|
Programs |
|||||||||||||||||||||
Final Report for the AIDSCAP
|
|
|||||||||||||||||||||
|
Table of Contents I. Country Program Description
III. Non-Subproject Highlights II. Subproject Highlights Interventions with Commercial Sex Workers: Avancemos Project - COIN
Background The Centro de Orientación e Investigación Integral (COIN) was the first NGO created in the Dominican Republic to prevent HIV/AIDS among high risk behavior groups. Since its inception, COIN has expanded its prevention services to include peer education, condom social marketing and distribution, health care and laboratory services, and STI/HIV/AIDS education. The NGO's activities cover extensive areas of Santo Domingo as well as Boca Chica, La Romana, Haina and Santiago. Research has evidenced that female CSWs in the Dominican Republic are particularly vulnerable to HIV infection. They have a low level of education evidenced in the 1996 KABP study among this group which showed that 52% of those interviewed had between 5 and 8 years of schooling. There is also a high turnover of CSWs, with ever younger CSWs in demand. Of the CSWs interviewed during the KABP, 91% were below the age of 35. Fifteen percent were between the ages of 11 and 19. Older CSWs find themselves forced out of brothels into more marginalized areas such as parks and the streets where it is even more difficult to receive STI/HIV/AIDS education. Objectives COIN began the "Avancemos" project in 1989 to reach female CSWs and men involved in the commercial sex industry (MICSI), such as commercial sex workers, their clients and partners, and bar and brothel owners. With each new funding cycle, COIN expanded the contents of its trainings to meet the ever changing demands of the epidemic. The project's STI/HIV/AIDS prevention activities took place in Santo Domingo, Santiago, La Romana and San Cristobal. The project focused on three outputs:
Accomplishments Project educators, HMLs and HMVs attended continuous training sessions throughout the duration of this intervention. During the educational training sessions, HMs acquired skills enabling them to serve as peer to peer educators. HMs learned how to produce and direct plays and to write scripts, enabling them to train others in the techniques of educational theater. Finally, to prepare for the daily stress of dealing with violence and emotional problems encountered by CSWs, the HMs attended a Human Development session where they examined their own self-esteem and formed support groups. Project educators were trained in strategies for preventing HIV transmission to women during LOP. Health personnel at other clinics were constantly requiring HMLs and HMVs' assistance, thus evidencing the credibility of the Avancemos project within the public health system. As previously mentioned, the mobility of CSWs is extremely high in the DR. In order to maintain the health messenger network, new volunteers were continuously recruited for an average number of 15 HMLs and 350 HMVs throughout the LOP. This HM network and the staff made 5,667 training contacts (5,208 women and 459 men) with new and old health messengers. MODEMU, an organization of health messengers, was established with COIN's assistance. Its action plan includes extending the Avancemos Project to other areas of the country after the close of the AIDSCAP project. HMLs reached CSWs through weekly education sessions both at their workplace and at STI clinics. Men Involved in Commercial Sex Industry (MICSI) received basic project information through face to face sessions and collective activities such as correct condom use demonstrations and group discussions led by HMLs and/or HMVs. During 1996-1997, brothel and bar owners also participated in "Gender and HIV/AIDS" educational sessions to increase their awareness of the CSWs' vulnerability to HIV infection. Another successful educational component of the project was the use of provocative theater techniques, carried out in brothels, bars, areas surrounding active businesses as well as frequented commercial sex zones(i.e. streets and parks). The theater brought educational messages to clients and to CSWs who worked night shifts and thus were difficult to reach through the messenger network. Throughout the LOP 148,324 individuals (120,861 women, 24,407 men and 3,056 gender not specified) were reached through theater. AIDSCAP provided technical support to COIN in the design of new educational materials and the upgrading of previously designed materials for its target populations such as the Mario and Maritza comics. An exciting aspect of this project was the newspaper entitled "La Nueva Historia". In 1994 the health messengers took on the full responsibility for producing this newspaper with input from CSWs. The newspaper served as a viable mean for women to express their social and health problems. This information was then used to adapt aspects of the educational interventions to address these issues and served as a launching point for the first national CSW conference. In all, COIN workers distributed 95,735 different educational materials throughout the LOP. COIN held the first conference focusing on the CSW issues in May 1995. The CSWs created a union seeking to exert more control over their working conditions and to establish links with similar international CSW movements. In 1996, COIN reported that the majority of CSWs who were involved in the Avancemos project as peer educators had left the commercial sex industry altogether. Another peer educator who was HIV+ formed her own AIDS support group. These stories testify to COIN's success in human and labor rights, as well as in raising CSWs' self-esteem and preventing AIDS. AIDSCAP provided technical assistance to COIN staff for the development of condom social marketing techniques in the early phase of the project. During 1994-1995, this aspect of the project was evaluated and redesigned to focus on sales by health messengers in hotels and motels. By the EOP 937,137 condoms were either sold (869,480) or distributed for free (67,657). COIN played a big part in the implementation of the Pantera Condom Social Marketing project in collaboration with the private sector. The HMLs an HMVs formed part of its sales force. However, competition from black market condoms and a higher price of the product hindered COIN's ability to successfully undertake its role in the Pantera condom distribution scheme. COIN then implemented a 100 percent Condom Use pilot project targeting brothel and other sex business owners. The purpose of this pilot project was to design and validate BCC materials for the 100 percent condom intervention. Several agreements have already been signed with GOs (i.e. Ministry of Health and Social Security System) in support of the 100 percent condom use policy. AIDSCAP supported the expansion and improvement of COIN's STI clinic facilities during the 1994-1996 funding cycle. These improvements led to substantial increases in the number of people who attended the clinic. COIN also provided STI services through its mobile clinic, which visited brothels by appointment. Thousands of STI check-ups were conducted in both of COIN's clinics during the LOP. Other CSWs were referred to nearby SESPAS clinics in order to eliminate the geographic barriers to receiving STI services. In 1997, COIN developed a sustainability strategy which includes a fee-for-service component to ensure that interventions continue beyond the AIDSCAP project. By the end of the project, five businesses had already agreed to contribute to the fee-for-service program. Constraints The project successfully completed and surpassed its original indicators without major obstacles. The most significant constraints were the disruptions in funding between the fall of 1993 and spring of 1994 and again in the fall of 1996. Some prevention activities were continued despite the breaks in funding primarily because of the flexibility of personnel and the HMLs and HMVs. COIN encountered some difficulties with the availability of printed materials. Due to the high turnover of CSWs, additional materials were needed for the new CSWs reached. Another obstacle that had to be overcome in the beginning of the project was the womens' lack of training in condom social marketing and consumers' resistance to purchase condoms at the new prices. Findings and Recommendations COIN took an integrated and innovative approach to reaching female CSWs which should serve as a model for future interventions with this target population. The Avancemos project strategy sought to improve the self-esteem of CSWs, promote healthy behaviors, and how to effectively negotiate condom use. Also, CSWs were educated on STI symptoms and where to access treatment, as well as how to correctly use a condom. The NGO acknowledged the need to educate other persons involved in the commercial sex industry beyond just the CSWs. As a result, the project incorporated strategies to address these additional players (i.e. long term clients, brothel owners, CSWs' fixed partners, etc.). COIN went one step further and integrated a gender component into the prevention model. Moving beyond a purely health approach, COIN looked at both the social and biological vulnerability of women as well as their surroundings in the commercial sex world in order to deal with the factors underlying the high risk behavior. By addressing issues such as self-esteem, violence against female CSWs, and CSWs' rights as citizens and individuals, the Avancemos project achieved unexpected positive prevention responses. It should be noted that the project was able to remain flexible and creative in making the latest information on HIV/AIDS prevention and education operational. This was possible through constant training and updating of its project personnel throughout the LOP. Another lesson, which should not be underestimated, was the importance of sound planning followed by weekly education and supervision in the field, both the project educators towards the HMLs and the HMLs towards the existing HMVs. This allowed COIN to recruit new volunteers and ensured that everyone was working towards common outputs. COIN reported a continued need for gender education among brothel owners, so as to increase awareness of the vulnerability of their employees. This set the basis to implement a 100 percent condom use policy in their establishments. Provocative theater was very effective engaging clients and brothel staff and should be continued. The system used by HMs to refer CSWs for STI check ups expanded during the course of the Avancemos project. COIN recommends that the incentive system be strengthened with bonuses such as low prices and facilities for CSWs' children to ensure continued clinic attendance.
Endnotes
|
||||||||||||||||||||||
 |
||||||||||||||||||||||
