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Final Report for the
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BCC Recommendation: Future programs should consider the negotiation of free time with the large communication companies such as radio and TV networks, newspapers, and magazines. Media is an important vehicle for disseminating the most effective practices on HIV/AIDS prevention. Several communications strategies using participatory approaches such as role playing theater presentations, use of mazes, and the use of fortune tellers were used for HIV/AIDS prevention in Brazil. Recommendation: The increasing use of participatory approaches in which the individuals and the groups participate actively in the process is highly recommended as a strategy on behavior change communication. Participant involvement should be considered a highly effective approach. An important variety of IEC materials were produced in Brazil for different target groups. There is a relevant need to collect and evaluate the quality of the materials produced. Recommendation: Future programs should consider this possibility. "Do not reinvent the wheel" -- several excellent IEC materials such as videos, brochures, manuals, technical guidelines were produced by some groups but not accessible to others. It was common to discover materials by different groups with similar messages and target populations; however, there were varying degrees of quality. Recommendation: Identify, translate, adapt, and reproduce IEC materials of good quality. This procedure should be considered one of the most efficient practices in HIV/AIDS prevention. As important as reporting what works is the registration of what did not work in behavior change communications. Recommendation: BCC strategies that are limited and generally not effective should be reported and registered. The sophistication and quality of HIV/AIDS programs are highly dependent on the quality of people that are in front-line and pilot programs. Recommendation: Qualified professionals should test and evaluate BCC strategies and work directly with target groups. There are huge amounts of IEC materials produced and distributed on HIV/AIDS prevention in Brazil. The availability of information is very high according to the analysis of the DHS Session on HIV/AIDS and STIs, but this is not reflected in condom use which is incredibly low (4.3 percent among women and 5 percent among men). Recommendation: It is time to invest more in BCC activities related to Condom Social Marketing. It is urgent to have better access to condoms throughout the country. Comprehensive CSM is an urgent need. The need for person-to-person communication involving the target community will increase as the epidemic in Brazil moves to the low-income strata of society, especially to youth and women. Recommendation: Increase the use of person-to-person, face-to-face interventions, small group discussions, role-plays and dialogue. The use of BCC materials that facilitate interaction and participation, should be listed and promoted by target group. Logistics of IEC materials are very important as part of the programs. Recommendation: Implementation of logistics for IEC materials on the prevention of HIV/AIDS/STI is highly recommended. Contrary to HIV/AIDS, the DHS shows that the level of basic information on STIs are very low. Recommendation: Production of IEC materials with basic information on STIs should be emphasized in the next program. STI Recommendations Preventing STIs effectively prevents HIV. Simple etiological diagnosis and treatment does not offer much in the way of a prevention program, especially given the current structure of the public health system in Brazil. The syndromic approach to STI management has shown itself to be both viable and pragmatic. The procurement and distribution of STI drugs is costly, but the cost benefit is high. In the health clinics where the sub-project was implemented, STI syndrome management proved to be an effective alternative for STI/HIV prevention. Nevertheless, in order to ensure the success of project activities, several points should be considered such as: Medication and condoms should be available in all treatment centers. The logistics system should be implemented. The system allows stock to be distributed as needed, and avoids the problem of depletion of stock, allowing medications and condoms to be supplied to clients on a regular basis. Regular supervision of the health centers by trained teams is essential. Continuous direct contact is necessary for supervisors to identify and understand any problems that may occur during the admission, diagnosis, explanation of treatment, and counseling of clients. Early detection and correction of difficulties in the system could prevent repeated infections among clients and their partners. The recognition of system limitations allows supervisors to develop solutions and to follow the program guidelines and procedures. STI prevention program activities have been integrated with those provided by the Program de Assistencia Integral à Saúde da Mulher, Criança e Adolescente (Integrated Health Program for Women, Children and Adolescents). These services were linked due to the fact that 70 percent of STI clients are women who attend gynecology and pre-natal clinics, and because the most serious health-related consequences tend to occur among women and newborn children. The current stage of development of the MOH STI program requires the consolidation of monitoring and evaluation mechanisms. The methodology being used within the health centers presupposes the utilization of data provided to the health centers via standardized monthly forms (notification of the number of STI cases and management of medications and condoms). Activity reports and reports of meetings with municipal program managers to assess difficulties, which may be occurring at the local level, are important to be carried out. The experience of AIDSCAP to assess a number of indicators, for example, the client's perception of the quality of care provided, risk assessment and changes in attitudes and behavior in relation to relative risk of STI/HIV should be expanded to other municipalities. While significant improvements in surveillance, data collection, and STI diagnosis and treatment have been made during the life of this project, further improvements can be made in these areas as well as in the quality of STI care and in the partner referral system. Efforts made during AIDSCAP should not end, experiences can be used as a model for the second loan of the World Bank. The STI programs in Brazil were implemented due to the relevant counterpart contribution from local government that committed resources for the procurement of STI drugs. Recommendation: USAID should establish continuous dialogue with the World Bank, UNAIDS and MOH in Brazil to consider the procurement of STI drugs as a priority in HIV/AIDS prevention. Interventions to address the practice of males seeking STI treatments at pharmacies need to be considered. Recommendation: Training of pharmacists on STIs is one intervention approach, but strategies should also be developed to improve male attendance at STI services in the polyclinics. AIDSCAP/Brazil also recommends the implementation of a pilot study, similar to the M-STOP project in Cameroon where STI kits based on the syndromic approach were distributed to men seeking treatment in pharmacies. Social marketing programs at drugstores in Brazil for the treatment of urethritis should be considered. Medical training programs in Brazil are still resistant to the syndromic approach. The wide dissemination of AIDSCAP project results could sensitize the universities and encourage adoption of the syndromic approach. Recommendation: Considering the relevant results of AIDSCAP, USAID should allocate future resources to disseminate outcomes of AIDSCAP to teachers at university levels. The best way to do that would be through sophisticated and specialized public relations. Further Recommendations: AIDSCAP/FHI STI handbook, Control of Sexually Transmitted Diseases: A Handbook for the Design and Management of Programs, should be translated into more languages for further distribution based on the overwhelming response the Portuguese version received by the HCP and polyclinics. Conduct research for the development of rapid, inexpensive and simpler diagnoses of STIs to facilitate treatment and strengthen the target population's ability to prevent and control HIV and STIs. Lack of complete, accurate and reliable reporting of STIs is a major problem in Brazil. Considerable resources will be necessary to establish a comprehensive information system to properly monitor STIs in Brazil. Considering the low level of knowledge of STIs in Brazil, massive informational campaigns using all available media is an important need. Programs should continue to focus on early identification and treatment of STI. Condoms Condom social marketing (CSM) has proven to be an efficient, cost-effective, sustainable program that increases the availability of condoms to target groups and spreads through the general population. In Brazil, CSM has proven to be one of the most relevant tools in HIV/AIDS prevention. Recommendation: High priority should be given to the implementation of CSM programs. Although NACP/MOH had 250 million US dollars as part of the World Bank loan, in the last 5 years the availability of condoms for free distribution to the public sector was unstable, insufficient and problematic. Logistics cycles were also not in place. In the light of this situation the 15 million units of condoms donated by USAID to the AIDSCAP projects were crucial for the success of the programs, especially in consideration of the high risk to the low-income strata of AIDSCAP target groups. Recommendation: Despite all the difficulties involving condom donations to Brazil, buffer donations should be considered in the future, especially in the northeast. The increased collaboration of DKT do Brazil and local NGO was highly facilitated by ASF. Recommendation: FHI and PSI should consider the positive partnering between DKT do Brazil and ASF on HIV/AIDS prevention. Thus, future collaboration should be encouraged. Furthermore, ASF can facilitate the increase on the collaboration between DKT with HIV/AIDS NGOs as well as women's groups and unions. Limited resources are limiting the expansion of CSM strategies in Brazil. Recommendation: Dialogue should be established with other donors to motivate them to fund CSM in Brazil as an essential strategy in the prevention of STIs and HIV. The control of quality of condoms in Brazil has proven to be problematic on several levels. The participation of AIDSCAP on the commission for condom certification and the establishment of condom norms and regulations could have positively influenced this process. Recommendation: In future HIV/AIDS prevention projects, the participation of a representative of the project in these commissions should be considered. In addition, HIV/AIDS is increasing among women and therefore CSM of the female condom as well as water-based lubricants and STI kits for drugstores need to be considered in future programs in Brazil. Policy In addressing HIV/AIDS prevention programs to women, sterilization may play a very important role in Brazil resulting in the low adoption of condom use. Working close with gynecological associations and the scientific societies along with women's groups and the women's health program from the MOH are relevant strategies to address this issue. There is a need to encourage HIV listing among pregnant women and if needed use of AZT to prevent the vertical transmission of HIV. Considering country size and budget limitations, HIV/AIDS prevention programs should focus on geographic areas with the highest prevalence of HIV/AIDS/STIs and incidences of infection. In the light of the epidemiological increase of HIV/AIDS among youth, it is necessary to start interventions at the primary school level. The present AIDSCAP technical strategy has been proven and is results-driven. The implementation of AIDSCAP/Brazil included at project level issues such as integral health care, human rights, and the exercise of basic citizenship -- and all have proven to be effective. Considering the synergism between HIV and STI in areas where the HIV/AIDS epidemic is in its early stages, prioritizing interventions to treat and prevent STIs is crucial. Special attention should be place on settings where high rates of STIs are found in CSWs due to the possibility of acquiring and transmitting STIs, as well as HIV, to a large number of individuals. Collaboration should be coordinated, strengthened and expanded with CDC, NIH, UNAIDS, MOH and other donors to establish country-specific policies, agendas, and priorities according to the status of HIV/AIDS epidemic in the region. Capacity building should remain one of the most important aspects of future programs. The development of effective programs is strongly related to individual investments and institutional capacity building. In the light of the increase of HIV and STIs among women and adolescents in the Southeast region of the country, policies to integrate HIV/STI prevention and empowerment into the women's and youth health programs are an important need. In Brazil, NGOs are involved in relevant advocacy for treatment of HIV/AIDS. The implementation of advocacy for prevention strategies, such as the integration of STI/HIV/AIDS prevention into all aspects of reproductive health, should be encouraged. Evaluation Prevention research should be translated into the design of effective prevention services. Several studies conducted in Brazil with the general population and specific target groups show that the level of information on HIV/AIDS is high. However, behavior change that occurred in some intervention target groups such as MWM, CSW, did not become replicated in the general population. Support studies (quantitative and qualitative) that investigate the maintenance or relapse of behavior change in specific target groups should be conducted. Training of new investigators, scientists and public health specialists to conduct effective HIV/ AIDS prevention should be a high priority. The several KABP carried out by different organizations with different methodologies, with small and homogeneous sample sizes were not the best means to monitor overall behavior change. Therefore, behavioral surveillance surveys (BSS) are recommended in the future. Considering the need to improve evaluations, it is necessary to invest in the capacity building of new investigators in the area of HIV/AIDS/STI-related research. Thus donors might consider the allocation of resources to support HIV/AIDS/STI research and investigators. It is critical to actively encourage and involve exceptionally creative and productive individuals to devote at least a portion of their research effort to HIV/AIDS-related areas. Results of research and evaluation should provide feedback for program design implementation and should influence policy charges. Lessons learned from programs that were not effective should be carefully documented, analyzed and disseminated at national and international forums. Management and Implementation The implementation of the AIDSCAP/Brazil program through a legally established Brazilian NGO provided the potential to develop sustainable HIV/AIDS prevention programs in Brazil. One crucial, fundamental factor was the understanding, vision and support of USAID/Brazil in this process. Implementation of creative and innovative prevention on HIV/AIDS/ STI was highly linked with the decentralization process of actions especially in relation with private sector. With the support of the USAID/Brazil, the local AIDSCAP NGO ASF started to seek funds from other donors. This procedure was fundamental for the development of activities that allowed ASF and the AIDSCAP program to develop a series of complementary activities, which included further fundraising. Recommendation: Missions should support long-term initiatives on HIV/AIDS prevention encouraging the umbrella NGOs responsible for the implementation of USAID-funded projects to seek monies from other donors. In addition, a plan for sustainability needs to be developed as part of program design. Carefully designed strategies are crucial, and should be planned and implemented within six months. Bureaucratic process has been slow in the review and approval process of program implementation. In Brazil, there was an 11 month approval process; furthermore, the review and approval process of sub-agreements took six additional months. Recommendation: Mechanisms for a more effective review and approval process are needed for strategy and implementation plans as well as sub-agreements and amendments. The installation of automated computerized information systems in the technical and financial areas, followed by specialized training of implementation agencies are fundamental to building the local capacity to register data and generate financial and technical reports according to USAID norms and regulations. Recommendation: Future programs should use automated and computerized systems as much as possible. Ongoing training to NGO staff and individuals are a relevant need for the development of the capacity-building program. The availability of the Rapid Response Fund (RRF - small grants) should be used to test pilot interventions, seek activities which complement a larger project, or be allocated for research. The efficacy of activities developed during AIDS World Day, Carnival, or short term limited interventions are not cost effective in the prevention of HIV and STIs. Recommendation: RRF should be used to complement larger activities or to pilot planned activities. A bridging process to USAID-funded projects at the level of NGOs is a relevant need between funding periods, otherwise there is a great chance of destroying the model programs created with USAID resources. For example, a fundamental accomplishment in Brazil was that the programs in Santos for CSWs were maintained with resources from the MOH and the World Bank which prevented the dispersion of trained staff to other activities. This insured that there was minimal loss of the experience acquired during five years of front-line work with the target population. Recommendation: Whenever possible, USAID-funded projects should encourage NGOs to seek funds from other donors and encouraged to implement intervention projects funded by different donors. It is important for continuity to diversify the funding base and not to depend solely on USAID funds. In the history of the HIV/AIDS epidemic in Brazil, many prevention programs were implemented and closed based upon donors' visions of need and budget constraints. Many NGOs have had to constantly change their focus and missions based upon funding. Recommendation: To build upon the programs implemented and the lessons learned, it must be communicated to donors that model programs cannot be sustained without resources. Programs cannot fulfill their potential without resources, therefore mechanisms are needed to sustain the model programs. Revamping a system already in place at an NGO to meet the specific "requirements" of the donor does not encourage efficient use of funds or experience. The lessons learned in five years of the AIDSCAP implementation can provide relevant feedback for future program design. Recommendation: Program design should take into consideration the lessons learned in previous research and implementation and ensure that HIV-prevention interventions are integrated and that there is comprehensive building upon lessons learned from the AIDSCAP project. For example, to maximize a program's effectiveness, previous research will point towards focusing interventions on those populations most vulnerable to new HIV infections. The use of e-mail system should be refined or implemented at the level of IAs. The use of the Internet is an important networking tool and decreases the costs of communication. Recommendation: Install and train of NGO to use e-mail systems and Internet in the future programs. Epidemiological data (AIDS cases, seroprevalence studies, sentinel studies, cohort studies) among different groups, as well as other factors, are necessary to evaluate the country situation in the face of HIV/AIDS. It is well known that in the light of limited resources, programs should focus on geographic areas where epidemiological analysis shows concentrations of HIV/AIDS cases. Recommendation: Future programs in Brazil should concentrate on the Southeast region of the country, which encompasses more than 70 percent of the AIDS cases. This way, major resources would be concentrated where USAID will be able to show the greatest impact on the prevention of HIV/AIDS in Brazil. Furthermore, the implementation of HIV/AIDS prevention programs for women in São Paulo, especially young women, is urgently needed. It is not well documented which program practices and strategies related to behavior change were not successful. It is important to know what did not work well and why it did not work well and to have a listing of least effective strategies. Inter-Institutional Relationships The AIDSCAP project was implemented within the complex and diverse participation of many institutions, e.g., FHI and nine subcontractors, country offices, USAID/Washington, USAID missions, IAs, and the MOH. This reflects not only the size of the program, but the need for different areas of expertise. However, this complex system generated communication problems. Recommendation: New programs need basic guidelines to provide structure in the methods and means of communication and an overview of "players," which reflects the needs and requirements of communication within the USAID missions. After setting up guidelines for external communication, specifications can be developed at the local level in conjunction with the local mission policies and country culture. This would reduce the potential for communication problems on several levels. The PVO grant program channeled through Childhope New York and the behavioral research channeled through the University California San Francisco (UCSF) generated confusion about which entity was funding the program. In addition, this generated misunderstanding of the role of country office and FHI. The capacity-building survey showed that the local IA working with Childhope and UCSF did not benefit from ongoing financial technical assistance. Recommendation: Although it is desirable to encourage the cooperation between US based universities and PVOs, clear mechanisms and guidelines for more effective program implementation are needed. Logistics Logistics sustainability depends upon complex political decisions at federal levels regarding the overall logistics management of HIV/AIDS/STI drugs and condoms in Brazil. Until now, the States depended upon federal decisions for shipment of commodities and therefore there is a need for a logistics coordinator at the federal level for HIV/AIDS prevention. Considering the size of the country and the Unified Health System, a logistics system for AIDS prevention needs to be inserted in the complex local health system. Logistic positions need to be created at federal, state and municipal levels. In this sense, the AIDSCAP project has established a model to serve as a basis for the expansion of a logistics system in the country. The appropriate technology along with training needs to be created and universally implemented. |
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