Final Report for the AIDSCAP
Program in the Dominican Republic
October 1993 to April 1997: Lessons Learned and Recommendations

This report comprehensively summarizes the FHI/AIDSCAP program in the Dominican Republic (1993-1997). The report discusses program accomplishments and constraints, as well as providing behavioral outcome data, lessons learned and recommendations.

IV. Lessons Learned and Recommendations

BCC

• Participative planning of BCC interventions must constantly reflect and accommodate the changing target population.

Insuring target population involvement in project development-- a key to program success-- is a challenge with mobile target populations and youth. As youth "age into" the target population, and as mobile target population members and staff/volunteers turnover, projects must "reinvent" themselves and invite the target populations in project design once again. Likewise, the participation of "gatekeepers" must be continuously renewed. Another consideration is the need to retarget efforts to segments of target populations which are less responsive to prevention methods. This effort may run counter to the involvement of target population members who have been actively involved in, and shaped, the focus of the project up to that point.

• Creating BCC messages for specific target populations requires an understanding of the complex subgroups within these target groups.

Qualitative research found significant variation within target groups once thought to be relatively homogeneous. For example, research on sexual identity found five main subgroups within the MWM community. Sexual behaviors and HIV prevalence varied among these groups, indicating a need for behavior change interventions tailored to each group. Other studies have found that street-based CSWs tend to be more at risk than their brothel-based counterparts, who have more negotiating power with clients. CSW interventions need to take into account the vulnerability of street-based CSWs. Youth from marginalized, urban barrios need different educational interventions than do middle class youth.

• BCC interventions with youth need a clear and practical approach.

HIV/AIDS prevention programs targeting youth and young adults need tailored approaches which provide honest, direct messages and clear guidance. Although behavior modification is more successful at an earlier age, messages of fidelity and monogamy are often inappropriate and can be confusing to this group. Gatekeepers, such as parents and teachers, need to be targeted to reinforce the messages youth receive. Youth and young adults can be effectively reached by the mass media. Polished, professional media spots are likely to be accepted by youth. High quality PSAs are a good investment because they are likely to receive private media support, and thus be aired more frequently.

• Educational interventions which address individual behavior must be complemented by strategies to change those structural and environmental factors which contribute to risky behavior.

Knowledge of HIV transmission and prevention, and intent to change behavior, are clearly not enough to protect individuals from HIV infection. Factors which create or encourage greater risk behaviors, including alcohol and drug use, poverty and unemployment, sex tourism, women's inability to negotiate condom use, poor availability of and lack of access to condoms, must be addressed in association with poor knowledge of HIV to insure the success of HIV prevention efforts.

• Workplace educational interventions need management's support in order to be effective and sustainable.

To overcome management resistance to workplace educational programs, it may be helpful to work through local business associations, chambers of commerce and/or the Ministry of Labor. Management may be more inclined to listen to messages about HIV/AIDS prevention when those messages come from fellow business executives, rather than public health officials. Socio-economic impact studies may be the catalyst business owners need to begin addressing HIV/AIDS among their workforce.

• International exchange of BCC materials can and should take place in settings where immigration is common.

The Dominican Republic experiences an annual influx of Haitian laborers who come for the sugar cane harvest. These immigrants are at high risk of STI/HIV and may benefit from educational materials printed in Creole or French. Many Dominican CSWs work in the Haitian capital of Port-au-Prince. These CSWs should have access to prevention materials written in Spanish. Posters or other materials designed for the semi-literate may be appropriate for these populations.

STIs

• The institutionalization of the syndromic management approach to STI treatment requires a long-term commitment and continuous support.

Institutional support is necessary to overcome health care provider resistance to obtaining additional training in a country where continuing education is not customary. The routine dissemination of current, local data on trends in STIs can be instrumental to maintaining clinician interest in STI programs. High turnover of clinic personnel is another reason why continuous training is necessary in order to maintain adequate services.

• Ensuring that STI drugs are available at the primary health center level demands political commitment from the top, a strong logistics system and an educated staff at the clinic level.

NGOs have limited ability to influence the management of essential drugs at the national level. However, they can play a crucial role in advocating for the rational distribution of STI drugs, and can provide technical assistance to national drug management programs. Clinicians involved in STI treatment can be valuable advocates for appropriate drug management. Historically, few resources have been devoted to STI control. However, as recognition of the link between STI and HIV grows, STI control and treatment are likely to improve from the national to the primary health center level.

• Algorithms and risk assessments for the syndromic management of STIs can be effectively modified for individual countries.

Given the high prevalence of STI in the DR, syndromic management should emphasize sensitivity over specificity. Research on the effectiveness of risk assessment showed that changing certain criteria, such as age and marital status, increased the sensitivity of the algorithm. Because men can have urethritis in the absence of urethral discharge, researchers recommend expanding the treatment protocol to include men complaining of pain with urination, whether or not they have urethral discharge at the exam. In settings where speculum examination is available, the addition of "signs and symptoms" to the vaginal discharge algorithm improved its effectiveness without the need for laboratory tests. Because most STIs in women are asymptomatic, populations at extremely high risk, such as CSWs, may need periodic screening in addition to the syndromic approach. Patients with suspected herpes should also be treated for syphilis and chancroid because multiple agents can be present in genital ulcers. Herpes patients need thoughtful counseling on how to protect their partners from this chronic infection which may increase HIV transmission.

Condoms

• The change from free distribution of condoms to commercial sales requires a paradigm shift for implementing agencies, government officials, and most importantly, the general population.

Acquiring necessary skills for condom social marketing is complicated and often costly and can sometimes pull the implementing agency away from its original mission. Policies regarding free distribution of condoms need to be carefully considered and thoughtfully implemented to avoid disrupting social marketing programs. Careful inventory control is necessary to prevent the leakage of donated condoms into the black market. Overcoming religious and social barriers to condom distribution and sales is difficult and time consuming. An aggressive marketing strategy, support from mass media and systematic endorsement by public figures is necessary in order to de-stigmatize condoms.

• Creating specific environments where condom use is expected may be a way of jump-starting social norms around condoms.

Brothels where 100% condom use is expected have been successful in reducing the transmission of STI/HIV among CSWs and their clients. These structural/environmental approaches are often more effective than individual risk reduction counseling because the target population feels a sense of group solidarity. Interventions of this type may prove to be an effective way of encouraging condom use with other sexual relationships. However, care must be taken not to stigmatize condoms, which many Dominicans associate with prostitution. A 100% condom campaign for brothels might be most successful when complemented by educational materials encouraging condom use for all sexual relationships.

Program Evaluation and Management Lessons

• Ongoing evaluations of interventions are vital to the success of HIV prevention programs and must be conducted through the balanced partnership of implementing agency staff and technical experts.

Data collection systems for process indicators must be jointly defined early in project implementation, and should be easy to maintain (particularly given resource limitations) and provide useful data for project monitoring as well as reporting. IA personnel must be involved throughout the process of study design to facilitate access to research populations, and to build local capacity. This process however can take a considerable amount of time and guidance from experts in the field is necessary. The level of involvement of IA personnel in research should be carefully defined to avoid jeopardizing program implementation.

• Decentralization of decision making is crucial to effective program development.

Flexible contractual mechanism and the decentralization of decision making are important conditions to allow immediate responses from field-based staff to emerging opportunities or challenges. When available, local technical assistance should prevail over imported expertise. It is more readily available, more culturally sensitive and often more cost-effective.

• The private sector can be a valuable resource and a willing partner in prevention efforts.

When dealing with the for profit sector, simple negotiation procedures must be developed. Local executives often express interest in HIV prevention, but may be deterred by convoluted donor requirements.