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Final Report for the AIDSCAP
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Table of Contents I. Country Program Description (See Below)
III. Non-Subproject Highlights I. Country Program Description The AIDSCAP/DR program followed the AIDSTECH and AIDSCOM projects funded by USAID/DR through 1992. At this time there was evidence that HIV was well established and increasing in the general population. However, a general lack of awareness about the seriousness of the epidemic still remained especially among public and private sector policy makers. During its first year, as an associate country, the DR program provided technical and financial assistance to non-governmental organizations previously supported by USAID/DR. AIDSCAP/DR was established as a priority country after a technical assessment was conducted, and a Strategic and Implementation Plan (S&IP) was defined for the 1993 -1996 period. As a part of a Family Planning and Health Umbrella Project sponsored by USAID/DR, the S&IP was aligned with USAID/DR objectives to improve reproductive health, address unmet needs in HIV/AIDS prevention and coordinate activities with national and international efforts. The Plan was based on a multi-disciplinary approach for primary prevention of sexually transmitted HIV, and it focused on three technical strategies:
These strategies were aimed at the primary target groups identified for the program: commercial sex workers, men who have sex with men, people in the workplace (PWPs), adolescents and young adults (A&YA), and family planning (FP) acceptors. The supporting program areas that complemented and enhanced the effectiveness of the targeted interventions were condoms logistics management (CLM), private sector leveraging (PVL), policy reform, HIV/STI surveillance and program related research. In addition, evaluation activities were a vital component of the AIDSCAP/DR program. They facilitated measuring the impact and effectiveness of the overall program and the modification of strategies to maximize the effectiveness of interventions. Using these strategies and supporting program interventions, AIDSCAP/DR was able to accomplish the following strategic objectives:
Dominican Republic Country Program Logical Framework The logical framework developed along with the S&IP was reviewed and modified in accordance with the new logframe model developed by the AIDSCAP Headquarters Evaluation Unit in 1994. The wording of various indicators were refined and articulated in such a way that aspects of quantity, quality and time could be better identified. The new indicators accurately reflect the developments on World Health Organization/Global Program On AIDS (WHO/GPA) prevention indicators (PIs) as well as AIDSCAP's consensus on relevant indicators. The revised logical framework for the DR program is as follows:
The HIV/AIDS epidemic has become well established in the Dominican Republic over the past ten years. The United Nations Programme on AIDS (UNAIDS) now estimates that over 85 percent of the HIV infections in the Caribbean are in Haiti and the Dominican Republic (UNAIDS 1996). While the first phase of the Dominican HIV/AIDS epidemic occurred among groups at particular risk for HIV infection (CSWs, MWM), more recently measurable rates of HIV infection have occurred among groups representative of the larger Dominican population. The second phase of the HIV/AIDS epidemic is consistent with patterns found in other countries with significant HIV/AIDS epidemics -- early and dramatic increases in HIV among risk groups followed by rising levels of infection among sexually active men and women, then slow and steady increases in HIV prevalence in the general population. The National AIDS Control Program established an HIV Sentinel Surveillance Program in 1991 to track HIV infection among the Dominican population. The system was expanded in 1992 to include other geographical areas, but it is still limited to a few large cities. These sentinel surveillance data, together with other scientific studies conducted in the DR, help trace the status and trends of the Dominican AIDS epidemic. However, given the small size of the country, and the high mobility of the population, it is possible that high rates of unmeasured HIV infection are present in areas not covered by the sentinel surveillance system. Data collected by PROCETS surveillance of reported AIDS cases are underestimated by 50-70 percent. There is a also a limited ability to conduct in-depth interviews to accurately determine the characteristics and routes of infection of many of those reported with AIDS (PROCETS, 1997). The increasing rates of HIV prevalence among prenatal women, especially in Puerto Plata, is alarming. Rates range from 2.9 in 1994 to 7.9 in 1996, rivaling rates found in such locations as Bangkok, Thailand and some areas of Sub-Saharan Africa. It is estimated that the current HIV seroprevalence rate for sexually active Dominicans is now 2.5 percent. Recent projections estimate this may increase up to 4.3 percent by the end of the decade. (Gomez, Sweat, et al, 1996). As of January, 1997 the total number of AIDS cases reported to the National AIDS Control Program (PROCETS) was 3,631. Of the cumulative reported cases 67 percent have been male; and the male to female ratio of AIDS cases has decreased progressively, implying an increasingly heterosexual epidemic. The male to female ratio of cases was 7:1 in 1984, and 2.2:1 in 1991, with a cumulative ratio of 2.13:1 by 1996. Over 80 percent of the cumulative cases has been through sexual transmission. Seventy-five percent has been through heterosexual transmission, and 9 percent through homosexual or bisexual transmission. Every year since 1986, the percentage of heterosexually acquired AIDS has increased. Although controls for blood screening have been in place since 1986, 6.6 percent of AIDS cases are attributable to blood products. Among the cumulative reported AIDS cases 55 percent are between 15 and 35 years old, evidencing a youth driven epidemic. The geographic distribution of AIDS cases includes 45.6 percent from the National District (capital city and suburbs). Followed by the main cities of the country: 7.3 percent from Puerto Plata, 5.5 percent from Santiago, and the remaining 41.6 percent of cases scattered throughout the entire country. Every province has reported cases of AIDS. A number of factors contribute to the spread of the epidemic: an ever-growing commercial sex industry (male and female); a thriving tourism industry; poverty; social and gender inequity; migration, especially Haitian inflow and US/DR seasonal migration; and, alcohol abuse. DR programs to address the epidemic have been mainly developed by the non-governmental sector. These have been small scale and mostly supported by international donor agencies. Donor involvement in support of HIV/AIDS programming has expanded in the past couple of years. New European funders have recently become more involved, in addition to some private American foundations. Significant European Union (EU) funding will be available for the next couple of years. However, USAID donation continues to be the major support to HIV/AIDS programming in the DR. Furthermore, UNAIDS has increasingly played an important role in political advocacy and has been instrumental in raising awareness about the need for coalition building and coordination. Public sector initiatives and programs have been limited due to lack of resources and governmental support. PROCETS' budget is insufficient to support the comprehensive program needed to face the epidemic. Financial limitations, along with political changes, have dispersed key technical personnel, jeopardizing PROCETS' ability to play a lead role in program development and coordination. However, the socioeconomic and political environment in the Dominican Republic has changed recently. New government leadership consolidates a growing democratic process and brings hope for greater attention to prevention and control of HIV. Interest in improving social welfare in the areas of health and education has been expressed. Thus, it is anticipated that policy changes will result which could positively affect the HIV/AIDS projects supported to date. The newly appointed minister of health has established HIV/AIDS as one of the main health priorities in the country, and has promised to support and promote action plans that improve services. The emergence of the new government also poses new challenges in terms of negotiating further collaboration between governmental organizations, NGOs, international donors, and the private sector. The AIDS NGO Coalition formed by the five principal implementing agencies funded by AIDSCAP/DR has been approaching these issues. Introduction During the last five years the AIDSCAP/DR program made significant achievements in STI/HIV/AIDS prevention in the Dominican Republic. Knowledge and behavior change in specific target populations were significantly influenced. Changes attained with specific audiences were measured by the EOP KAPBs (described in the Project Outcomes section). Furthermore, the 1996 Demographic Health Survey (ENDESA/DHS) demonstrated an almost universal knowledge of basic HIV/AIDS concepts, prevention measures, and knowledge of where to access adequate STI services and condoms. The AIDSCAP/DR program contributed significantly to these achievements through its mass media campaigns and targeted interventions. AIDSCAP/DR also played a strong role in advocacy and policy for STI/HIV/AIDS prevention, attaining wide public and private sector support and involvement. In particular, AIDSCAP/DR was very successful in leveraging support from the private sector. Throughout the last five years this sector increasingly supported AIDS prevention efforts. In a joint venture with a pharmaceutical distributor, new market niches were devised to make condoms more accessible. Other examples of private sector collaboration are the support of the media in the dissemination of HIV/AIDS information and the youth and HIV/AIDS prevention campaign. STI diagnosis and treatment services were also considerably improved through upgrading of facilities, training programs for health care providers, STI drug logistics and STI treatment norms identification. Successful program implementation was achieved through a combination of strategic planning, hard work, excellent human resources, and patience and perseverance to overcome the multiple constraints encountered. Most of these constraints relate to political issues, personnel turnover, coordination and timing issues. Accomplishments and Constraints Behavior Change Communication AIDSCAP/DR's efforts in the BCC program area were focused on strengthening existing STI/HIV/AIDS programs, broadening the reach of HIV/AIDS prevention activities and expanding interventions within the targeted populations in the DR. As the program evolved, AIDSCAP/DR's role in communications support surpassed what was originally envisioned in the S&IP. AIDSCAP/DR also developed BCC materials in support of the targeted interventions which far exceeded the stated program goals. Additionally, the program was involved in a variety of activities designed to raise awareness on STI/HIV/AIDS, including educational and informational campaigns in coordination with the private and public sector. Television and press interviews and dialogues with key people in the country were also an important part of communication activities. Major accomplishments within this program area are as follows: Development of National BCC STI/HIV/AIDS Prevention Strategy -- The AIDSCAP/DR program provided technical assistance and logistics support to PROCETS for the development of the National Information, Education and Communication Strategy for HIV/AIDS prevention. This strategy has guided all BCC initiatives surrounding HIV/AIDS prevention in the DR. Target audiences prioritized in this strategy were addressed with interpersonal interventions supported by mass media communication campaigns. Youth Mass Media Campaign -- A growth in public awareness about STI/HIV/AIDS has been evidenced during the last two years. This can be partially attributed to the youth mass media campaign, successfully implemented since 1995. With 38,495 television and 454,770 radios spots aired between September 1995 and March 1997, this aggressive campaign has gained public attention and has influenced other groups of society. Evaluation showed a high recollection of key messages and an increase in risk perception to STI/HIV among youth. This campaign was developed by AIDSCAP/DR in close collaboration with PROCETS and key organizations working with youth in the country. AIDSCAP played a leading technical role in the development of the strategy and in the production and dissemination of the mass media messages. To promote health and information seeking behavior among adolescents, AIDSCAP/DR sponsored the standardization of criteria on STI/HIV/AIDS information, education and counseling services among organizations working with youth. Approximately 100 organizations working with youth and health throughout the country were trained in STI/HIV/AIDS prevention. Participants received a manual that was developed in support of criteria standardization for HIV/AIDS prevention. Dissemination of this campaign was very successful. Tremendous support was obtained from the private sector with a contribution of free air time. The campaign won first prize as the best educational effort for adolescents at the Second Seminar on Communication and Sexual/Reproductive Health for Adolescents of Latin America and the Caribbean. This seminar was held in Zacatecas, Mexico in November 1996, and was sponsored by the Japanese Organization for International Cooperation in Family Planning (JOICFP). The campaign materials were reproduced and distributed among 15 participating countries for evaluation purposes. A third phase campaign spot won the 1996 Best Award for the DR granted by Mercado/Advertising Age. This is the local partner of the US based association of advertising and marketing agencies worldwide. Advertising Age, in turn, selected the spot for their worldwide competition. BCC STI/HIV/AIDS Prevention Strategy/Campaign Targeting Young Women -- During its last year the AIDSCAP/DR program sponsored the development of a BCC STI/HIV/AIDS Prevention Strategy targeting young women. This strategy was developed in close coordination with PROCETS and the DGPM (the Ministry of Women's Affairs). A number of organizations working with women and youth were also actively involved under the leadership of the NGO Coordinadora de Animación Socio-Cultural (CASCO). This strategy emphasized the empowerment of women to decrease their vulnerability and dependency on men. It also promoted the strengthening of their negotiation power regarding sexual and reproductive issues. A methodological manual was developed and printed along with the strategy to guide the development and implementation of programs targeting young women. The mass media plan of this strategy was developed during a workshop held in collaboration with CASCO. Participants were representatives from youth and women organizations and HIV/AIDS NGOs. This workshop was significant in the DR because for the first time HIV positive women, non-CSWs and women not linked to a risk group, talked about their seropositive condition. Mass media efforts developed under this campaign consisted of two television and radio spots, supported by a poster, brochure, flyer and billboard. The campaign spots will continue to be aired beyond AIDSCAP EOP. Materials were extensively distributed through participating organizations and other women's groups and associations. Production of Targeted Program Educational Materials -- The high quality of BCC materials produced during the life of the AIDSCAP/DR program is widely acknowledged. Small media materials such as flipcharts, brochures, pamphlets and fliers were developed for the targeted interventions and in support of mass media campaigns. Materials developed for youth include those produced for the Acuario project of CASCO/ Instituto Dominicano de Desarrollo Integral (IDDI). A total of five different materials targeting youth were developed for this project. Other materials were developed for a broad range of target audiences including:
A variety of STI/HIV/AIDS materials were produced to further HIV/AIDS awareness among groups outside the targeted population and to complement those developed within subprojects. Some were policy tools, such as the AIDS Law and the Status and Trends of the HIV/AIDS Epidemic document. Others were small media produced for special audiences, such as the military and residents of sugar cane plantations (bateyes); and for special events and activities, such as World AIDS Day, Holy Week (Spring break) and carnival and basketball season. As part of its capacity building efforts, the country office (CO) also assisted organizations in developing institutional materials such as brochures, bulletins, newsletters, organizational marketing dossiers etc. All materials developed with AIDSCAP/DR's assistance were based on research, target audience participation and the application of BCC theoretical models. They were all subject to an extensive field-testing process and changes were incorporated accordingly. For BCC accomplishments during 1992-1997, see Non-Subproject Highlights. Intersectorial participation and coordination is a new trend in the DR. Due to a lack of tradition or experience, the process of coordination was often challenging and time consuming. People assigned by the organizations to participate in the team process often were not delegated authority to make timely decisions. It also proved difficult to maintain the same point person throughout the whole process. This resulted in delays when coordinating BCC activities that required intersectorial collaboration. Furthermore, overcoming technical staffs' personal bias was difficult because sometimes it was sometime contrary to field-test results and this made it difficult to come to agreement on material content. Thus, producing materials that truly responded to target audience concerns became time consuming. Another constraint faced was that on several occasions the Ministry of Health (MOH) paid the mass media to air health related public service messages therefore setting a precedent. This called for stronger negotiation skills to obtain support from the private sector mass media for free airing of AIDSCAP-created television and radio spots. Sexually Transmitted Infections AIDSCAP/DR's efforts in this program area were centered on capacity building towards implementation of effective and sustainable services to prevent and control the spread of sexually transmitted infections. Efforts were also concentrated in improving access to quality STI services that provide and promote appropriate diagnosis, treatment and prevention of STI, including: counseling; condom promotion; compliance with antibiotic treatments; and contact tracing/partner notification for the treatment of sex partners. STI Syndromic Management Training -- AIDSCAP/DR contributed greatly to the improvement of STI service delivery through the development of a training program targeting clinician and non-clinician service providers serving the target population. This program was based at a local university, Instituto Tecnológico de Santo Domingo (INTEC), and was the first systematic STI training in the Dominican Republic. Expertise remains at this educational center to further replicate training as described below. In total, 854 people were trained in the syndromic approach to STI diagnosis and treatment. This included 325 clinicians and 529 non-clinicians. The program successfully established a standardized method for diagnosing and treating STIs as a means of AIDS prevention without relying on elaborate laboratory techniques. Trained personnel have been able to implement these skills throughout the DR where sophisticated health infrastructure is limited. Other STI accomplishments include STI drug logistics assistance to the National Essential Drug Program (PROMESE), STI treatment guidelines development, algorithm validation research, reporting and referral system development. Overcoming the barriers of clinicians to syndromic versus etiologic diagnosis and clinical management remains difficult. Additionally, logistics system problems continue to affect STI drug distribution. Personnel turnover at PROCETS delayed the process of defining national STI treatment guidelines. Condoms Efforts in this program area were concentrated on improving the availability and accessibility of condoms for HIV/AIDS prevention through appropriate logistics management, community distribution and social marketing. Budget limitations constrained program design options, and the funding of a full condom social marketing program did not materialize. Innovation was necessary, and within the confines of severe resource limitations, the accomplishments of AIDSCAP were significant, and, from a design perspective, quite interesting. The two main areas identified for technical assistance were condom distribution expansion and logistics management strengthening and training. Condom Distribution Expansion -- The AIDSCAP/DR program took important steps to increase the availability of condoms for STI and HIV prevention in the DR. A condom retail audit conducted by AIDSCAP/JSI in 1994 found the non-availability of low cost condoms nationwide. Thus, the new condom brand "Pantera" was developed for the USAID-donated Panther condom. Market research was conducted to test consumer preference for condom packaging and to identify market opportunities. Subsequently, partnerships were negotiated involving the AIDS NGOs and a private sector multinational pharmaceutical company SmithKline Beecham. This partnership with the private sector was a unique and first time endeavor to ensure access to good quality, low-priced condoms on a national scale. AIDSCAP/John Snow Incorporated (JSI) was instrumental in fostering these agreements and provided the technical support to initiate the venture. The support obtained from the private sector significantly contributed to AIDSCAP's strategy for private sector leveraging. Through SmithKline Beecham, the Pantera condom was sold to Colmados (convenience stores), supermarkets, and drug stores nationwide. Through the NGOs the Pantera condom was sold through hotels, motels and bars established in the geographical areas where their HIV/AIDS prevention programs were being implemented. Within a year SmithKline moved Pantera into the number three spot in the country in terms of sales, and into first place in terms of breadth of distribution. By July 1997 an additional 200 retail outlets were selling condoms compared to October 1994. Technical assistance and training in marketing and sales were also provided, and a promotional plan and advertising materials for the Pantera condom were produced and delivered through the NGOs. Furthermore, AIDSCAP/DR has also used its media leveraging power to air public service announcements (PSAs) in support of condom distribution through colmados. Profits generated through the transactions between the community-based distribution (CBD) program and the private sector partner will continue to support condom availability. Efforts to make this a sustainable social marketing venture will continue beyond the end of the AIDSCAP project. Results of the relatively short social marketing effort were impressive. Two major advertising campaigns were financed by the income from sales, and the distributor invested significantly in the brand. Logistics Management Strengthening -- AIDSCAP/DR provided a high level of technical assistance and training in logistics management of condoms and STI drugs to both the NGOs and the private sector partner to ensure the success of condom distribution. Technical assistance and training in logistics management was also provided to the public sector through PROCETS, the National Council for Family and Population (CONAPOFA) and the Essential Drugs Program. This resulted in the procurement of four million condoms by the government of the Dominican Republic (GODR) to be distributed free of charge to underserved populations. Lists of appropriate STI pharmaceuticals to support syndromic management were provided to the managers of PROMESE. However, supply levels were irregular and many logistics problems persist. The private and public sector partners encountered some difficulties which delayed full implementation of the program. Overcoming barriers to condom sales through non-traditional outlets continues to be a difficult process. Also, project initiation was delayed for over one year while the private sector partner underwent a merger with a multinational company and while sales tax issues were resolved. A fire at PROMESE's warehouse destroyed most of the condom inventory. This created a gap in free condom supply to undeserved populations that remains to date. STI drug distribution to primary health care facilities was obstructed by logistics problems related with inventory control and demand from the field and condoms are made available through this distribution system. Thus, problems impacting the drug system affected condom distribution. Future technical assistance to improve condom logistics management must include revision and an upgrade of the whole system. Policy AIDSCAP/DR's activities in this area were oriented towards providing decision makers with the information and motivation to develop national policies conducive to supporting and implementing HIV/AIDS prevention programs, and to mobilize necessary resources for sustainability. Epidemiological information is vital to create awareness and motivate action at the policy level. Therefore, support to policy and surveillance activities were considered under one programmatic support area within the AIDSCAP/DR program. The following activities were successfully accomplished: Policy/Surveillance Activities -- Throughout the life of AIDSCAP/DR, efforts were made to increase awareness and response to STI/HIV/AIDS among policy makers in the DR. Special events, such as forums, conferences, workshops, television interviews/talk shows, and press releases were used to target key public and private sector decision and policy makers, high level government and church officials as well as the general population. Projections of the HIV/AIDS epidemic up to the year 2000 were developed in 1993 and presented at most of these events. Two versions of an HIV/AIDS Status and Trends document were produced: one for lay people and another for technical audiences. The second document was essential in guiding HIV/AIDS control and prevention activities and continues to be used by PROCETS and other organizations as a resource in most HIV/AIDS awareness activities. Revised projections as of February 1997 resulted in an updated version of this document that will undoubtedly be as useful as its predecessor. The presentation of these projections to high level government officials may have been instrumental in having the AIDS law enacted. The projections were also presented in international events such as the 10th International AIDS Conference held in Japan and the third USAID Prevention Conference held in Washington. Support to the PROCETS Sentinel Surveillance Program -- Throughout the last five years AIDSCAP/DR collaborated with the Sentinel Surveillance Program of PROCETS which was created in 1991 to track levels of HIV infection in eight health regions, as well as determine patterns of transmission and trends of HIV prevalence. AIDSCAP/DR and the Pan-American Health Organization (PAHO) supported the HIV Sentinel Surveillance Program in numerous ways. AIDSCAP assisted PROCETS with the transportation of blood samples and provided all of the reagents, such as the Elisa kits, necessary to test these samples. The data collected were compiled into periodic Epidemiological Bulletins and Sentinel Surveillance Bulletins which also contained articles and editorials on topics such as AIDS legislation, updates on the national adolescent campaign, and the role of the church in HIV/AIDS prevention. PROCETS and AIDSCAP developed the program contents of two seminars which updated health personnel and public opinion leaders on the HIV/AIDS situation in the Dominican Republic,. Two additional seminars allowed professionals to analyze the trends of the epidemic during the period of 1991-1995, evaluate the results obtained by the Sentinel Surveillance Program, and provide recommendations to improve the system. AIDSCAP also provided technical assistance to PROCETS on the development of a database of STI/HIV/AIDS research in the Dominican Republic. Specifically, AIDSCAP worked with PROCETS on the design of indicators for 78 STI/HIV/AIDS research documents in the database, a system to update the database and a plan for disseminating information from data searches. Dissemination of National AIDS Law -- AIDSCAP/DR, in collaboration with the Instituto Nacional de la Salud (INSALUD), the DR equivalent to American Public Health Association, provided support to promote and increase awareness about the AIDS Law and its implications among policy makers and public opinion leaders. Four meetings were held to disseminate the AIDS Law among women associations, health care providers, and law enforcers. Policy Related Research -- The AIDSCAP/DR program sponsored a Socioeconomic Impact Study of AIDS in the Industrial Zones of the DR in February 1996. Results were used to increase awareness among the business community about the dimension of the epidemic and its present and future socioeconomic impact on industries. In collaboration with COIN, results were used to develop a set of guidelines on "AIDS in the Workplace". These will facilitate initiation of HIV/AIDS prevention programs in the workplace. A separate study was conducted in the tourism sector in collaboration with the Ministry of Tourism (MOT). Interviews were conducted with tourists, hotel workers and management staff and commercial sex workers. This study assessed how tourism and HIV/AIDS are related in the DR and what the potential impact of HIV/AIDS is on tourism. The results were presented to selected sector businessmen and policy makers in collaboration with the Ministry of Tourism. Data collected will guide future policy endeavors with this sector. PROCETS has not been able to assume a leading or supporting role due to budget limitations, high personnel turnover, and lack of consistent political support from higher GODR levels. The scope of AIDSCAP/DR's influence on policy matters was limited by USAID/DR's regulations regarding direct involvement with local authorities. Furthermore, in various situations (especially electoral periods), any attempt to influence policy makers regarding the AIDS agenda would have been politically inadequate. Other health and education problems that affect the DR population in a more visible way than AIDS have been designated as higher priority by policy leaders and decision makers. Private Sector Leveraging AIDSCAP/DR successfully managed to identify ways to facilitate collaboration from the private sector. Consequently, extensive contribution and involvement of this sector in HIV/AIDS prevention activities was attained. The following is a summary of AIDSCAP/DR's efforts in this area. Workplace Programs -- The AIDSCAP/DR program sensitized businessmen to support workplace STI/HIV/AIDS prevention programs. Several meetings held with business associations to discuss the AIDS law were supported by AIDSCAP/DR. The National Association of Young Businessmen began collaborating in AIDS law dissemination and has facilitated program activities. Results of the study on socioeconomic impact of AIDS on the Industrial Zones of the DR were used to assist IAs in leveraging support from the private sector. These results were shared with private sector businessmen during a workshop at the AIDS Conference in July 1996. Partnership with the Private Sector -- As explained in the condom section of this report, the AIDSCAP/DR program was instrumental in establishing an agreement between a local NGO and a private sector multinational pharmaceutical company, SmithKline Beecham for condom distribution expansion. The financial resources of this partner significantly contributed to sustain the condom distribution program. This includes covering packaging costs, advertising and some promotion and market research. It also covered part of the costs for managerial staff, transportation and warehousing. Other Private Sector Collaboration -- During the last five years, the AIDSCAP/DR program intensively leveraged private sector support for STI/HIV/AIDS Prevention. Private sector product and service providers, such as advertising agencies, printing companies and graphic artists contributed to AIDSCAP's prevention efforts. The most impressive example, however, was the support obtained for the mass media campaign targeting Dominican youth. Production costs were under 50 percent of market price due to collaboration from an advertising agency and local artists. Dissemination of the Youth Campaign was extensive. From September 1995 to March 1997, 38,495 television spots and 454,770 radio spots were aired free of cost. This represents over US $9,000,000 in free air time. The Dominican press also contributed to BCC efforts by publishing numerous articles on the campaign. The AIDSCAP/DR program also collaborated successfully with the Central Romana Corporation (CMR) in the integration of STI/HIV/AIDS services into their existing private health care system. They provided training facilities and logistics support to medical staff and lab technicians being trained in STI/HIV/AIDS. CMR also collaborated with the Algorithm Validation Study which produced a profile of women at high risk for STIs. They facilitated sample collection and covered a substantial part of the costs incurred in this activity. Industrias Nigua, a private sector paper product manufacturer, has produced over 30,000 thousand notebooks for high school students with two different AIDS prevention messages on the cover page. Program Related Research The following Program Related Research were studies conducted during the life of the AIDSCAP/DR program in support of specific program areas and/or projects. The studies encompassed formative research for design of new interventions, as well as qualitative and quantitative assessments to redirect and/or evaluate strategies and interventions. Sexual Behaviors and Risk Factors for HIV Infection among MWM (COIN) -- A cross-sectional study of men who have sex with men (MWM) was conducted in 1994. The purpose of the study was to identify the types of sexual identities among MWM in the DR, assess socio-demographic and behavioral characteristics and measure the prevalence of HIV-1 and syphilis of this population. The study recruited 354 MWM who completed questionnaires about sexual behaviors, sexual identity and history of STIs. Men known to be HIV positive were excluded from the study. After giving informed consent, the men were tested for HIV and STIs. The study identified five main sexual identities within the Dominican MWM community: homosexual, cross-dresser, gigolo, bisexual and heterosexual. Significantly, half of MWM self-identified as heterosexual. In general, homosexuals and cross-dressers practice both receptive and insertive oral and anal intercourse while gigolos, bisexuals and heterosexuals practice mainly insertive oral and anal sex. Commercial sex work was prevalent among all groups. Sex with women was nearly universal among gigolos, bisexuals and heterosexuals and quite common among cross-dressers and homosexuals. Consistent condom use was infrequent during sexual encounters with men and especially rare during sex with women. Rates of HIV infection were higher among those MWM who practiced receptive anal sex than among those who practiced only insertive anal sex. HIV was especially prevalent among cross-dressers, many of whom were involved in the commercial sex industry. Syphilis emerged as the most important independent predictor of HIV infection; men with syphilis were four times more likely than uninfected men to have HIV, regardless of whether they practiced insertive or receptive anal intercourse. Results of this study have guided strategy for educating the MWM community. The finding that syphilis is highly correlated with HIV infection suggests that the MWM community needs access to prompt and thorough STI treatment services. Inconsistent condom use with both male and female partners indicates a need for aggressive behavior change interventions in this population. Women in "Bateyes" -- This study was conducted with women living in bateyes (sugar cane plantations) of a large private sugar cane processing company in the Eastern part of the country. The purpose of the study was to determine risk factors for HIV infection. Five hundred and nine (509) women volunteered to be interviewed and tested for STIs and HIV. Fifty-three percent of women interviewed were Haitian. Fifty-eight percent had no formal education. Results indicated that women living in bateyes have a high HIV prevalence, similar to that of Dominican CSWs. Independent predictors of HIV infection included being under age 35, being single with children, having had more than one sex partner in one's lifetime and self-identification as a CSW. Haitian women coming to the DR alone were more likely than those in union to be HIV infected. Less than 4 percent of women reported condom use at last intercourse. These results indicate that HIV/AIDS prevention needs to prioritize education on condom use and to improve access to condoms. Developing employment opportunities and adult education for women may reduce risky commercial and transactional sex. Two posters for semi-literate audiences were developed to address these issues. Educational efforts, however, need to be furthered and structural changes identified and implemented. Also, syndromic management of STIs needs to be continued. Algorithm Validation Study -- In order to evaluate the effectiveness of the WHO algorithms for the syndromic management of STIs, researchers from the University of Washington conducted a study of CSWs and STI clinic attendees. Syndromic management for urethral discharge and genital ulcers was found to be successful and easily implemented. The researchers suggested expanding the treatment protocol for urethral discharge to include men complaining of pain with urination but without urethral discharge on examination. They also recommended expanding counseling and condom promotion for genital ulcer patients with suspected herpes. Some modifications were recommended for the vaginal discharge algorithm. In women most STIs are asymptomatic, and many patients complaining of vaginal discharge do not have STI but rather non-sexually transmitted infections such as bacterial vaginosis or yeast. In order to identify which patients are more likely to have STI the researchers suggested creating a scale for risk evaluation, using socio-demographic variables, such as age and marital status, which are correlated with STI. In addition, the researchers encourage the use of simple "signs and symptoms" tests that can be done under speculum exam but do not require laboratory resources. These changes improved overall accuracy and validity of the vaginal discharge treatment protocol. This study complemented the STI Syndromic Management Training Program conducted from 1995-1996 by Centro de Enfermedades de Transmisión Sexual y SIDA-Instituto Tecnológico de Santo Domingo (CETS-INTEC). Results were essential to the promotion of the syndromic approach as the national norm for STI treatment. Gender Study -- During 1995-1996, a study was conducted among female adolescents, ages 15-24, from squatter settlements in Santo Domingo. The purpose of this study was to identify barriers to adopting safer sexual practices. Twenty-four focus group discussions were held to analyze the influence of sexual roles and the ability of females to assume safer sex practices, and to identify agents and information needed to achieve modifications in sexual conduct. Differences in attitudes about condoms were observed according to the women's sexual experience and partner status (having or not having a steady partner.) Women without sexual experience viewed condoms as a contraceptive method. Women with steady partners resisted condom use. Sexually experienced women without steady partners viewed condoms as a means to prevent STI/HIV/AIDS. The majority of females interviewed preferred receiving information and counseling from older and more experienced health promoters. They also preferred education in small groups without the presence of males. Results were used to improve educational strategies for youth programs, and to develop the National BCC Strategy for STI/HIV/AIDS Prevention for Young Women. 100 Percent Condom Use Study -- The 100 percent condom pilot project was modeled after a successful 100 percent condom program which the Thai government instituted in commercial sex establishments in that country. Formative research to determine feasibility for a 100 percent Condom Use Program in the DR was conducted in 1996. The study was conducted in the catchment area of COIN's educational intervention for CSWs. In depth and key informant interviews were conducted with 69 participants. The participants included COIN's Health Messengers, CSWs, their partners, brothel clients and brothel owners. Personal histories, demographic data, and information on beliefs and knowledge related to STI/HIV/AIDS were collected. The study found that while condom use had become nearly universal in brothels, condom use was less consistent in bars associated with the commercial sex industry. Brothels typically serve higher socioeconomic status patrons while bars tend to serve a lower socioeconomic class. In addition, the study found that CSWs were less likely to use condoms with regular clients or with their partners (boyfriends and husband) than they were with non-regular clients. The researchers felt that the steady partners of CSWs needed to be targeted for education regarding condoms and STI/HIV/AIDS. A 100 percent Condom Use Pilot Program was initiated in March 1997 based on research findings. In addition to targeting bar and brothel owners, the program addressed policy makers and public health officials about the importance of implementing a 100 percent condom use policy in Dominican brothels. COIN hopes to work with the national STI control program to develop a 100 percent condom seal for commercial sex establishments adhering to the 100 percent condom policy. Socioeconomic Impact of HIV/AIDS in the Free Trade Zones -- The objective of this study was to determine how businesses are currently being affected by HIV/AIDS and to estimate how the epidemic's socioeconomic impact may change over time. Socioeconomic impact studies provide vital information to business leaders who are reviewing the possible benefits of initiating HIV/AIDS prevention programs in the workplace. The study of the socioeconomic impact of HIV/AIDS on the free trade zones found that the epidemic is poised to have a significant negative impact on the Dominican economy. Free trade zones employ only 5 percent of the Dominican workforce but account for 60 percent of the country's exports. This population is young, often single and highly mobile, in other words, at risk of STI/HIV/AIDS. Surveys indicate that only 21 percent of workers in the free trade zones use condoms consistently, and more than 40 percent of workers know someone who has AIDS. Currently about 6,000 workers are HIV positive, a number which is expected to rise to between 9,000 and 10,000 within the next five years. The study estimates that the economic impact of AIDS in terms of lost productivity is approximately RD $680 per worker. Comprehensive HIV prevention programs cost between RD $200 and RD $335 per worker. Tourism and AIDS in the DR -- This study summarized a number of surveys completed with tourists, hotel workers and managerial staff and CSWs. The interviews assessed how tourism affects the spread of HIV/AIDS, how HIV/AIDS may, in turn, affect tourism and how tourists are likely to react to prevention campaigns. Interviews with male tourists who had had sex with Dominican women found that a majority did not self-identify as sex tourists, despite stating that they had paid for sex while in the DR. Seventy-five percent of these tourists reported using condoms. CSWs indicated high (but not universal) rates of condom use with tourists. Condom use with friends, boyfriends and husbands was much lower, suggesting that CSWs may be at greater risk of contracting STI/HIV from their steady partners than from their clients. Many CSWs interviewed stated that some tourists offered to pay more for sex without a condom. Most tourists stated that they either supported or were indifferent to HIV/AIDS campaigns in the DR. Few tourists stated that seeing HIV prevention materials in the DR would deter them from visiting again. Findings indicated the need to target specific groups with HIV/AIDS prevention messages in order to minimize the social and economic impact that could occur within the tourism industry and the country as a whole. Both workers in the tourist industry and tourists themselves are at high risk of contracting and transmitting STI/HIV. These groups, especially "entertainment" workers who tend to have sex with tourists more often than other workers in the industry, need to be aggressively targeted for educational interventions. It may be useful to create HIV/AIDS prevention materials in languages other than Spanish since many tourists are native speakers of German, English, French or Italian. Further research will be necessary to assure that messages are adequately designed and presented to the selected populations. KABP Study among University Students -- This was a self-administered survey among 1,013 students from the universities Universidad Autónomo de Santo Domingo (UASD) and the Instituto Tecnológico de Santo Domingo (INTEC). The purpose of the study was to assess KABP about STIs among university students, to determine the appropriate channels to provide information to this population and to identify service delivery needs. The results obtained through the survey revealed significant gender inequities in Dominican society. Women typically have fewer opportunities than men to obtain information about sexuality and STIs. In addition, women are not provided condoms as often as men, even at logical condom distribution centers such as STI clinics. Finally, women appear to have little ability to control their sexual lives. The inability to negotiate condom use or to refuse sex from a partner places women at risk of acquiring both STI and HIV. The study highlights the importance of targeting both male and female university students for condom distribution and educational interventions. STI treatment services need to become more accessible to women. The results of the study were used for the development of STI educational material targeting this audience. This information will also serve as a baseline for future educational interventions. Summary Process Indicator Accomplishments for Aggregate Country Program Table 1: Summary Process Indicator
Project Outcomes Evaluation research has shown several positive trends resulting from AIDSCAP's HIV/AIDS prevention interventions. First, HIV prevalence has been stable in several sentinel populations, and declines have been noted among CSWs. Second, knowledge of HIV prevention methods is nearly universal among target populations. Third, an overwhelming majority (85 percent) of men report having changed their behavior to lower their risk for HIV infection. Fourth, condom use increased significantly among all target populations, and CSWs report nearly 100 percent condom use with non-regular clients. Nonetheless, several persistent negative factors continue to hinder HIV/AIDS prevention in the DR. First, high levels of STIs were reported in the general population and among youth. Second, beliefs in incorrect means of HIV transmission are widespread. Third, negative attitudes towards PLWHIV/AIDS create a hostile and discriminatory environment. The following section discusses in more detail biologic and behavioral trends in the Dominican Republic. Biologic Impact HIV/STI Prevalence -- AIDSCAP and PAHO have supported PROCETS in the establishment of an HIV sentinel surveillance program among three target populations:
HIV trends among antenatal and STI clinic attendees have been more or less stable over the last five years, with the exception of antenatal women in Puerto Plata, which has seen increases from 3 percent in 1994 to 8 percent in 1996. Among CSWs in Santo Domingo, HIV seroprevalence seems to be declining, although the factors behind this decline are unclear. (See Table 2 below.) Table 2: HIV Sentinel Surveillance Trends in Three Target Populations 1991-1996
In addition to sentinel surveillance, AIDSCAP supported an STI/HIV study in 1994 among MWM in Santo Domingo. Serologic evidence of syphilis was found among 7.3 percent of the participants (56 percent of whom had active syphilis). This same study also tested the participants for evidence of antibodies to HIV. Of the 344 participants, 11 percent were HIV seropositive. The percent of seropositivity varied by sexual identity: cross dressers (34.4 percent), homosexuals (11.7 percent), bisexuals (6.1 percent), gigolos (6.5 percent) and heterosexuals (8.2 percent). While there is no baseline data to compare with these results, they should be used in the future as baseline data for other studies. STI data are also limited, both in terms of availability and in terms of quality, consistency, and ability to interpret. In 1989 there were 14,321 cases of reportable STIs reported to PROCETS. Chlamydia accounted for approximately 20 percent of all STI cases followed by syphilis (11.3 percent), and Gonorrhea (8.6 percent). In 1996, the number of reported cases dropped to 6,365, a decrease of more than 55 percent. The most commonly occurring STIs were: Vaginal Candidiasis (13.5 percent), Chlamydia (13.5 percent), and Indeterminate Cervicitis (12.3 percent). This apparent decrease may be due to under reporting and to a lag on service delivery due to political turmoil associated with the presidential elections. Outcomes Knowledge -- Knowledge of HIV transmission and prevention varied widely by target population in baseline studies conducted in 1992 and 1993. High risk target populations had the highest levels of recognition of HIV/AIDS and knowledge of HIV prevention. Knowledge was highest among men who have sex with men, with almost universal understanding of HIV prevention methods. CSWs were similarly well informed, with over 90 percent correctly identifying HIV as an STI. Low income youth in Santo Domingo reported much lower levels of knowledge of HIV prevention. A baseline survey conducted in 1992 found that 85 percent knew that HIV was a STI, but that only 45 percent believed that it was preventable. Only 22 percent (28 percent of male youth and 18 percent of female youth) believed that condoms helped to prevent the spread of HIV. At follow-up, knowledge of two or more prevention methods was universal across every target population (Table 3). Table 3: Percentage of Various Target Populations with Knowledge of 2 or more HIV Prevention Methods, 1996
In addition, the 1996 national ENDESA/DHS survey of the general population found that nearly 100 percent of the population surveyed were aware of HIV/AIDS. However, the survey also found a significant amount of myth and misinformation surrounded HIV/AIDS knowledge. Among men, 26 percent reported that a good diet could prevent HIV, 50 percent reported avoiding public bathrooms was a prevention means, 39 percent reported not touching a person with HIV, 43 percent reported not sharing food with a person with HIV, and 63 percent reported avoiding mosquito bites. Gaps in correct knowledge may lead to individuals believing they are taking the right precautions when in fact they are not. This might then lead to increased transmission of HIV. An additional impact of these misconceptions is continued discrimination against people currently infected with HIV. Decreasing these fears is essential in the struggle against the spread of the virus and in ensuring that people living with HIV and AIDS are treated with compassion and respect. Perception of Self-risk -- Perceived risk for HIV infection varied among each target group: youth reported the lowest overall level, with 22 percent perceiving "some" risk, and MWM the highest level, with 71 percent perceiving "some" risk. The level of perceived risk among different target populations is a difficult indicator to analyze. Accurate risk perception requires knowledge of HIV transmission and prevention, self-assessment of risk behaviors, and estimates of exposure to HIV (for example the prevalence of HIV within the target population). While relatively few youth report perceiving risk, this low overall perception of risk could be due to the fact that the youth also report fewer sexual partners and increased condom use, compared to baseline studies. Results of focus groups conducted with youth found that a perception of risk that was group based, and not individual. They were aware of the potential risks and know that they are not invulnerable. Thirty-seven percent of CSWs reported "some" perceived risk for HIV infection in 1996. This figure is barely changed from baseline studies conducted in 1993, which found 33 percent. Paradoxically, the post-intervention study found that 74 percent of CSWs had changed their behavior to reduce their risk for HIV infection. It seems possible to speculate, therefore, that the higher level of behavior change resulted in little increased perception of risk. Little difference can be found between the pre- and post-intervention studies with employees in the hotels as well. As among CSWs, this lack of change could be due to reported behavior changes, specifically the increased use of condoms among this population. On the other hand, a dramatic increase was reported at post-intervention time among MWM. At baseline only 30.3 percent of the men surveyed perceived themselves to be at some risk of contracting HIV. This percentage more than doubled to 70.9 percent. Sexual Behavior -- The 1996 ENDESA/DHS study revealed that 84.9 percent of men and 25.8 percent of women had changed some aspect of their sexual behavior due to the threat of contracting HIV. The most commonly selected forms of behavior change among men were: have only one sex partner (29.4 percent), avoid sex with CSWs (25.7 percent), reduce the number of sex partners (24.9%), and use condoms (22.8%). Among women the most commonly selected forms of behavior change were: have a steady spouse (11.3%), have only one sex partner (7.9%) and do not have sex (4.3%). The disparity between men and women in terms of the percentage reporting behavior change illustrates the different options available to men and women in terms of reducing risk for HIV infection, and the different "baseline" levels of risk behaviors. While many men have chosen to reduce their risk through the reduction of the number of sex partners, for many women, their only "choice" to hope that their partners become faithful. Trends towards decreased non-regular partners, and increased regular, or steady, partnerships, were found among the targeted populations as well. A comparison of baseline and post-intervention results with the hotel employees shows a reduction in non-regular sexual partners and an increase in steady partners. Furthermore, at baseline, slightly less than half of the MWM respondents reported having a stable partner. At post-intervention this had risen to 59.4 percent of the respondents and within the worksite population, 96.1 percent reported having a steady partner. Among low-income youth, a dramatic decline was found in the percentage who reported being sexually active, declining from 72.9 percent in 1992 to 30.3 percent in 1996 . Condom use and access improved significantly in all groups. (See Table 4 below.) Baseline data found much higher rates of condom use among brothel CSWs than bar CSWs (80% vs. 50%). While condom use with clients increased significantly over the intervention period, condom use by CSWs with "steady friends" did not. Baseline studies found that 20 percent of CSWs reported condom use with a steady friend in 1993 versus only 21 percent in 1996. Table 4: Percentage of Various Target Populations Reporting Condom Use during Last Intercourse with Non-Regular Partner, 1992 vs. 1996
In addition, free trade zone workers reported significant increases in condom use, with only 20 percent reporting sometimes using condoms with occasional partners in 1993, and 61 percent reporting sometimes using condoms in 1996. Overall, 43 percent reported last time condom use with non-regular partners. As would be expected, access to condoms increased as well, with more than 90 percent of all target populations in 1996 able to cite at least one location where condoms are sold. For example, ninety-four percent of workers in free trade zones were able to identify a source of condoms in 1996 versus only 75 percent in 1993. Sites of condom sales varied and included pharmacies, grocery stores, health centers, bars, hotels, and brothels. Sexually Transmitted Infections -- Although STIs continue to be a significant problem in the DR, there is no adequate mechanism in place for STIs to be accurately tracked. Moreover people tend to self-treat and do not clearly recognize the symptoms of STIs, making self-reporting lower than reality. Nonetheless, available data shows decreases in self-reported cases of STIs, an increase in generalized knowledge of where to access STI services and an increase in STI symptom recognition. Table 5: Percentage of Various Target Populations Self-Reporting STI in the last 12 months, 1992 vs. 1996
For populations with comparative baseline and follow-up data, decreases were seen in self-reported STI incidence. Among hotel employees a dramatic decrease in self-reported STIs over the previous 12 months was noted from baseline to follow-up, 15 percent at baseline and 1.3 percent at follow-up. CSWs also showed a decrease in self-reported STIs over the previous 12 months, 11 percent at baseline and 7 percent at follow-up. CSWs also reported high rates of regular STI screening: 98 percent reported required screening at follow-up, as opposed to 89 percent at baseline. Knowledge of sources of STI treatment also significantly increased during the AIDSCAP project. For example, 100 percent of CSWs in Puerto Plata know STI treatment locations, an increase from 77 percent at baseline. Among workers in the workplace, an increase from 75 percent to 94 percent was found. Rates were lowest among youth (85 percent) and among MWM (87%), two groups which commonly face social and economic barriers to adequate care. Despite these positive trends in AIDSCAP's target population, additional research continues to underscore both the high prevalence, and the poor recognition of STIs among youth and the general population in the DR. The 1996 national ENDESA/DHS survey found that one-third (33%) of women surveyed had a STI in the previous 12 months. The most common STIs were: vaginal infection (26.9%), pelvic inflammation (8.6%), chlamydia (6.2%) and genital ulcers (2.3%). While the youth KABP survey found low reported rates of STIs (3%), 44% of youth reported a burning sensation during urination and 12 percent reported having had a sore on their genitals in the past 12 months. Attitudes -- Attitudes towards PLWHIV/AIDS continue to be strongly negative in the DR. Thirty-seven (37%) percent of youth surveyed in 1993 said that AIDS is a punishment from God. As mentioned previously, beliefs in social transmission of HIV are very high (39% of men surveyed believed that touching someone with AIDS could transmit HIV, 43% believed that sharing food with someone with HIV was dangerous). While recent BCC campaigns have focused upon tolerance and social acceptance of individuals with HIV, the general population continues to be fearful and discriminatory. Capacity Building One of the main objectives of the AIDSCAP/DR program was to build the capacity of local organizations to carry out STI/HIV/AIDS prevention programs and to ensure their long-term sustainability. The program grew in scope and collaborators, thus, demand for technical guidance and assistance from organizations working in HIV/AIDS prevention increased. During the last five years AIDSCAP/DR made great efforts to create awareness among organizations about the importance of institutional development and sustainability. These areas became a major component of most AIDS prevention activities. Organizations executing major projects were assisted with tailor-made institutional development and sustainability plans. These plans were developed following institutional situation analyses. Specific capacity building actions carried out included:
Technical, Organizational and Management Skill Building AIDSCAP/DR sponsored 44 consultancies for approximately 20 different organizations through local and international consultants. There was a considerable transfer of knowledge, skills and technology during these consultancies. In most cases consultants worked with one, or several, individuals from the organizations as counterparts. Areas of technical assistance included: program support areas, data analysis, communication materials development, project evaluation and marketing. There was also a considerable transfer of knowledge and skills from AIDSCAP/DR's technical staff to the organizations implementing the prevention projects. This process took place through daily interaction and monitoring of projects. AIDSCAP/DR sponsored 45 courses and workshops, through which 1,313 individuals were trained in technical, programmatic and clinical areas. Training was provided on a one on one as well as collective basis. Most of the individual trainings took place out of the country and consisted of specialized courses and workshops. Training areas included the following: behavior change communication, strategic planning, project design and evaluation, condom logistics. As a result of these capacity building efforts the five central implementing agencies working with AIDSCAP/DR are producing higher quality work. In addition, these groups have prepared marketing plans, informational brochures and have received international funding to sustain project activities. Organizational Systems Development -- AIDSCAP/DR sponsored the development and strengthening of systems within implementing organizations to assure and facilitate more effective management of programs and projects. Systems designed and strengthened include information, finance and administration, as well as logistics management. When necessary, AIDSCAP/DR also provided IAs with the required equipment. Networks and Global Learning Enhancement The AIDSCAP/DR program fostered interinstitutional and intersectorial collaboration, as well as networking, among organizations working in AIDS in the Dominican Republic. Special assistance was provided to specific NGOs executing joint projects in terms of strengthening their ability to work together. This assistance facilitated the definition of institutional roles and responsibilities and unified criteria and methodologies. In 1997 the group of AIDS NGOs supported by AIDSCAP/DR since 1992, Coordinadora de Animación Socio-Cultural, Instituto Dominicano de Desarrollo Integral, Inc., Centro de Orientación e Investigación Integral, Comité de Vigilancia y Control del SIDA, and Amigos Siempre Amigos formed a coalition. The establishment of this coalition is seen by AIDSCAP/DR as the result of years of creating awareness about the need to unify AIDS program planning and strongly advocate in favor of the HIV/AIDS agenda. AIDSCAP/DR also supported initiatives to link local projects and organizations with US-based community-based organizations (CBOs). The Areas of Affinity Initiative promoted exchange between local and US organizations working with the same target audiences. Three local organizations, COIN and CASCO/IDDI, were linked with US-based organizations. Latino Health Institute in Boston and the Alianza Dominicana in New York. Field visits were made to strengthen links between these organizations. For further details on AIDSCAP's capacity building efforts during 1992-1997, see Non-Subproject Highlights. Constraints Coordinating training with many people involved was difficult because of different agendas and levels of basic knowledge and interest, and high turnover. Key staff from implementing agencies lacked the time away from project implementation to receive training. Also, there is no tradition of continued education in the DR. This posed a barrier for updating those who already perceive themselves as experts in a given field. Coordination with Family Planning Agencies Over the life of the project AIDSCAP/DR worked with Development Associates (DA) and a number of family planning (FP) organizations to facilitate inclusion of HIV/AIDS information into their programs. FP personnel were also included in AIDSCAP-sponsored training which improved STI information and services to their clients, such as the STI Syndromic Management training program. A total of 31 clinicians and 121 non-clinicians participated. Individuals trained were included in the referral guide for STI/HIV/Counseling services. A total of 63 FP clinical and non-clinical personnel also participated in counseling workshops. AIDSCAP/DR's support in the area of BCC consisted in the review and field testing of STI/HIV/AIDS prevention materials as part of the overall material production team. Different priorities and schedules between AIDSCAP/DR and DA made coordination of technical assistance for family planning agencies difficult. However, considerable assistance was provided in the areas of BCC and training as described. Implementation and Management Issues Program Implementation Background The AIDSCAP/DR program began in the DR as an associate country program in September 1992, upon termination of the AIDSCOM and AIDSTECH programs. The USAID/DR Mission had already decided to continue supporting the seven STI/HIV/AIDS prevention projects previously funded by AIDSTECH and AIDSCOM. One-year bridging subagreements were developed with these implementing agencies. Funding was provided to AIDSCAP/DR through a Mission Operating Year Budget (OYB) transfer. Project Design, Start-Up and Evaluation In 1993 a Strategic and Implementation Plan was developed to guide the implementation of the AIDSCAP/DR program during 1993-1996. This plan responded to the needs identified through a technical assessment of the AIDS situation in the DR conducted in December 1992, in addition to multiple site visits made throughout 1993. This three-year program was integrated into and financed under USAID's seven-year Family Planning and Health Project. Under this project AIDSCAP/DR provided technical assistance in STI/HIV/AIDS prevention directly to the HIV/AIDS NGOs in coordination with PROCETS, and to FP organizations coordinating activities through the institutional contractor, Development Associates. When the AIDSCAP/DR Program became a priority country program in 1993, the USAID/DR Mission obligated $1.2 million for FY94, under the terms of the AIDSCAP Cooperative Agreement. At this time AIDSCAP/DR made a request for proposals. Five on-going interventions were selected for financial support during FY94-96. While USAID/DR and FHI were working to finalize the priority country agreement, USAID/Washington converted the AIDSCAP Cooperative Agreement into a contract. The local USAID Mission was assured that the switch in the mechanism would only take one to two months and programming would not be interrupted. However, the entire conversion process took over six months. In order to maintain on-going projects bridge agreements and cost extensions were processed, and finally, budget amendments made. These activities were time consuming and disruptive to program implementation. In November, 1994 a Country Program Midterm Review was conducted. The program was found to be well managed and implementing a strategic plan that continued to be appropriate. However, this review pointed to the need to relieve the resident advisor (RA) the burden of management to free more of her time for policy and advocacy work. The enormous workload the CO had in response to the demand for TA and funds of new organizations involved in AIDS was also analyzed. As a result, more support personnel were hired. Finding qualified staff was yet another challenge to overcome. Since then, however, the AIDSCAP/DR staff have developed into a competent team of people with extraordinary commitment. In August 1996 the subagreements developed for FY94-96 came to an end. The AIDSCAP/DR program completed the three-year cycle described in the Strategic and Implementation Plan. All actions envisioned, plus a few others not considered originally, were successfully accomplished. At this time the Delivery Order Contract was extended one year, from August 27, 1996 to September 21, 1997. This extension was executed in order to continue providing technical, administrative and financial assistance to selected organizations implementing HIV/STI/AIDS activities, and to further initiatives aimed at achieving the sustainability of the projects. New subagreements were developed with IAs for the six month period October 1996 to April 1997. Under these agreements field activities continued at a minimum level. The main goal of these projects was to assist IAs in the development of marketing strategies and materials for the projects to utilize in their search for sources of funding. At the beginning of FY97, AIDSCAP/DR assisted the USAID/DR Mission in defining options for the STI/HIV/AIDS strategy for the next five years (1997-2002). During the months of September and October 1996 AIDSCAP/DR held consultation meetings with key individuals and professionals involved in AIDS prevention in the DR, as well as HIV positive people. The purpose of these activities was to identify intervention areas for STI/HIV/AIDS prevention that should be prioritized during 1997-2000. Based on information gathered, AIDSCAP/DR prepared and presented to USAID/DR the document "Options in STI/HIV/AIDS Programming in the Dominican Republic". AIDSCAP and the USAID/DR Strategic Objective Number 2 (S02) team collaborated in the elaboration of this document. Throughout life of project AIDSCAP/DR's RA held periodic meetings with USAID/DR's AIDS Technical Monitor. The purpose of these meetings was to discuss with the Mission representative overall status of the program and subprojects, secure approval for new projects and activities, discuss possibilities for intersectorial and interagency coordination, etc. Throughout the life of the AIDSCAP/DR program there were three different health, population and nutrition (HPN) officers. Coordination for the most part was constructive because the technical monitor was always the same person. However, AIDSCAP/DR had to deal with a natural change in program emphasis and management styles as individuals at higher levels changed. This demanded extra flexibility and negotiating skills from the AIDSCAP/DR staff. After the re-engineering of the USAID/DR Mission, a team approach was adopted, making support to AIDSCAP/DR more efficient. Due to a series of management and continuity related issues, in January 1990 the AIDSCOM and AIDSTECH USAID/DR-sponsored projects were instructed to shift their assistance to the non-governmental sector, providing only minimal technical assistance to the government's program. Since then, USAID's support to PROCETS has been limited to technical assistance, some logistics, and procurement support for the sentinel surveillance and blood banking components. This hindered AIDSCAP/DR's possibilities for further collaboration with PROCETS. Coordinating actions without providing direct financial support was a next to impossible task.. Coordination with the National AIDS Control Program was also difficult because of the frequent change of its directors. From 1992 to 1997 PROCETS had four executive directors. Each of these directors had a different perception of AIDSCAP/DR's role, which usually took some time to clarify and finally set the ground for collaboration. Each of these directors also had his/her own agenda and priorities, thus hindering continuity of activities. In spite of these difficulties, substantial support was provided by AIDSCAP/DR to PROCETS as mentioned throughout this report. Program Management Country Office AIDSCAP is a centrally funded and managed project. This created a certain level of centralization, standardization and bureaucracy which at times constrained the local program and slowed the process of review of contractual agreements. The decentralization of this review process to the Regional Office helped facilitate the review process somewhat. Throughout the life of the AIDSCAP/DR Program the AIDSCAP LACRO Director and staff were extremely supportive of the CO's needs, always facilitating and expediting agreements and concurrences among other things. Personnel The AIDSCAP/DR program inherited personnel as well as an office infrastructure from the AIDSTECH and AIDSCOM programs. Most of the personnel were support rather than technical staff. It was anticipated that AIDSCAP programs would run with minimal personnel structures. As the program evolved, it became evident that in order to respond to the constant demand for technical assistance the office needed qualified technical staff in-house. However, this was not possible from the beginning due to budget constraints. Hiring competent technical staff took place during the life of the project. Finance & Administration Policies and Procedures -- At the beginning of the program a financial review was conducted, determining major systematization needs. Proper administrative and accounting procedures were developed locally. Later, they were adapted to FHI's accounting and management system. Policies and procedures for the program area were also developed by the DR CO. AIDSCAP/FHI's, as well as local USAID Mission's guidelines and procedures were considered and integrated into these manuals. In order to acquaint NGOs with AIDSCAP's policies and procedures and to facilitate their daily interaction with the program, an NGO policy and procedure manual was developed and distributed. This manual explained very clearly AIDSCAP's policies and procedures regarding the use of the motor pool, equipment, office space, procurement, reporting, etc. Updates were done on a regular basis. Audits -- Since its inception, the AIDSCAP/DR program was subject to external annual financial reviews on behalf of FHI with satisfactory results. An audit from the Government's Administration Office (GAO) was also conducted in 1993. The results of this audit were also satisfactory, with only a few observations regarding subproject information systems. AIDSCAP/DR made periodic revisions of supporting financial documentation to guarantee subproject compliance with USAID's regulations. In addition, training and technical assistance was provided to the NGOs to aid them with counterpart contribution identification and registration. Project Monitoring When the AIDSCAP/DR program began, subproject data collection was done using the same Process Indicator Form (PIF) used by the AIDSTECH Program. There was one standard format for all the projects. This form proved to be inflexible, since reporting needs were unique among the different types of interventions. In May 1994 the data collection system was modified and PIFs were designed individually for each subproject based on its specific indicators. This made it impossible for the data collected prior to May 1994 to be added to those collected after that date. EPI-Info, a statistical software application, was installed at each of the NGOs and training provided to their technical staff so they could check their cumulative data, monitor their projects better and pass the information on diskette to the CO. The NGOs had a difficult time adapting to the new system. Some of them had never used a computer before and had strong resistance to it. So even though they were trained on this system mistakes were sometimes made at the time of inputting the numbers or calculating project totals. Sometimes they forgot to include numbers in the PIFs and sent the extra information to the CO long after the PIFs had been sent to AIDSCAP headquarters. This situation generated a difference between the numbers in the CO and those in HQ that took a lot of time and effort to reconcile. The PIF system was later decentralized and AIDSCAP/DR started sending aggregated data to LACRO. Capacity Building When the AIDSCAP program started in 1992, responses to AIDS were being mounted by small NGOs. These NGOs were dedicated and hardworking however they were poorly organized and completely dependent on donor funding. Therefore, the need for capacity building was identified by the Country Office as a key component of the program. After the first training courses were provided, the need to reorient the program's capacity building strategy was obvious: participation was not adequate and enthusiasm was low. An assessment of the situation was made, discovering that NGOs felt AIDSCAP/DR was imposing the trainings on them and felt they were being coerced to participate. To address this issue, a sensitizing process was initiated to make them more receptive to capacity building and to further develop and strengthen their organizations. Training and technical assistance plans were then developed in a more participatory manner, defining these needs individually with each organization. Issues such as availability of time were also discussed. Trainings were tailored to the specific needs of the individual organization or several organizations combined, when appropriate. The DR country program also succeeded in utilizing "unconventional" methods including group unification and human relation workshops to resolve internal and inter-institutional differences. This is a necessary and important step to institutional growth and progress. However, it must be a continuing process to be successful. Subproject Implementation The AIDSCAP/DR subprojects were extremely successful not only in surpassing their projected outputs, but also in achieving improvements in knowledge and behaviors leading to HIV/AIDS prevention. Each implementing agency encountered its own obstacles to implementation which are discussed under the section on "constraints" for the individual projects. However, two funding disruptions to project implementation should be noted here as they were experienced by all of the AIDSCAP/DR subprojects. The first funding gap occurred in the fall of 1993 when USAID converted the AIDSCAP/DR cooperative agreement to a contract. This action caused great uncertainty as to what the legal, financial and technical process for implementation would be. During this time all existing subprojects came to an end. Each implementing agency had to sign a bridging document to support the second phase of project activities while the contract was being approved. These bridging documents underwent a review and approval stage and were later extended because of delays in the disbursements of USAID funds even after the new contract was approved. Once the USAID funds were available, the implementing agencies had to adhere to new reporting requirements. This required technical assistance in the areas of program and financial management and a third subproject review and approval phase. The third project documents were written to carry the activities through the end of the AIDSCAP/DR program. The second gap in funding occurred at the scheduled end of the AIDSCAP project in August 1996. USAID granted a one-year extension to the AIDSCAP project, but not before all of the subprojects had completed subproject activities. Thus, a fourth subproject review and approval phase was needed to extend the projects from the fall of 1996 through the spring of 1997. Despite these interruptions the IAs achieved remarkable success in contributing to the decrease in HIV/AIDS nationwide. The following sections contain information regarding each of the subprojects throughout the life of the project. |
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