developed in Rio de Janeiro, São Paulo, Salvador and Fortaleza. The RRF contents were: Opening: An Overview Of AIDSCAP Project; a summary of RRF projects; the RRF proposal form (including FHI and USAID regulations); Evaluation of RRF; Financial Report of RRF; brainstorm of ideas and discussion of partnerships, and deadlines for the proposals. A total of 51 people participated of the RRF workshops and as a result a total of 33 RRF proposals (15 from São Paulo, 4 from Salvador, 10 from Rio de Janeiro and 4 from Fortaleza) were received by the end of October, 1996. The selection process was performed by a team which included representation from AIDSCAP country office (RA and SPO), USAID Local Mission (Coordinator of AIDS Program), AIDSCAP LAC/RO (Director) and AIDSCAP Women's Initiative (Associate Director).
• Training in Reproductive Health and STI/AIDS Prevention for Health Professionals in October and December 1996. A 32-hour training was carried out in the Northeast (Ceará and Salvador) and in São Paulo (Santos) for a total of 104 health professionals.
• Writing Skills: A two-day course on "Writing Skills for Secretaries" was attended by the Secretary Telma Antoniolo, Program assistant Elvira Carmo de Oliveira, data clerk João Batista Fonseca Aguiar and the bookkeeper Aparecida Verdu Caminoto on October, 1996.
• Neurolinguistic: The Evaluation Officer, Luis Antonio V. D'Angelo attended a one-day training course on neurolinguistics in order to improve abilities of work place communication and decision-making on October, 1996.
• Emotional Intelligence: RA, Maria Eugênia Lemos Fernandes and SPO, Elisabeth Meloni Vieira, attended one-day training course in Emotional Intelligence, November, 1996 in order to improve communication and decision-making at work.
• NGO Directors Partnership Workshop held in January 1997 in Arlington, VA, USA at AIDSCAP Headquarters. The main objective of this one-week workshop was partnership and sustainability.
• Gender and STI Workshop held in January 1997 in Arlington, VA, USA promoted by AWI. This workshop approached Gender Issues in STI/HIV Prevention.
• NGO Financial Officer Workshop held in January 1997 in Arlington, VA, USA.
• ASF staff members Retreat held in March, 1997 in a Farm Hotel in Socorro, March 1997. The meeting had as main objective to build capacity as an independent NGO.
• In conjunction with SUNY (State University of New York) sponsored participation of 20 professionals in the training course, "AIDS Program in Prevention and Assistance," Pernambuco, July 1997.
• HIV-Risk Behavior Surveillance: Country Examples, Lessons Learned and Recommendations for the Future workshop, Thailand, August 1997.