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Final Report for the
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Background and Country Context The AIDSCAP/Haiti project worked to improve the clinical care and support for STI and AIDS patients as well as create an environment conducive to social and policy reform to foster behavior change. A. Epidemiology of HIV/AIDS and Other STIs The epidemiologic profile of HIV and AIDS in Haiti is more similar to high HIV prevalence countries of sub-Saharan Africa than it is to Haiti's Caribbean neighbors and Latin American counterparts more generally. Haiti has, in fact, been singled out by epidemiologists as having a very advanced AIDS epidemic compared to countries in the entire northern hemisphere. Among urban antenatal women, HIV prevalence rates have been 8 - 10 percent for the last 10 years. Overall, HIV prevalence in Haiti is estimated to be 10 percent in urban adult populations and 4 percent in rural areas, with the female to male ratio of HIV-infected persons approaching 1:1. Of all HIV infections reported in the country, 80 percent occur in young adults between 20 and 44 years of age, many of whom contracted the infection at the debut of their sexual lives during their adolescent years. An HIV prevalence rate of 8 percent among pregnant teenagers in Port-au-Prince potently reveals this disturbing trend. Prevalence data in individuals at especially high risk for HIV also parallel sub-Saharan African patterns, for example, some studies in female sex workers report HIV prevalence at 70 percent. Intravenous drug use, by all accounts, is virtually absent in Haiti and is not significant to HIV transmission there. Altogether, these data indicate that sexual relations between women and men is the dominant mode of HIV transmission in Haiti. Moreover, the overall high infection rates suggest that the Haitian AIDS epidemic has spread substantially beyond "core groups1." Reports from 1992 showing that 60 percent of urban hospital beds were occupied by patients infected with HIV bring into focus the profound impact of AIDS on Haitian health and on Haiti's health care system. The epidemiology of STIs other than HIV further attest to the severity of the situation. An AIDSCAP-funded baseline study of STI prevalence among pregnant women living in Cité Soleil reported the following results2: STI Prevalence Among Pregnant Women Living in Cité Soleil
* Positive for T. pallidum by rapid plasma reagin and microhemagglutination tests. Considering the serious reproductive health consequences of delayed or inappropriately treated STI, such high infection rates in women bespeak the urgent need for aggressive interventions to improve professional STI care and to promote prompt treatment seeking behaviors among Haitian STI patients. Such data become even more relevant in light of the well documented association between "classic" STI infection and HIV transmission, highlighted by recent evidence that increasing cure rates of bacterial STIs can lead to a reduction in incidence of HIV. AIDSCAP-supported initiatives in Haiti directly responded to the epidemiologic contours of HIV and other STIs in the country, to the social and policy spheres related to prevention and control, and to the existing health care needs. As HIV rates in the general population are relatively high, programmatic emphasis in the form of targeted behavior change interventions was placed on interrupting "core group" transmission as well as on preventing transmission in more broadly defined vulnerable or at-risk populations. The AIDSCAP project in Haiti, consequently, aimed to improve the quality of professional STI care, and to create a social and policy environment conducive to bottom-line behavior change and improved clinical care for STIs. In addition, in light of the increasing number of AIDS patients in Haiti, AIDSCAP integrated projects that focus on providing care and support to AIDS patients and their families. The precise strategic approach and programmatic makeup of AIDSCAP's work in Haiti are delineated below. The point to be reiterated here is that the program's design was firmly grounded in the epidemiologic, social, and health care environments that exist in the country. B. Response to AIDS in Haiti and Importance of Aba SIDA Precursors to AIDSCAP/Aba SIDA The first cases of AIDS in Haiti were recognized in 1982. A coordinated national response to the epidemic began taking shape five years later in 1992 with the establishment of the Comité National de Lutte Contre le Sida (CNLS), a multi-sectorial and -ministerial body composed of 13 members representing both public and private sector institutions. While this multi-sectorial group conceptualized national priorities, policies and strategies related to AIDS prevention and control, the actual supervision and coordination of intervention plans was charged to the Bureau Central du Programme National de Lutte Contre le Sida (BCPNLS), constituted in 1988 and comprising a small staff. In that same year, the CNLS developed a short-term plan to program $500,000 of initiation funding provided by the World Health Organization's Global Programme on AIDS (WHO/GPA). Later in 1988 the country's first five-year medium-term plan for controlling AIDS was conceived. A number of donors committed financial and technical support to Haitian governmental and non-governmental institutions to implement the nation's AIDS control plan (see Attachment C). In June 1989 USAID/Haiti provided assistance to support surveillance and Family Health International's (FHI) AIDSTECH project to prevent the sexual transmission of HIV/STI. The project was expanded in April 1991 with the elaboration and initiation of Haiti's Aba SIDA (meaning "Down with AIDS" in Haitian Creole) project. Only four months into the expanded Aba SIDA project and less than two years into the democratically chosen government of Jean Bertrand Aristide, in September 1991 a military coup d'état abruptly redirected the political course of Haiti and in the process paralyzed virtually every aspect of normal daily functioning. Concomitant with this unpeaceful shift in political power were widespread threats to civilian security and a near total collapse of public and economic life. In October 1991, the United States responded to the unlawful assumption of power by Raoul Cedras by revoking development assistance to the Haitian government, and in this move officially restricted the Aba SIDA program. By November, other donors followed suit and the Organization of American States had further instituted an economic embargo on Haiti. The absence of donor assistance brought, in effect, a halt to nascent AIDS prevention work in the country. This situation was fortunately only temporary due to US policy exempting AIDS prevention from its withdrawal of development assistance, and in April 1992 Aba SIDA resumed its activities but exclusively with non-governmental institutions. Under a new cooperative agreement with Family Health International, technical assistance responsibility for Aba SIDA was transferred to FHI's AIDSCAP project in October 1992 and continued to June 1996. This report covers the period of Aba SIDA under AIDSCAP. In partnership with Family Health International and a number of local Haitian institutions, USAID, with its initial 1989 AIDSTECH project, entered into an extended, if not at times turbulent and uncertain, commitment to AIDS prevention in Haiti. As a result of the retraction of other donor support and the dissolution of the Haitian public health infrastructure, the USAID-AIDSCAP-Haitian institutional partnership, coalescing in the Aba SIDA program, came to assume special importance for AIDS prevention and control in Haiti. For several years, in fact, Aba SIDA represented the whole of AIDS prevention efforts in the country. Adapting to Adversity With the unfortunate political turn of events in Haiti, Aba SIDA strategically redirected its original design under AIDSTECH. First, aspects of the program that involved collaboration with public sector institutions were diverted to non-governmental organizations. Only after the reinstatement of Aristide to power in 1994 was government collaboration pursued. Almost all of the activities described in this report were conducted in collaboration with private sector organizations, both NGOs and commercial establishments. Circumventing the official sector of Haiti to conduct AIDS prevention was neither easy nor desirable, but it was necessary and in the end effective. The Aba Sida configuration of an exclusively non-governmental program in Haiti accommodated the US government's policy imperative of nonsupport of Cedras's regime, but was also programmatically sound, as the results highlighted in this report indicate. Second, AIDSCAP/Aba SIDA took into consideration the technical and resource gaps left by the retraction of other donor support. This latter point was especially important with regard to withdrawal of Canadian assistance to Haiti's national AIDS control program to conduct education and communication activities. AIDSCAP, hoping for a rapid resolution of the political crisis, prepared for two programmatic scenarios in its Strategic and Implementation Plan, one with government collaboration in the event of resolution and the other exclusively with non-governmental organizations. In the end, political impasse and enduring crisis prevailed. In June 1993 the international community increased the pressure on the illegal Cedras government to step down by instituting a fuel embargo. Ensuing fuel shortages profoundly affected Haitian life, crippling the country's transportation network and undermining the already fragile economic base. Most products and services were also in short supply or simply unavailable, rendering every day activities and project operations difficult at best. Persistent security threats to the civilian population produced a general climate of fear and tension, and political violence on very unfortunate occasions personally affected certain personnel of the Aba SIDA projects. In such a climate, the most carefully laid plans for conducting training of health care providers, educating peers on sexual risk and ways to avoid it, or distributing condoms were frequently and necessarily abandoned to be reorganized only as circumstances permitted. Throughout this period of extreme adversity, however, AIDSCAP, its project partners and community-based collaborators remained committed to making the concept of Aba SIDA a tangible reality in Haitian life. Operating at times in what might best be described as a programmatic state of emergency, preparedness to adapt to events as they unfolded was emphasized over rigid implementation schedules of precisely planned activities. Endnotes
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