Subproject Highlights
A. Targeted Interventions To Change Individuals' Behavior
STD/AIDS Prevention Among Haitian Youth
| Aba SIDA partner: |
Comité d'Action des Jeunes contre le SIDA (CAJES) Volontariat pour le Développement d'Haïti (VDH) |
| Geographic focus: |
Urban and peri-urban sites in four northern regions: Nord: Cap-Haïtien, Quartier Morin; Nord-Est: Fort-Liberté, Trou du Nord; Nord-Ouest: Port-de-Paix, Saint Louis du Nord; Artibonite: Gonaïves, Saint Marc |
| Target population: |
Adolescents and young adults, 12 to 25 years old |
| Project dates: |
Phase 1: September 1993 to December 1994 (for CAJES); Phase 2: March 1995 to March 1996 (for VDH) |
Background and Scope of the Intervention
Epidemiologic data from Haiti combined with behavioral research results indicating that many Haitian youth are sexually active at young ages attest to the importance of targeting adolescents and young adults with STI and AIDS prevention programs. With Aba SIDA assistance, the Volontariat pour le Développement d'Haiti (VDH) responded to this need by conducting an intervention targeting youth living in urban and peri-urban areas of four districts of Haiti's northern region. Youth peer educators who also served as condom vendors represented the core of the VDH project. Training peer educator trainers and peer educators themselves, producing materials to support peer education sessions, and integrating condom social marketing into the peer education network represented the key activities and outcomes of this project.
This peer education project began as a coalition intervention involving three NGOs: the Centre de Développement des Ressources Humaines (CDHR), the Volontariat pour le Développement d'Haïti (VDH), and the Boy Scouts of Haiti. Their partnership was recognized as the Comité d'Action Des Jeunes Contre le SIDA (CAJES), and was the initial recipient of AIDSCAP assistance in October 1993. CAJES's Prévention Contre les Maladies Sexuelles (PREKOMAS) project involved integrating STI/AIDS peer education and condom vending into the already established youth networks of VDH and the Boy Scouts, while CDHR assumed administrative and financial management responsibility for the project. PREKOMAS continued through December 1994, but midway through the project the Boy Scouts withdrew. Due to internal organizational difficulties in the coalition, and more specifically to an uneven commitment to the project by CAJES's member organizations, the second phase of this project was restructured. In phase two, AIDSCAP provided assistance solely to VDH, which continued and expanded the peer education initiative under the revised project title "STD/AIDS Prevention Among Haitian Youth." For purposes of simplicity and clarity, the remainder of the summary will refer exclusively to VDH; however, the summary of the accomplishments that follows includes the activities and outputs of both phases of the project.
Principal Accomplishments
Despite the early organizational difficulties experienced by this project, overall it accomplished the major objectives outlined in subagreements with AIDSCAP. Highlights are summarized below:
Peer Education
- 400 peer educators and 16 field supervisors were trained during the first phase of the project. They subsequently held educational and motivational sessions for over 10,000 VDH members and Boy Scouts.
- Curricula for training youth peer educators, and trainers of peer educators were developed.
- 120 new peer educators were trained in the second phase of the project in basic STI/AIDS education and prevention, and communication and animation skills during 14 six-day training sessions.
- Four 3-day refresher training courses focusing on animation and communication techniques were conducted for 120 STI/AIDS peer educators.
- Five 5-day training sessions were organized for 4 field coordinators and 17 other VDH staff; this training focused on management and leadership skills and prepared coordinators and VDH staff to conduct peer educator training.
- A total of 1,577 peer education sessions were conducted in the second phase during which 20,979 Haitian youth learned about STIs and AIDS and how to prevent these infections.
- Five meetings between peer educators and field coordinators were held to provide educators a forum to discuss their experiences and difficulties in successfully conducting peer education.
Development of IEC Materials to Support Peer Education
- 400 peer educator guides were produced and 195 distributed to peer educators. With technical guidance by VDH staff, youth themselves conceptualized the content of the peer education guides, thus defining from their own perspectives the key issues related to STI/AIDS and strategies for prevention. Copies of these guides were distributed to other Aba SIDA partner projects for their reference and use.
- Peer education participants received printed materials to reinforce key messages in peer education sessions. 15,000 supplementary educational materials were produced and 11,804 distributed.
Integrating Condom Social Marketing into Peer Education
- Four 3-day training sessions in condom social marketing were conducted with 48 peer educators.
- 96 condom vending sites conveniently located for youth were established by the end of the project.
- Compared to projected condom sales of 2,500, youth peer educators sold 23,073 condoms during the project period.
Important Constraints
Apart from the political strife that affected all aspects of project implementation, the most important constraint for this intervention was the organizational failure of the coalition during the first phase of the project. Although this was resolved in phase-two which was carried out by VDH, the organizational problems within the coalition caused overall delays in completing and operationalizing some of its basic activities, including initiation of peer educator training and integration of condom social marketing.
The high demand for condoms among youth was unanticipated, reflected in the disparity between projected sales (2,500) and actual sales (23,073); an additional 3,300 were given away free of charge. Such high demand for condoms clearly indicate an important degree of success of STI/AIDS prevention efforts in Haiti. The fact that condom shortages were experienced by this peer education intervention, however, also underscores an emerging condom conundrum in STI/AIDS prevention work more generally: creating demand for protected sex through condom use that cannot be met with the present level of resource commitment to the cause of prevention.
Lessons Learned and Recommendations
The onset of sexual relations among Haitian youth is generally very young, between 10 and 13 years old. Formal research results and informal information gathered from years of experience of working with Haitian youth are consistent on this point. In light of this, two related recommendations are offered: (1) More needs to be understood about sexuality and sexual behaviors of Haitian children, and about the social environment in which children become sexually active. Qualitative research methods that are best suited for such a pursuit should either replace or supplement focus group research. Important topics that need to be explored in more depth include the process and key factors related to youths' sexual decision making; the extent and nature of sexual coercion; and the role and nature of peer, adult, and overall social pressure to initiate sexual activity; and (2) Appropriate interventions with young children are urgently needed. If, as Aba SIDA data and experience indicate, children are sexually active as early as 10 years old, and sometimes even younger, then STI/AIDS prevention projects inclusive of very young children should be actively explored.
Many adolescents and young adults are responsive to STI/AIDS education and eager to use condoms for self-protection. The high demand for condoms in this target audience bespeaks the need to continue policy efforts aimed at securing support, materially and otherwise, from private and public sector institutions. Sustained behavior change requires continuous and long-term commitment to interventions. Until such time that the Haitian government is in a position to support interventions, continued donor assistance to ensure sufficient condom supplies, widespread condom distribution, and aggressive and high-visibility promotion of condom use, should be considered a high priority to protect Haitian teenagers and young adults from AIDS and other STIs.
The advantages of successful coalition projects -- extending the intervention impact to the combined reach of member organizations, facilitating exchange of experiences and lessons learned between organizations, capitalizing on the shared technical and material resource base of multiple partners, etc. -- are very appealing. While the concept of coalition interventions is almost always ideal, in practice, coalitions are not necessarily the best way to conduct public health programs. Aba SIDA's experience with the CAJES coalition demonstrated this unfortunate fact. While coalition projects can be highly effective, as Aba SIDA's NGO Coalition in the Central Plateau region showed, when conceptualizing coalition interventions it is important to examine carefully issues such as organizational compatibility and levels of commitment among the various coalition partners.
Summary of Process Indicators
| Aba SIDA Partner |
Process Indicators |
Actual |
| Comité d'Action des Jeunes contre le SIDA (CAJES), a coalition of VDH, Boy Scouts of Haiti, and CDHR |
Individuals trained |
416 |
| Individuals educated |
10,182 |
| Materials distributed |
4,400 |
| Volontariat pour le Développement d'Haïti (VDH) |
Individuals educated |
20,979 |
| Individuals trained |
313 |
| Materials distributed |
11,999 |
| Condoms distributed free |
3,334 |
| Condoms sold |
23,073 |
| Condom outlets created |
96 |
Community Education for STD/AIDS Prevention
| Aba SIDA partner: |
Centre Haïtien de Service Social (CHASS) |
| Geographic focus: |
The Carrefour zone of Port-au-Prince |
| Target population: |
Adolescents and young adults, 14 to 24 years old |
| Project dates: |
Phase 1: March 1993 to May 1994; Phase 2: June 1994 to April 1996 |
Background and Scope of the Intervention
Nowhere is the need for effective AIDS prevention in Haiti greater than in the slums of Port-au-Prince's Carrefour zone. A major impetus behind the Centre Haïtien de Service Social's (CHASS) inclusion of an AIDS prevention component in its social and health agenda in the Carrefour zone was the discovery of excessively high HIV prevalence in this population in the mid-1980s. Conjointly with Haiti's newly established national AIDS control program, CHASS launched one of the country's first AIDS prevention interventions for youth in 1987. This intervention effectuated a wide-scale mobilization of diverse sectors in the Carrefour community to participate in its AIDS education efforts aimed at youth. Beauty and hair salons, neighborhood boutiques, lottery stands, and many other neighborhood establishments all became engaged in an extensive network of information dissemination and promotion of AIDS prevention focusing particularly on youth.
CHASS first collaborated with Aba SIDA in 1992 on the initial Alerte SIDA! campaign. The enthusiastic response of Carrefour youth to that campaign led to a longer-term partnership with Aba SIDA that lasted from March 1993 to April 1996. With Aba SIDA's financial and technical support, CHASS was able to build on its strong ties to the Carrefour community and the extensive network it mobilized during its previous AIDS prevention efforts. Aba SIDA funding permitted CHASS to establish "STD/AIDS prevention posts" throughout the community. These prevention posts constituted a network of sites where teenagers and young adults could come for information on STIs and AIDS, peer education, and condoms. To extend further its community impact, CHASS held STI/AIDS awareness and education sessions for diverse youth groups as well as to teenagers and their parents. CHASS had to rely on substantial support and goodwill from religious and various other community members to conduct this activity. Such key persons and organizations in Carrefour provided CHASS not only their consent for the activity, but their facilities for holding the educational meetings.
The urgency of STI and AIDS prevention in Carrefour youth was such that CHASS did not depend solely on adolescents, parents, and youth groups coming to the STI/AIDS prevention posts or attending group educational sessions. It made its presence and the importance of STI/AIDS prevention known to another 1,523 families in Carrefour by conducting home visits. Through such home visits, CHASS was able to provide key family members with important information on STIs and AIDS, encourage behaviors to prevent infection, and refer adolescents and parents to sources of additional information and services. In the process of these home visits, CHASS staff learned more fully about the concerns, needs, perspectives and living circumstances of its primary target audience.
CHASS's firmly established relationships in Carrefour and its strategic history of assertively engaging diverse segments of the community in prevention efforts are clearly important underlying aspects of this project's success. Despite Haiti's plunge into severe political discord and economic despair during the project period, STI/AIDS prevention among Carrefour youth proceeded with almost boundless community support and enthusiasm.
Principal Accomplishments
Information, Peer Education, and Condom Sales: Community-Based STI/AIDS Prevention Posts
- 300 STI/AIDS information, peer education, and condoms sales posts in diverse locations throughout the community were operational by the end of the project.
- Through a total of 58 sessions organized, 237 volunteer peer educators who staffed the posts received training in STI/AIDS issues and condom social marketing.
- 59 "community educators" were trained to monitor and provide support for the educational and condom sales services at community-based posts.
- Pantè condom sales were integrated into the services provided at 174 STI/AIDS prevention posts; close to 200,000 condoms were sold at these newly established outlets, and an additional 8,417 condoms were given away free of charge at prevention posts and via other educational activities.
Other STI/AIDS Education in the Community
- Through 42 group sessions, 1,118 youth from a wide variety of community groups - Catholic and Protestant churches, neighborhood associations, public and private school committees - were educated about STI/AIDS and means of prevention.
- Parents of teenagers participated in 7 CHASS-organized educational sessions for youth; although below the project's objective for achieving parental participation, this activity firmly established a precedent for dialogue with parents on teenagers' risk of STIs and AIDS.
- 1,523 home visits were conducted by CHASS staff during this project, from which CHASS gained an in-depth understanding of the difficulties faced by Haiti's poorest urban families. The information and experience gained from these home visits is useful for conceptualizing future health interventions in this poor community.
Production and Distribution of Supporting Materials
- A 12-page booklet on STIs and AIDS was produced and pre-tested by CHASS.
- At prevention posts and via other community-based educational efforts, 12,684 educational and promotional materials were distributed, including informational pamphlets on STI/AIDS, T-shirts, and posters.
Important Constraints
The greatest constraint experienced by this project was the relative immobility of the population due to rampant insecurity and a transportation crisis that accompanied Cedras's illegal seizure of power. This had a particularly negative effect on CHASS's attempts to engage parents in educational sessions, resulting in a less than satisfactory fulfillment of this planned activity.
Lessons Learned and Recommendations
CHASS's home visits provided them a glimpse of the intimate living environments of Haiti's poorest urban youth. As adult members of these families pursue their daily struggle to get by in Haiti's poverty, there is little time or resources left to attend to even the most primary needs of young children and teenagers. CHASS research and experience revealed a critical link between extreme poverty of the Carrefour zone, high rates of risky sexual behavior, and early onset of sexual activity in youth. In such an environment, interventions should aim to break the cycle of poverty and high risk sexual behavior. For youth in particular, behavior change interventions must necessarily be supplemented by activities that offer youth opportunity for professional and economic self-enhancement, such as income generation projects.
Summary of Process Indicators
| Aba SIDA Partner |
Process Indicators |
Actual |
| Centre Haïtien de Service Social (CHASS) |
Individuals educated |
6,082 |
| Individuals trained |
296 |
| Materials distributed |
26,430 |
| Condoms distributed free |
8,417 |
| Condoms sold |
196,920 |
| Condom outlets created |
487 |
Alerte SIDA! 1992-1993: School- and Community-Based AIDS Education
| Aba SIDA partner: |
Various Aba SIDA partners |
| Geographic focus: |
Port-au-Prince |
| Target population: |
Adolescents in-school and in the community |
| Project dates: |
Selected months in 1992 and 1993 |
The Alerte SIDA! campaign was uniquely designed for adverse political conditions. It was conceptualized and initiated several months into Cedras's rule as Haiti's political impasse worsened and fear and tension in the civilian population grew. By the time Alerte SIDA! was launched in mid-1992, the Cedras government's stance of intimidation and terror had produced an awkward and uneasy silence in the Haitian population. In the process of stamping out public discourse of all kinds, Haiti's new military powers had effectively muted popular discussion of AIDS. Alerte SIDA!, as Aba SIDA Director Eddy Genécé described, was intended "to fill the silence1."
Following a six month interruption of Aba SIDA activities stemming from Haiti's political crisis, the Alerte SIDA! campaign was designed to achieve immediate, widespread, and high-visibility results. The Alerte SIDA! campaign provided a forum for reintroducing the subject of AIDS - and a new Aba SIDA program under AIDSCAP - to the Haitian population. It involved providing small rapid-response grants to several Aba SIDA partners operating in different locations throughout Port-au-Prince. The theme was peer education with youth in schools and in the community. Aba SIDA provided guidelines for various peer education models, however the individual Aba SIDA partners selected the intervention format that suited their capacity and interests and needs of the communities in which they worked. In the first 1992 Alerte SIDA! campaign, 140 schools were reached through the combined efforts of nine Aba SIDA partners and community-based peer education supplemented interventions in the schools. The enthusiastic response by participating adolescents and Aba SIDA partner organizations to the 1992 campaign resulted in an expanded and diversified campaign in 1993. In addition to community- and school-based peer education, the 1993 campaign included an AIDS telephone hotline for adolescents, providing them with the opportunity to request AIDS information in privacy.
Alerte SIDA! accomplished its main objective of achieving a rapid and widespread focus on AIDS prevention in Haiti. Despite an increasingly tense ambiance in Haiti at the time, Alerte SIDA! succeeded in spotlighting AIDS through its peer education activities. The project was enthusiastically received by youth all around Port-au-Prince. During the 4 to 6 month long campaigns that ran in 1992 and again in 1993, over 15,000 teenagers participated in Alerte SIDA! peer education interventions. These activities have since been extended with WHO/PAHO financial assistance.
AIDS Prevention in the Workplace
| Aba SIDA partner: |
Groupe de Lutte Anti-SIDA (GLAS) |
| Geographic focus: |
Port-au-Prince |
| Target population: |
Adult workers |
| Project dates: |
Phase 1: February 1992 to May 1994; Phase 2: June 1994 to March 1996 |
Background and Scope of the Intervention
Rapid spread of HIV in urban areas underscored the urgent need for interventions that reached a broad population. Targeting Haiti's adult factory workers provided the venue for such an intervention. Factory workers between 20 and 40 years old represent a majority of Haiti's formal-sector workforce, and in this sense they constitute the backbone of the country's official economy. AIDS prevention among factory workers is significant, not only as a mechanism for reaching a wide and diverse segment of Haiti's adult population, but also for protecting an important economically productive class. The Groupe de Lutte Anti-SIDA (GLAS), a Haitian nonprofit organization composed of concerned private business owners and health professionals, recognized this need early on in Haiti's AIDS prevention efforts. GLAS was formed in 1987 and has received USAID assistance since 1988, initially via AIDSCOM and AIDSTECH and beginning in February 1992 via AIDSCAP. USAID's commitment to GLAS paid off in an important way: it allowed a nascent indigenous institution the time to develop into a programmatically and managerially sound organization.
With Aba SIDA's help, GLAS developed a dynamic approach to peer education with factory and parastatal workers. Underlying their success was a continuous process of self-monitoring and -evaluation, permitting the organization to continuously identify and fill needs and gaps in its peer education strategy. As a result of this ongoing evaluation, GLAS learned that a powerful behavior change approach stresses peer education as a process, involving a series of educational sessions with individuals and where each session complements and builds on prior educational sessions. GLAS's peer education process entailed a four-staged curriculum that was conducted by fully trained peer educators in groups of approximately 10 participants. The first session covered basic education and information on STIs and AIDS. Building on the basics, a second educational session emphasized personal risk assessment and risk reduction behaviors. The third stage shifted the focus from abstract educational concepts to concrete prevention practice and participants in this session were given the opportunity to practice condom use skills on anatomical models. The fourth session involved the creation of 20 peer support groups which provided a forum for participants to share their individual problems and experiences related to STI/AIDS and the adoption of safe sexual behaviors, and to learn from the advice and shared experiences of peers in problem-solving and decision-making in this regard.
To ensure focused attention to and a high quality of peer educational sessions, GLAS hired a core group of peer educators as part of its permanent staff -- all former factory workers -- and provided them with extensive training in communication and animation skills, group facilitation and management, and STI/AIDS prevention. GLAS's permanent peer educators completed a basic peer educator training program and each received individualized follow-up training as indicated by the peer educators themselves or by observations of their performance during education sessions. All peer educators received refresher training in basic knowledge and in interpersonal skills. With the technical assistance of a Haitian psychologist, GLAS peer educators and 22 other factory workers received specialized training in effectively facilitating peer support group sessions.
Appropriately printed materials were distributed during peer education sessions which emphasized and reinforced important themes and information covered in the sessions. Condoms supplied during educational sessions were made available via factory-based sellers. The GLAS project conducted and collaborated on a number of special events as well. The important function of such events was to call attention to and stimulate discussion about the risk and health consequences of STIs and AIDS among an even broader worker population than those who participated in GLAS's peer education sessions.
A critical first step in conducting workplace-based peer education was to win commitment from factory owners and managers. Thereafter, it was necessary to maintain their continued support and enthusiasm for GLAS activities. The firm support demonstrated by company managers and owners throughout the project was key to its success, in the most essential and immediate terms -- for example, giving GLAS access to workers and giving workers time to participate in educational sessions -- as well as in terms of a longer term view towards leveraging more substantial material support from private sector institutions for HIV/AIDS prevention.
Principal Accomplishments
Gaining the Support of Employers
- Employers from 34 factories and 4 parastatal companies permitted GLAS activities with their workforce by the end of the project.
- Individual "motivational" meetings were conducted with 30 employers to secure their continued support of GLAS activities at their businesses and 25 employers participated in a group meeting with the same objective.
Employee Peer Education and Support
- A total of 3,288 educational sessions -- including basic educational, personal risk assessment and risk reduction, condom use practice, and peer support -- with 28,583 employees (approximately 10 employees per session) were conducted at factories and parastatal worksites.
- Eight GLAS staff received intensive training and refresher training in basic knowledge on STI/AIDS, interpersonal communication skills, and group facilitation techniques as part of their peer education training.
- With the technical assistance of a Haitian psychologist, GLAS's 8 peer educators and an additional 22 factory workers received specialized training in effectively facilitating and managing peer support groups.
Production of Support Materials and Special Events
- 53,911 posters and brochures on STIs and AIDS were placed in worksites and distributed to workers, and additional promotional items (30 cassettes with the GLAS jingle, and 4,000 balloons, 150 fans, and 28 bags with the GLAS logo) were distributed at various occasions.
- In collaboration with PSI, 22 special promotions including STI/AIDS and condom use education, promotional raffles, and presentations by a local theatrical company were conducted with a total participation of 2,520 workers.
- Special events planned around World AIDS Day and other community outreach activities reached over 100,00 factory workers and their families with educational messages delivered through popular entertainment supplemented by printed materials.
Providing Condoms
- 99,204 condoms were sold and 744,821 distributed free to workers participating in GLAS educational sessions.
- 25 factory-based condom vendors were trained.
Important Constraints
Fuel shortages and subsequent transportation crises made it impossible at times for project staff to get to the office and for peer educators to get to worksites. Temporarily abandoning its short- and medium-range scheduling during the most turbulent period, GLAS adopted a flexible planning and intervention strategy that responded directly to daily changing circumstances. When excessive time was spent in waiting lines at gasoline stations, for example, peer educators improvised by conducting animated educational "sessions" with other drivers and passengers also waiting to buy fuel. Systematic documentation of these make-do intervention activities was unfortunately not conducted. Their significance for GLAS's project staff, however, is apparent from progress reports submitted to Aba SIDA. Continuing its AIDS prevention work, however aberrant it was from the original plans, was critical for maintaining staff morale and motivation during a period of deepening crisis and chaos in the country.
Fuel shortages, embargoed raw materials, and public insecurity affected many companies that were targeted by GLAS. Plant closures and massive layoffs of employees were widespread and a nationwide threat to Haiti's private sector during the crisis. Anxiety about job loss and fear of the violence that had become rampant in Haiti's slums were simply not conducive to creating an interest in learning about AIDS or motivation to change sexual behaviors.
Lessons Learned and Recommendations
Longer-term donor commitment pays off in indigenous institutional capacity building and programmatic efficacy. Intense and consistent investment is key. USAID through its AIDS prevention projects supported GLAS activities during a period of approximately eight years. In its incipient phase, it needed time to establish its organization and activities, test its intervention strategies, modify strategies based on experience gained and lessons learned over time, and adapt to the larger social and political environment that so severely affected Haitian life during most of the AIDSCAP project period. This sort of iterative intervention process - conducting interventions, evaluating their effects on an ongoing basis, and modifying interventions based on continuous self-evaluation - is only possible with continuous and long-term support. AIDS prevention in Haiti is just over 10 years old. GLAS has had the good fortune of receiving financial and technical assistance during most of those years and as a result was able to grow into a technically and managerially sound organization whose experiences, strategies and lessons learned has much to contribute to other similar organizations working in Haiti or elsewhere.
Private sector partnerships can be highly fruitful and should be encouraged. Conducting public health interventions via worksites has significant advantages: it provides ready access to certain target population segments; employers support of health education interventions conducted in the workplace serves to legitimize the educational issue at hand; and collaborative efforts over time would likely result in increasing private sector resource provision for the activities. Even if private sector organizations are initially reluctant to contribute funds or materials for prevention efforts, as private sector managers begin to see the benefits of health promotion among their employees, it is likely that their commitments to such activities would begin to encompass resource contributions.
Summary of Process Indicators
| Aba SIDA Partner |
Process Indicators |
Actual |
| Groupe de Lutte Anti-SIDA (GLAS) |
Individuals educated |
146,646 |
| Individuals trained |
55 |
| Materials distributed |
58,851 |
| Condoms distributed free |
744,821 |
| Condoms sold |
99,204 |
| Condom outlets created |
25 |
Mobilizing Low-Income Communities in STD/AIDS Prevention
| Aba SIDA partner: |
Centre de Promotion des Femmes Ouvrières (CPFO) |
| Geographic focus: |
Port-au-Prince |
| Target population: |
Low-income communities, emphasizing employed and unemployed female industrial-sector workers |
| Project dates: |
Phase 1: August 1993 to November 1994; Phase 2: December 1994 to April 1996 |
Background and Scope of the Intervention
As noted earlier in this report, women are particularly vulnerable to HIV infection and adverse health consequences and pregnancy complications due to classic STIs. STI rates among Haitian women are very high and HIV infection is mounting at an accelerated rate. Women now account for at least 40 percent of all HIV infections in Haiti. Data in Haiti and elsewhere unequivocally implicate poverty and low socioeconomic status in higher rates of HIV/AIDS and STIs and their complications in women of developing countries. This has made STI/AIDS prevention and control in poor women an international health priority.
In Haiti, the Centre de Promotion Des Femme Ouvrières (CPFO) has been working to improve the health and social conditions of poor women since 1985. It works in low-income communities and has focused specifically on meeting the needs of women working in Haiti's industrial and assembly sector. CPFO conceptualized women's health holistically, and therefore supports social, literacy, and legal counseling programs in addition to their Women's Health Care Clinic, which provides full reproductive health services. Aba SIDA assistance provided CPFO with the resources necessary to expand and intensify their STI/AIDS prevention activities. While the intervention centered on women, education and awareness campaigns were extended to their families and the communities in which they live. A variety of intervention activities -- including a forum for health advocacy organizations, community round tables, special educational sessions for women and their partners, and community health promotion -- served complementary and mutually reinforcing purposes.
Principal Accomplishments
CPFO managers attribute its success to achieving Aba SIDA's anticipated outputs - institutional capacity building, behavior change communication, and condom distribution - to the close alignment between Aba SIDA-supported activities and CPFO's already established training and clinical operations. Specific achievements with Aba SIDA support include the following:
Raising Awareness and Confronting Key Issues
- To highlight the health and social significance of STIs and AIDS on women and adolescents, CPFO organized and led a forum on women that included more than 20 organizations involved in promoting women's health and social well-being.
- Three pilot sessions were conducted with 52 women to allow them to consider collectively women's sexual risk and the sociocultural and economic impediments to women's sexual behavior change.
- CPFO organized 5 educational sessions that included women factory workers, their partners, and their teenage children; in addition to STI/AIDS education, the purpose of these sessions was to encourage dialogue on sexually transmitted infection prevention between sexual partners and between parents and their adolescent children.
Training CPFO Staff and Health Promoters
- Four refresher training courses in STI and AIDS prevention were conducted for 61 CPFO health promoters; health promoters also received training in animation techniques and group facilitation.
- Twenty-one CPFO staff participated in specialized training conducted by GHESKIO in interpersonal skills for dealing with the psychosocial aspects of STI and HIV diagnoses in patients.
Community-Based Behavior Change Intervention
- A total of 140 round table discussions involving 4,273 participants were organized in low income neighborhoods. Along with basic STI and AIDS education, participants were informed of the CPFO Women's Health Clinic and encouraged to come to the clinic for STI testing. Educational materials and condoms were also distributed.
- As a result of the round table discussions, 650 women and 122 men came to the CPFO clinic for STI testing.
- 130,723 condoms and 6,643 educational materials, mainly educational pamphlets, were distributed after round table discussions and via CPFO health promoters.
Important Constraints
As with the GLAS project, CPFO's activities were very directly affected by company closures due to the international embargo and restricted mobility resulting from the transportation crisis. In addition, the closure of printing presses interfered with the production and dissemination of certain printed materials.
Lessons Learned and Recommendations
CPFO's strategy of bringing sexual partners and parents and adolescent children together in educational sessions has the important potential of replacing adversarial encounters over STI/AIDS and sexual behavior -- both between sexual partners and between parents and their teenage children -- with more constructive and supportive communication. These mixed educational sessions promote a situation where all individuals involved -- both sexual partners, mothers, fathers, and teenage children -- share a basic understanding of sexual risk, special health concerns for women and their infants, and how STIs and HIV can be effectively avoided. This shared knowledge and understanding is essential for individuals to broach sensitive subjects related to sexual behavior.
Through community-based educational activities CPFO aggressively promoted the STI services available at its Women's Health Clinic and the results were excellent. AIDS education projects need to more forcefully integrate messages on risks and health consequences of STIs, symptoms recognition, and the importance of prompt STI treatment at qualified clinical facilities. In this latter regard, CPFO's experience indicates the need for behavior change interventions to establish links to clinics that have the capacity to provide appropriate STI care. The overall poor quality of STI care throughout much of the developing world renders general educational programs to improve symptoms recognition and promotion of treatment seeking behavior insufficient. To ensure that patients receive appropriate care and gain confidence in professional services, clinic-specific promotion should be integrated fully into behavior change interventions.
Summary of Process Indicators
| Aba SIDA Partner |
Process Indicators |
Actual |
| Centre de Promotion des Femmes Ouvrières (CPFO) |
Individuals educated |
4,273 |
| Individuals trained |
82 |
| Materials distributed |
8,173 |
| Condoms distributed free |
130,723 |
Strengthening STD/AIDS Prevention Interventions for Commercial Sex Workers and Their Clients
| Aba SIDA partner: |
Implementing Agency for Cooperation and Training/Inter-Aide (IMPACT/Inter-Aide) |
| Geographic focus: |
Urban areas with a focus on coastal cities: Port-au-Prince, Cap-Haïtien, Petit-Goâves, Les Cayes, Saint-Marc, Gonaïves |
| Target population: |
Commercial sex workers and their clients |
| Project dates: |
September 1992 to October 1993; November 1993 to December 1994; January 1995 to April 1996 |
Background and Scope of the Intervention
Due to the epidemiologic significance of commercial sex in the persistence and spread of sexually transmitted infections, the continued support of targeted interventions with sex workers and their clients is imperative. Since 1988 the Implementing Agency for Cooperation and Training/Inter-Aide (IMPACT/Inter-Aide) has been working to reduce STI/HIV transmission among sex workers and their clients, originally concentrating its efforts in Port-au-Prince and Gonaïves. Through Aba SIDA support since 1992, it has been able to expand to four other coastal cities in Haiti: Cap-Haïtien, Petit-Goâves, Les Cayes, and Saint-Marc.
Over the ten years of experience working with this community, IMPACT has come to distinguish three kinds of commercial sex: 1) an organized form of prostitution that is frequently based out of bars and nightclubs and caters to patrons of these establishments; 2) informal sex workers, who tend to work independently on the streets, and may drift in and out of sex work depending on their shifting economic circumstances; and 3) a more ambiguous form of "sex work," pertaining to an increasingly large number of Haitian women, involving a clearly definable transactional element to sexual relations, however which is not identified or considered prostitution by the women or others in the community. This latter category of sex work has grown in importance as Haiti's persistent and deepening economic crisis pushes women into trading sex for money or economic support by several men. Male clients of commercial sex include men who are frequently away from home due to their professions, such as long-distance drivers, men in the military, marines, etc., as well as a broader population of men who resort to buying sex in their home communities.
IMPACT's intervention project was comprised of activities that directly reached the different target populations in both the formal and informal sex trade. Its organizational structure extended directly into the targeted low-income communities where it worked. Each branch office had a project coordinator, who was responsible for the administration and management of activities and at least one project supervisor/animator who was directly responsible for conducting educational sessions with various target groups. Technical monitors at each project site assisted in organizing educational sessions and overseeing various administrative and logistical aspects. Project "collaborators" interfaced with the target communities, encouraging participation in project activities, serving as condom vendors, and participating in education and group education/animation sessions. Hundreds of women were trained by IMPACT as peer educators, and thus served to further extend the project's reach into the community. IMPACT's group education and animation sessions were conducted for bar-based and street-based sex workers and their male clients. Community-based education extended its reach to individuals engaged in the less clearly defined sex trade.
Condom use was a central theme of the group educational sessions conducted by project supervisor-animators. In addition to basic AIDS education and a discussion of complications from classic STIs, a major emphasis was on effective condom use negotiation skills. This was communicated by role plays and the viewing of a video, both focusing on real life problems for women in negotiating condom use with their clients or other sexual partners. Follow-up discussion reinforced messages about the importance of consistent condom use to prevent STIs and AIDS, ways to make using condoms more sexually agreeable, and included demonstrations and practice of condom use on anatomical models. Participants of group sessions were also given various printed materials with useful information and important educational messages.
In collaboration with Population Services International (PSI), the IMPACT project also established an extensive condom distribution network via a variety of small retail outlets throughout the targeted communities. A carefully structured distribution and resale mechanism was elaborated with PSI: IMPACT was ensured sufficient cost recovery from its condom sales to project collaborators in order to continually replenish its stocks; project collaborators, acting as "wholesalers," would sell their stocks to various small retail establishments throughout the community at a small but sufficient profit to keep them motivated to continue the activity; retailers - small boutiques, stores, pubs, pharmacy stands, etc. - would, in turn, offer a packet of condoms to the consumer at an affordable price of 1 Gourde per packet, while at the same time making a small profit to maintain their interest in keeping the product stocked. The success of the IMPACT-PSI partnership was phenomenal, making condoms easily available to sex workers, their clients and the general community.
As the epidemiological importance of STIs for the health of Haitian women and their association with HIV transmission came to light, IMPACT broadened its programmatic field to integrate activities intended to increase cure rates of these infections and to reduce the rate of transmission. In the latter part of the Aba SIDA program, IMPACT integrated a component into its intervention to strengthen STI care in clinics operating in their target communities and establish links with those clinics through referral by IMPACT's various field workers and peer educators.
Principal Accomplishments
Strengthening Behavior Change Communication Activities with Sex Workers and Clients
- 15 project supervisors and coordinators completed a training-of-trainers session focusing on communication techniques, key concepts in the peer education approach and social marketing skills. This training improved their capacity to better monitor and guide community-based collaborators and peer educators.
- 23 project supervisors, coordinators, and technical monitors participated in training and refresher training courses on STIs and AIDS, which prepared the project to expand into the third phase of linking interventions to STI clinical services.
- A video on condom use negotiation techniques and skills was produced and used during educational sessions.
- 3,230 peer education sessions were conducted by project supervisor/ animators, involving the participation of 169,472 people including sex workers, clients of commercial sex, and other sexually active adults in the community.
- To extend educational activities in low-income communities, IMPACT trained 291 women as STI/AIDS peer educators.
- 43,934 materials were distributed which reinforced messages and condom negotiation strategies promoted in peer education sessions.
Ensuring Ready Access to Social Marketing Brand Condoms
- In collaboration with the PSI condom social marketing project, IMPACT established a network of 961 points-of-sale for Pantè condoms. These points-of-sale represent a diverse range of retail outlets -- small boutiques, stores, pharmacies, nightclubs, pubs, etc. -- that were especially well placed to serve IMPACT's target audiences.
- 3,281,635 condoms were sold via IMPACT's condom vending network, representing by the end of the project a significant percentage of total condom social marketing sales. An additional 104,400 condoms were given away free of charge.
Creating Links to STI Services
- A clinical management system for STI care was developed for patient registration, notification and referral, and for managing stocks of STI drugs and condoms.
- To gain an understanding of health care utilization patterns and preferences of IMPACT's target audiences, a small focus group was conducted. Based on the information gained from this focus group, IMPACT was able to determine which health care facilities should be included in the needs assessment for upgrading STI services.
The capacity to deliver STI care was evaluated in 16 health care facilities in the IMPACT project cities. Based on this assessment, IMPACT selected 5 clinics in Port-au-Prince for upgrading STI case management. Physicians from these clinics participated in training for the syndromic management of STIs conducted by Aba SIDA partner Cornell-GHESKIO. Clinics were also provided with an initial supply of STI drugs and condoms, and with forms for patient registration, notification, referral, and for managing condom and drug supplies. By the end of the project, IMPACT animators, collaborators, monitors and peer educators were referring patients to these clinics.
Summary of Process Indicators
| Aba SIDA Partner |
Process Indicators |
Actual |
| Implementing Agency for Cooperation and Training (IMPACT/Inter-Aide) |
Individuals educated |
169,472 |
| Individuals trained |
329 |
| Materials distributed |
53,113 |
| Condoms distributed free |
104,400 |
| Condoms sold |
3,281,635 |
Endnotes
- Source: Aldebron, J. Haitian Youth Face One Another and AIDS. First Call for Children -- UNICEF 1993.
