The Aba Sida Program
The Aba SIDA program is made up of overlapping components to produce a comprehensive intervention model.
A. A Multidimensional and Multi-Leveled Intervention Strategy
AIDSCAP's strategic approach to AIDS prevention and control is based on three key variables in the sexual transmission of STIs: (1) the rate of sexual partner change; (2) the probability of infection (including the transmission efficiency) with each sexual contact; and (3) the duration of infectivity1. Interventions -- especially with "core groups" of individuals who have high rates of sexual partner change -- that influence one or all of these key variables can lead to a reduction of HIV incidence. AIDSCAP, therefore, supported interventions that aimed to reduce sexual risk, focusing on sexual partner reduction and increased condom use, or that aimed to increase effective treatment of curable STIs. While its ultimate goal was to reduce the incidence of HIV in target populations, its more immediate objective was to strengthen the technical and management capacity of local partners to conduct STI/AIDS prevention and control interventions. This emphasis on enhancing capacity reflects AIDSCAP's commitment to having a lasting impact in host countries.
The Aba SIDA program in Haiti involved collaborative partnerships with several Haitian institutions, most of which focus on urban and peri-urban areas. The program was designed to respond to an advanced AIDS epidemic and pronounced prevalence rates of other STIs. Its main target populations were, therefore, broadly inclusive: adults who are sexually active and adolescents, both sexually active and not. Various behavior change interventions were, in turn, tailored to meet the particular needs and perspectives of more specifically defined target population segments, including commercial sex workers and their clients, women and men in the workplace, adolescents in school and in the community, and patients with STI symptoms. The communication strategy shared by Aba SIDA's targeted interventions hinged on a multiplicity and diversity of behavior change messages, thereby accommodating individual variability both within and between target audiences. It should be emphasized, however, that Aba SIDA's behavior change interventions with specific target audiences were multifaceted projects. While behavior change communication (BCC) is the programmatic centerpiece of the interventions, distributing condoms, facilitating access to STI care, and engaging the support of influential persons in target communities were also important components.
Policy initiatives reinforced bottom-line behavior change efforts in target audiences. Recognizing, for example, that individuals' sexual and STI treatment decisions and behaviors are contingent on myriad factors in the larger social and health care environment, the program also targets "enabling" populations. The support of community and religious leaders, the professional skills of health care providers, or the decisions of policy makers, can either enhance or obstruct successful behavior change in at-risk target audiences. Such key "enabling" groups constituted an important "secondary" target population for the Aba SIDA program. Dynamic and high visibility media events and wide spread condom availability through condom social marketing further contributed to a supportive and "enabling" environment for individual behavior change.
Aba SIDA, in summary, had diverse program components that intersected and overlapped to form a comprehensive and integrated program. The triad model of "behavior change communication," "condom promotion," and "improving STI care" emphasized the technical interventions necessary to interrupt the cycle of STI/HIV transmission. "Policy dialogue" further enhanced this model by addressing the environmental dimension of prevention programming. However useful such technical division may be, it may unduly obscure the important degree of technical synthesis and programmatic coherence that Aba SIDA achieved. Its individual projects taken together comprised a multidimensional STI/AIDS prevention strategy and program, whose objectives and outputs can conceptually be represented as a hierarchical whole. As illustrated below, delineating the program in this manner highlights how embedded individual-level behavior change is in higher-level activities, interventions, and social environments.
Aba SIDA's Levels of Intervention and Behavior Change Options
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. .National Media and Policy Supporting Behavior Change
Mass media education and promotion: TV, radio, and video
Condom distribution through a national pharmaceutical distributor
Development of national guidelines for syndromic management of STIs
Press reports, informational packets, and fora to influence policy |
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. .Community Level Activities Supporting Behavior Change
Support from "gatekeepers" in the community
Support from business for workplace-based interventions
School- and community-based STI/AIDS prevention education
Upgraded STI treatment in community clinics
Pharmacy and non-pharmacy retail outlets for condoms
Capacity building in community-based organizations |
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.Interpersonal Agents of Behavior Change
Peer educators, outreach workers, and health promoters
Social marketing "independent vendors" and educators
Clinic-based STI and HIV/AIDS counselors
Workers' support groups . |
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.Individuals' Behavior Change Options to Reduce Sexual Risk
Condom use
Sexual partner reduction
Abstinence and mutual fidelity
STI treatment and partner referral |
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Rather than discrete program components, technical spheres in Aba SIDA merged in crosscutting and integrated interventions. There is, nevertheless, organizational value in discussing some interventions by their area of technical emphasis, and to some extent this provides the format of this report. Much of the content of this document is organized by the six major program areas of Aba SIDA: (1) targeted behavior change interventions; (2) increased condom access through condom social marketing; (3) increased access to appropriate care for STIs; (4) enhanced social and policy environment to support behavior change (policy dialogue); (5) strengthened technical, management, and evaluation capacity of Haitian NGOs; and (6) improved care and management for AIDS patients. The remainder of this section summarizes Aba SIDA's accomplishments and results, reviews key management and organization issues, and highlights important lessons learned from the program overall. The following section includes executive summaries of Aba SIDA projects, organized in groups of the six key program areas identified above.
Program Activities Timeline for Haiti
B. Significant Accomplishments and Results
Targeted Interventions to Change Individuals' Behavior
Programmatically segmenting broad target populations of adults and adolescents into smaller, more homogenous groups was at the center of Aba SIDA's strategic approach. Targeted interventions focused on influencing the behaviors in key groups of individuals who had high STI/HIV prevalence, were most severely affected by these infections, or whose marginal socioeconomic status made them especially in need of programmatic attention. Aba SIDA's behavior change interventions were based on communication strategies with themes, messages, and delivery channels that responded directly to different target audiences' particular perspectives, needs, and circumstances; they established distribution networks to ensure condom availability in places where targeted individuals reside, work, and socialize; they created appropriate links to high quality professional STI services available in target communities; and they actively engaged the support or participation of community leaders and influential persons where the interventions are conducted, representing a community-level "policy" component.
More than 800,000 people (approximately 37,000 youth, 150,000 workers, 170,000 high risk individuals, 400,000 low-income individuals and 25,000 individuals with HIV or their caregivers) were educated and more than 400,000 materials distributed as a part of BCC initiatives. Specifically, Aba SIDA conducted BCC campaigns to the general population, as well as youth, workplace and high risk populations (including female sex workers and their clients) through:
- Peer education and outreach
- Training programs
- Mass media (especially radio)
- Special events
- Condom promotion through social marketing activities
- Materials development (curricula and IEC)
Perhaps the most important aspect of targeted interventions was their focus on interpersonal communication and education activities. It was in the interpersonal encounter between an at risk person and a peer educator, outreach worker, health promoter, clinic counselor, or even an "independent condom vendor," that the former would most likely be motivated to commit to risk reducing behaviors. Trained in basic STI/AIDS education, and prepared to field questions from and respond constructively to the concerns of targeted individuals, these various community-, work-, clinic-, and school-based educators were perhaps the single most essential agents of behavior change in the Aba SIDA program. Their work represents the front lines of STI/AIDS prevention efforts in Haiti and all Aba SIDA behavior change interventions center around and support their efforts.
Most AIDSCAP projects relied heavily on peer education and outreach to reach key target audiences in Haiti. Aba SIDA supported a number of Haitian NGOs and community-based institutions who already had experience and contact with these target groups. The Implementing Agency for Cooperation and Training (IMPACT/Interaide), for example, received Aba SIDA assistance to expand and intensify their work in peer education and condom delivery targeting sex workers and their clients in Haiti's largest cities. The Groupe de Lutte Anti-SIDA (GLAS) focused on low-income workers, conducting workplace-based interventions in 30 large factories and parastatal businesses. To meet the special needs of low income women, the Centre de Promotion des Femmes Ouvrières (CPFO) targeted women factory workers living in poor neighborhoods. In an effort to improve the familial and social environment in which these women live, CPFO also implemented educational activities targeting women's families as well as members of their larger communities.
Three Aba SIDA interventions focused on adolescents. In urban and peri-urban areas in Haiti's central district, the Volontariat pour le Développement d'Haïti (VDH) relied on peer education, a variety of communication activities, and condom social marketing to reduce sexual risk in youth. The Centre Haïtien de Service Social (CHASS) worked in the poorest parts of Port-au-Prince and used a variety of communication and condom distribution channels to influence youths' behaviors. In addition to these NGO interventions, Aba SIDA supported Alerte SIDA!, a two-year campaign which provided technical assistance and small grants to nine Aba SIDA partners to conduct school- and community-based youth peer education. Alerte SIDA! activities have since been extended through WHO/PAHO financial support.
It is important to note that other Aba SIDA projects that are not cited here as behavior change interventions, in fact, had strong community education and condom promotion components. However, as they accented other technical domains, they are included in other sections of this report.
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Haiti: Creative Problem Solving
There were no complaints when iron workers at Stewart Industries in Port-au-Prince were summoned to leave their work stations on the hot foundry floor and attend a meeting in the foreman's air-conditioned office. The meeting was facilitated by a representative from the Group in the Struggle against AIDS (GLAS), a Haitian NGO focused on bringing HIV prevention messages to young workers in worksites throughout the Port-au-Prince area. Most international NGOs had departed the country following the fall of Aristede due to the insecurity and difficulty of operating in an environment of political, social and economic chaos. Despite the international embargo, AIDSCAP was able to gain access to the country on the basis of providing humanitarian aid and had provided technical assistance and training in organization and financial management to GLAS and about 12 other NGOs working in AIDS prevention and care. As a result of AIDSCAP support, GLAS was able to educate about 20,000 workers directly and reach thousands more through IEC materials promoting behavior change. Strikes, fuel shortages and embargoed raw materials closed down the transportation system and large worksites. This might have impeded the faint of heart -- but not GLAS. Instead, GLAS adapted with flexibility and creativity in their mission to reach their audience. When gas became scarce, GLAS educators created a portable HIV prevention message and took their presentation and a supply of condoms directly to the people waiting in gas lines. When surveys revealed that after one-hour training sessions workers had gained a high level of understanding of HIV transmission and an active interest in condom use but lacked knowledge and skill in how to use them, GLAS immediately delivered follow-up sessions with condom demonstrations to ensure workers knew how to use condoms correctly. As a result, 500,000 condoms were sold throughout the Port-au-Prince area between 1992 and 1996. "We are all learning how to be flexible and respond assertively to needs as they arise. That is the excitement of the program," states Gessy Aubry, Director of GLAS. "That is how we grow individually and collectively." |
Achieving Popular Access to Condoms Through Social Marketing
Condom social marketing has become a significant program component in many international AIDS prevention programs. In Haiti, Population Services International's (PSI) condom social marketing project assumed a decidedly central role to Aba SIDA's STI/AIDS control efforts. The PSI project coupled an inundation promotion strategy -- relying on print, mass, and special media -- with an interpersonal technique that used "independent vendors" and community agents who received basic training STI/AIDS and condom promotion and sales. PSI also established condom supply links to community educators and health promoters from other Aba SIDA projects, thereby dramatically increasing popular access to condoms and information about their correct use. As partner NGOs focused on key risk groups, this PSI-NGO collaboration had a particularly important impact on reaching Aba SIDA target audiences. To ensure that the Haitian population at large had ready access to condoms, PSI followed a more conventional condom social marketing model of establishing a commercial partnership with a pharmaceuticals distributor, DOBACO, with national coverage. This PSI-DOBACO collaboration ensured that condoms were available through commercial pharmaceutical outlets throughout most of the country.
Recognizing that simple brand promotion alone contributes little to behavior change efforts, the PSI project's advertising strategy went beyond a strictly brand-name approach. Using a diversity of media, PSI promoted messages that were informative, educational, and consistent with the overall Aba SIDA communications strategy. The social marketing project's advertising-educational campaigns were intensive, consistent, and wide-reaching. As such they were a constant source of stimulus for popular discussion about the risk of STIs and AIDS, and thus provided a base upon which targeted interventions could build to motivate individuals to change their high risk behaviors.
By the end of the project the price of condoms had decreased from $.25 to $.02 (a decrease of 92 percent), a total of 14,639,143 condoms were sold and condom sales increased from 3,000 to 300,000 per month. Seven hundred and sixty-five condom outlets were created, including outlets specifically targeting youth and women in such nontraditional places as beauty parlors, restaurants, etc., throughout the country in urban, semi-urban and rural areas.
Increasing Access to Appropriate Care for STIs
At the start of the Aba SIDA program in Haiti there were no nationally agreed upon standard protocols for treating STI symptoms. Effective treatment of STI patients was limited to a few clinics with diagnostic and treatment expertise, however even at these clinics the most up-to-date techniques were often unknown or not applied and clinical and laboratory skills among staff varied. An important constraint to achieving national consensus for clinical management of STIs and hence improved STI care in the country was a lack of basic data on prevalence rates of different STIs and on etiologies of genital ulcer disease and vaginal discharge. In order to improve STI patient access to appropriate professional care, Aba SIDA conducted basic research along with clinical and laboratory skills training.
The overall approach to improving STI care in Haiti involved three overlapping activities: (1) Conducting operational studies in order to develop effective standardized treatment algorithms and care services. These included epidemiologic studies on STI prevalence and risk factors for HIV and an acceptability study for partner referral and treatment; (2) Supporting, facilitating, and participating in the development of national standardized guidelines for the syndromic management of STIs. By the end of the Aba SIDA program these guidelines were being published and distributed to health care providers throughout Haiti; and (3) Upgrading the quality of care in various clinic facilities. This entailed strengthening the diagnostic, clinical, and counseling capacity of Centres pour le Développement et la Santé (CDS) clinics and the Groupe Haïtien d'Etude du Sarcome de Kaposi et Des Infections Opportunistes (GHESKIO) facility. Aba SIDA assistance to GHESKIO further aimed at creating an STD Center of Excellence, designed specifically to strengthen GHESKIO's capacity as a reference clinic and to provide STI training for other Haitian health care workers, many of whom work on other Aba SIDA projects. Extensive and consistent technical assistance to Aba SIDA collaborators from AIDSCAP headquarters and STI subcontractor (University of North Carolina) staff was critical to successfully achieving the key objectives of this important Aba SIDA program component.
The most important result of this component of the Aba SIDA project was the development, after extensive research and consensus building, of national STI guidelines and their launch at the end of the project. Other results include a significant improvement in STI case management in CDS centers (documented by an assessment conducted two and a half years into the project), increased drug availability and an increase from 10 to 69 percent of clinicians correctly diagnosing and treating the most common STIs. In addition, the availability of pre-test counseling increased through the GHESKIO project resulting in 250 people per month receiving counseling.
Improving the Social Environment for Behavior Change: Mass Media, Special Events, and Policy Dialogue
There are several facets of a supportive social environment for STI/AIDS prevention behaviors: popular awareness and knowledge of sexual risk and how to avoid infection, social support of and pressure on individuals to adopt safe sexual behaviors, and policy that is conducive to risk reduction behaviors. In differing degrees and ways, creating a supportive social and policy environment for individual behavior change was an intrinsic aspect of all Aba SIDA interventions. In addition to community-level targeted interventions, Aba SIDA supported major media productions, special events, and policy projects that were explicitly intended to influence the larger social and policy milieu in which STI/AIDS prevention efforts are conducted.
Media productions serve the important function of maintaining and increasing public attention to STI/AIDS issues. In addition to the PSI media campaigns, Aba SIDA financed three important media productions: "Sultana Mon Amour," a television serial drama that aired nationally; "Pouki Se Mwen?," a video drama that televised throughout Haiti; and "Fleet of Hope," an educational video produced for World AIDS Day 1995. Special events provided another means of reaching large numbers of people and spotlighting STI/AIDS prevention. Organized and coordinated by the Aba SIDA office, several special events were planned around specific themes and objectives and involved the joint participation of various Aba SIDA projects, especially during World AIDS Day campaigns. In addition to achieving high visibility of prevention messages, these joint efforts, which required collaboration and consensus among Aba SIDA partner NGOs, also contributed to the program's overall sense of cohesion and shared mission. Finally, two important "policy dialogue" activities in the official domain were achieved after the return of the Aristide government to Haiti: (1) assistance in the development of and participation in the consensus meeting on national guidelines for syndromic diagnosis and treatment of STIs, which is discussed in GHESKIO and CDS executive summaries; and (2) support of fora organized by the Alliance Des Femmes Haïtiennes (AFHA) intended specifically to ensure that the 1996-2000 National AIDS Control Plan adequately addresses the needs of women.
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Haiti: Consensus From the Bottom Up
Traditionally, national policies are determined at the ministerial level and then promulgated to the lower divisions. Not so in Haiti where the chaos following the deposition of the first democratically elected president in 1991 necessitated establishment of new procedures to respond to many urgent issues. In the case of national STD guidelines, the work was began at the local levels and then moved to the Ministry of Health. At a large seminar held in 1995, 70 of Haiti's leading health providers agreed about the need for national STI guidelines that would outline a new approach to diagnosis and treatment, a decision which had been rejected at a similar meeting three years earlier. This change in attitude came about as a result of the initiative taken in the intervening years by Dr. Eddy Genécé, AIDSCAP resident advisor in Haiti, who provided group members with results of studies sponsored by AIDSCAP which revealed the use of ineffective drug therapy in the treatment of some STIs, failure to routinely refer partners of STI patients for treatment and failure to routinely screen pregnant women for syphilis in clinics throughout Haiti. In addition, Dr. Genécé facilitated communication among all groups interested in STI control in Haiti, provided frequent technical assistance and training, and supported Haitian health professionals' participation in attending international meetings where new approaches to STI control were presented. The group at the 1995 meeting also agreed that conditions in Haiti required a low-technology approach and recommended an STI strategy based on the syndromic approach to STI management. This included training of clinicians in comprehensive STI case management at the primary health care level, training of nurses to provide prevention education, counseling to patients and their partners and promotion of safer sexual behavior and condom use, screening of pregnant women for syphilis and periodic updating of drug lists. Lessons learned regarding the elements of consensus building and policy development included availability of statistical evidence describing the dimension and complexity of the problem, access to information and reports of variables in dealing with similar problems in similar countries and situations, involvement of strong, positive key players into a core group which would maintain interest and momentum in dealing with the issue and the need for time, patience and negotiating skill in the consensus-building process. |
Strengthening Technical, Management and Evaluation Capacity of Aba SIDA Partners and Other Haitian Organizations
Enhancing the capacity of Haitian institutions to conduct STI/AIDS prevention and control projects was Aba SIDA's overall program objective. Strengthening local capacity occurred in many ways: through close work with NGO staff in designing interventions and developing proposals (AIDSCAP subagreements) for funding; through daily interactions between Aba SIDA and NGO staff regarding technical, management, and reporting matters related to project implementation and monitoring; through direct technical assistance for specific activities and outputs from Aba SIDA staff, AIDSCAP and subcontractor staff, or consultants; and through formal workshops and training projects supported by Aba SIDA.
During much of the Aba SIDA program, there was a complete absence of public sector structure in Haiti. The AIDSCAP/Haiti country office assumed a coordinating role, strengthening the links between and among AIDSCAP/Aba SIDA implementing agencies, providing opportunities for sharing resources and information among the implementing agencies and establishing a broader network of organizations working in AIDS prevention in the country.
Aba SIDA interventions that focused on increasing technical and management skills and efficiency in STI/AIDS prevention projects had a special role in fulfilling the program's capacity building objective. The Institut Haïtien de Santé Communautaire's (INHSAC) capacity building project with Aba SIDA partners developed multiple curricula that met a variety of training needs of Aba SIDA projects' staff and community-based workers. Due to the wide range of organizational experience and skills among the participating NGOs, INHSAC adopted an NGO-specific approach, focusing on initial training needs assessments followed by reassessments as NGO project capacity improved with INHSAC training. Save the Children's NGO coalition project in the Central Plateau Region, though less explicitly focused on improving specific skills, can also be considered an important capacity building project in the Aba SIDA program. In order to better serve this rural region's population, the Central Plateau coalition project formed to reinforce and combine the skills and experiences of nine NGOs involved in STI/AIDS prevention in the area. In large part due to the coalition model used to conduct the project, the collaborative efforts of these NGOs enhanced the organizational capacity in the region as a whole to provide high quality STI care and to deliver effective STI/AIDS education in the combined area population.
In addition, Aba SIDA implementing agencies improved technical skills through formal and informal assistance, training and experience. A rapid assessment survey and in-depth interviews were conducted at the end of the project to assess changes in capacity with positive results. Over the life of the project, 14 organizations reported enhanced capacities in the area of behavior change communications. For example, GLAS stated that one of the most significant technical improvements in their organization during the Aba SIDA project was the modification of their educational strategy in factories and improved educational methodologies. VDH reported staff skills in training improved from minimal to excellent. In addition, VDH reported they gained valuable skills in materials production over the life of the project.
Vast improvements were made in STI case management. Five organizations indicated improved capabilities in STI management and service delivery. For example, an STI case management survey conducted in 1995 showed that STI case management in the area covered by CDS from the Northeastern health centers to Port-au-Prince had improved significantly. Six organizations showed improvements in condom programming. PSI provided technical assistance and training to INHSAC, CHASS, IMPACT, GLAS, CDS and Save the Children in condom social marketing techniques. INHSAC developed curricula and materials to train condom sales people and INHSAC staff provided training to VDH in CSM.
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All of the implementing agencies reported improved capacity in evaluation methods including focus group discussions, surveys, data analysis and evaluation reporting. |
Three organizations, CDS, PMS and IHE, improved their capabilities in behavioral research. IHE developed behavioral research protocols and CDS worked with Johns Hopkins University on culture and sexuality research. PMS conducted qualitative behavioral research as part of end-of-project evaluation.
In the area of organizational and management skills, nine implementing agencies reported improved strategic planning skills. VDH cited the establishment of an organizational strategic plan as a major improvement in the organization's management, resulting in more efficient program planning and financial management. Eighteen implementing agencies participated in regular strategic planning meetings which improved the coordination of activities. All of the agencies reported improved financial management skills. CHASS reported the organization's minimal financial skills at the outset of the project improved to good skills by the end of the project. In addition, all agencies reported enhanced project monitoring and evaluation abilities.
Organizational systems were also enhanced over the life of the project with all agencies reporting improved financial and accounting systems and project monitoring and evaluation systems by the end of the project. Three organizations, PSI, INHSAC and IMPACT, established condom distribution systems which will continue to operate after the close of the Aba SIDA project.
Improving Care for AIDS Patients
The advanced nature of Haiti's AIDS epidemic increased the urgency and importance of improving HIV/AIDS care and management. Aba SIDA recognized this need and responded to it by supporting three projects that effectively integrated AIDS care and management and STI/HIV prevention. The care and management projects were implemented by hospitals -- Hôpital de Fermathe, Grace Children's Hospital, and Albert Schweitzer Hospital -- that had experienced dramatic increases in the number of HIV/AIDS patients over the past few years. Due to their long-term presence in Haiti and firm links to the communities they serve, these hospitals' AIDS care and management interventions had both hospital- and community-based dimensions. The interventions centered on improving hospital- and home-based care, improving social support for AIDS patients and their families, providing economic assistance to affected families through income generation activities, and integrating prevention services into care activities.
Throughout the life of the project, 27,542 persons living with HIV/AIDS and community members were educated, 785 hospital and community personnel were trained in AIDS awareness, care and counseling, and 1,287 materials were produced and distributed to these populations. Home caregivers were also supported during the project and scholarship aid and microenterprise loans were granted through the Fermathe and Grace Children's Hospital projects to families impacted by the epidemic. Grace also created 33 condom outlets and distributed 274,704 condoms. The Hospital Albert Schweitzer collaborated with 28 local churches. Each church formed a health committee which was trained in AIDS care and prevention. Emphasis was also placed on youth education and counseling people with AIDS.
C. Evaluation and Behavioral Research: Summary of Aba SIDA Outcomes
In addition to the program results described above, the collective impact of Aba SIDA programs can be demonstrated through the comparison of levels of knowledge related to HIV/AIDS and risk behaviors, before and after the project. More than 22 focus group discussions (FGDs) and 13 knowledge, attitudes, beliefs and practices (KABP) surveys were conducted and show a significantly increased understanding of HIV/AIDS transmission and prevention methods in both target populations, and the overall Haitian population. Preliminary, intermediate, behavior changes to lower risk behaviors were reported as well.
A comprehensive strategy was used to evaluate Aba SIDA outcomes and overall success. Four complementary approaches were applied: (1) collection of process indicator data from each project on a regular basis, thus providing cumulative accounts of the number of persons trained and educated, condoms distributed, and materials produced; (2) survey research in target populations to determine knowledge, attitudes, behaviors, and practices related to STIs and AIDS; (3) focus group research with individuals from key target audiences in order to gain a more contextual understanding of knowledge, beliefs and behaviors related to STIs and AIDS; and (4) in-depth interviews with project managers on their experiences with and lessons learned from Aba SIDA's behavior change interventions. Process indicator data are reported in each of the project executive summaries later in the report and are summarized together in Attachment D. Below the program's outcomes related to individuals' knowledge of AIDS, perceptions of risk, and sexual behaviors are reviewed. Baseline data2 from 1990 are compared to 1995 data from thirteen post-intervention surveys3 and 22 focus group discussions4.
Baseline and Post-intervention Survey Results
General knowledge
In 1990, knowledge of the existence of AIDS was quite high (98 percent), but characterized by inaccuracy and myths. Only 61 percent of the survey respondents, for example, knew that HIV was transmitted sexually, 37 percent believed the disease was transmitted by supernatural means, and 29 percent could not cite a single means of HIV transmission. When asked if it was possible to avoid HIV infection, 17 percent of the subjects believed that it was impossible and 12 percent were unsure.
Accurate knowledge about AIDS was substantially higher in 1995 compared to the 1990 study. In both women and men, 97 percent knew at least one means of HIV transmission, and 89 percent of the women interviewed and 92 percent of the men identified sexual intercourse as a mode of transmission. Over 95 percent of both women and men were also able to cite at least one means of prevention; 80 percent of adolescent women, 90 percent of adolescent men and 99 percent of female sex workers could cite a means of prevention. A few focus group participants expressed belief in supernatural means of HIV transmission or in conspiracy theories. In 1995, additional survey questions addressed issues of curable STIs. Between 56 to 78 percent of women and 35 to 67 percent of men could identify a source for STI treatment. Of individuals seeking treatment at qualified care facilities, 73 to 83 percent of women and 67 to 73 percent of men reported having notified their sexual partners of the need to seek treatment.
Knowledge of the means of transmission and methods of prevention (condoms) of AIDS among the general population in 1990 and 1995
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1990 |
1995 |
| Knowledge of at least one (1) method of transmission of AIDS |
71% |
97% |
| Knowledge of condoms |
62% |
95% |
Risk perception
A significant percentage of the population - 19 percent of men and 16 percent of women - were unable to assess their risk for HIV infection in 1990. In general, many people believed HIV transmission occurred exclusively among gay men and foreigners, and therefore felt that they personally were not at risk of contracting the infection.
In 1995, less than one percent of those interviewed were unable to estimate their level of risk, a dramatic reduction compared to 1990 results. Roughly the same percentage of women and men (between 20 and 30 percent) perceived themselves to be at risk of contracting AIDS. Risk perception was higher among sex workers (45 percent), clients of commercial sex (38 percent), and young people (31 percent of young women and 43 percent of young men). Eleven percent of the women interviewed perceived themselves to be at moderate or high risk; 90 percent of these women declared that infidelity of their sexual partners was one reason.
Perception of risk infection by HIV virus among general population in 1990 and 1995
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1990 |
1995 |
| Do not know their level of risk |
18% |
<1% |
Partners
The percentage of adults in 1995 reporting multiple partners in the last 12 months was 25-50 percent among men, and 10-20 percent among women (varying according to age and marital status). Twenty-five percent of men in union, living with their partner, reported more than one partner in the last 12 months (mean of 1.5). Fifty-one percent of men in union, not living with their partner, reported more than one partner (mean of 2.4). Of the men not in union, 41 percent reported no partners, 30 percent reported one partner, and 29 percent reported more than one partner (mean of 1.2). Among youth, 40-50 percent of men, and 60-80 percent of women reported sexual abstinence over the last 12 months, and among those sexually active, 60 percent of men and 10-20 percent of women reported more than one partner in the last 12 months. Twelve percent of young men, 12 percent of men in union, not living with their partner, and 22 percent of separated or widowed men reported paying for sex in the past 12 months.
When asked directly, "since you have heard of AIDS have you done something to reduce your risk of infection?", 31 percent of women and 68 percent of men reported they had changed their behaviors. Among women aged 15-19, the most common strategy reported was abstinence. For women over age 19, partner fidelity was greatly favored over condom use. Among men aged 15 to 29, avoiding casual partners and using condoms were equally favored. Among men aged 30 to 59 partner fidelity and avoiding casual partners were most cited.
Condoms
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Knowledge about and access to condoms increased dramatically between 1990 when the baseline study was conducted and 1995 when follow-up research took place. |
Only 54 percent of women and 69 percent of men interviewed knew of the existence of condoms in 1990 and access to condoms was limited. Among those individuals who knew about condoms, there was a widespread perception that they were of poor quality. Average condom prices were $0.25 per unit. By 1995, 95 percent of both men and women knew of condoms, and an almost equal percentage (ranging from 85-99 percent) knew of 1 or more sources to acquire condoms. Average condom prices were $0.02 per unit. Access to condoms (defined as the ability to get a condom today if needed) ranged from 80 percent for women to 95 percent for men.
Reported condom use in 1990 was extremely low, with only 6 percent of women and 16 percent of men claiming to have ever used a condom. By 1995 these rates had doubled to 12 percent and 32 percent. Reported ability to negotiate condom use in 1995 was also very high, 80 to 90 percent in sex workers and clients of commercial sex, 50 to 60 percent in young women and 65 percent in young men. Increases in reported condom use rates is perhaps one of the more impressive outcomes of the Aba SIDA project. Sex workers reported between 80 and 90 percent condom use with paying clients; with their regular sexual partners, condom use was much lower at 30 percent. Sixty percent of commercial sex clients stated that they had used condoms during their last sexual encounter. In the general population, 23 percent of single women interviewed reported ever using condoms, and 54 percent of these women claim to use them all the time. Among women who have regular sexual partners, 9 percent report having ever used a condom. For men, reported condom use ranged from 47 percent in single men, 41 percent of these stating that they use condoms during each sexual encounter, to 21 percent in men who live with their regular sexual partners. Only among young adults (15 to 25 years old) did reported condom use rates remain very low; roughly 50 percent of sexually active young men and 75 to 80 percent of sexually active young women reported never having used a condom.
Focus group research results indicate that while there do not seem to exist socioculturally-based barriers to condom use, a variety of other factors may be involved in limiting usage rates. A decrease in sexual pleasure and the idea that condom use undermines a sense of "trust" in relationships were both important themes brought out in this research. Many of the educational and promotional campaigns in Aba SIDA projects, and particularly the PSI social marketing project, directly respond to both of these issues. These focus group data, however, underscore the enduring and difficult-to-alter nature of such perceptions. Only with persistent promotion and education over time can such notions be changed. Focus group research with youth revealed very specific kinds of issues that can be addressed in future interventions. Perceived availability of condoms was lower in younger respondents as compared to older respondents. This may be related to the expressed sense of fear and embarrassment for youth related to purchasing condoms. Such results are highly useful in their specificity and provision of clues to future strategies for increasing condom use in this vulnerable population.
Percent of the general population who have ever used condoms
|
1990 |
1995 |
| Male |
16% |
32% |
| Female |
6% |
12% |
STI Treatment Seeking Behavior
Qualitative research on STI treatment seeking behavior conducted in 1992 among residents of Port-au-Prince found that few people considered STI symptoms to be infectious or sexually transmitted, and that many people self-medicated with herbal preparations. Partner referral for STI treatment was rare. By 1995, knowledge of effective STI treatment sources ranged from 40-60 percent among men, and 60-70 percent among women. Of those seeking effective treatment, approximately 70 percent of men, and 75 percent of women reported notifying their partners of their need for treatment.
Attitudes
As an increasing percentage of Haitians become personally acquainted with HIV/AIDS, and as knowledge increases on transmission methods and myths, increased compassion towards persons living with HIV/AIDS is being seen. Qualitative research found decreased social isolation of persons living with HIV/AIDS on the part of both individuals and institutions.
D. Organizational and Management Issues
|
Management efforts concentrated on decentralizing responsibilities while maintaining a strong network between and among Aba SIDA and its partners. |
During the years of political crisis, Aba SIDA in many ways assumed the role of a national AIDS control program. Management of the program reflected these unique circumstances. Bimonthly meetings between the Aba SIDA staff and key members of partners' staff allowed for continual clarification and affirmation of the overall program goals; review of the various contributions being made by the NGO partners; sharing of experiences and exchange of techniques and materials (e.g., GHESKIO's counseling manual and VDH's peer education guide) between the projects; the establishment of key links between projects, especially concerning the integration of condom social marketing into behavior change interventions; and the planning of joint campaigns that were so critical to keeping STI/AIDS prevention alive during even the most tense moments of crisis. Aba SIDA management involved maintaining a balance between supporting individual interventions in the implementation of their particular activities while at the same time guiding each project in such a way that its activities contributed to a larger, cohesive and integrated prevention program that had national-level significance and impact.
Endnotes
- Because of the association between infection with STIs and HIV transmission, the third variable is highly relevant for AIDS prevention.
- Sources: Adrien A and Cayemittes M. Le Sida en Haiti: Connaissance, attitudes, croyance et comportement 1991; and, Institut Haïtien de l'Enfance/CDC. Enquete Nationale Haïtienne sur la Contraception 1989.
- Conducted by the Institut Haïtien de l'Enfance (IHE) under a subagreement with AIDSCAP; also cited, IHE/DHS. Enquete de Mortalité, Morbidité, et Utilisation des Services EMMUS-II 1994-1995.
- Conducted by Calixe Clerisme of Professional Management Service under a subagreement with AIDSCAP
