Final Report for the
AIDSCAP Program in Haiti: Executive Summary

This report comprehensively summarizes the FHI/AIDSCAP program in Haiti (1992-1996). Program activity and outcome data are provided on the following strategies: targeted behavior change interventions; increasing condom access through condom social marketing; increasing access to appropriate STI care; enhancing the social and policy environment to support behavior change; strengthening technical, management and evaluation capacity of Haitian NGOs; and improving care and management for AIDS patients.

Table of Contents

Executive Summary (See Below)

I. Introduction

II. Background and Country Context

III. The Aba Sida Program

IV. Lessons Learned

V. Subproject Highlights

• Part 1
• Part 2
• Part 3

VI. Attachments

Glossary of Acronyms

Executive Summary

HIV prevalence in Haiti is estimated to be 10 percent in urban adult populations and 4 percent in rural areas. The female to male ratio of HIV-infected persons is close to 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. The prevalence of non-HIV STIs is also high. An AIDSCAP-funded study in 1,000 women attending an urban, impoverished antenatal clinic found that 46.9 percent of women in the sample were infected with at least one STI. Overall, STI/AIDS epidemiology in Haiti parallels high-prevalence patterns found in parts of sub-Saharan Africa.

USAID/Haiti began supporting AIDS prevention in Haiti in June 1989 through Family Health International's AIDSTECH project. In April 1991 the project was expanded and renamed in Haitian Creole Aba SIDA (meaning "Down with AIDS"). Shortly after initiation of the expanded Aba SIDA project a military coup deposed Haiti's democratically elected government and ignited a severe political and economic crisis in Haiti that lasted for close to four years. While the U.S. withdrew development assistance to Haiti in protest of the military government, AIDS prevention in the private and non-governmental sector was exempted, allowing for a continuation of Aba SIDA activities. The Aba SIDA project was the nations only response to the AIDS epidemic during this period. Under a new cooperative agreement with Family Health International in October 1992, technical assistance responsibility for Aba SIDA was transferred to FHI's AIDSCAP project. Aba SIDA under AIDSCAP continued, therefore, from October 1992 to June 1996. This report covers the period of Aba SIDA under AIDSCAP.

Twenty Haitian institutions received technical and financial assistance to conduct key interventions to reduce sexual transmission of STIs and HIV. The broad target populations in this project included general population adults and youth, as well as female sex workers and their clients, women and men in the workplace, adolescents in school and in the community, HIV positive individuals and STI patients. The overall program was comprised of seven broad and complementary strategic areas:

(1) Targeted behavior change interventions: Aba SIDA's behavior change interventions were multifaceted projects that were tailored to meet the specific needs and perspectives of key target audiences. The main targeted interventions in this component included:

• Implementing Agency for Cooperation and Training (IMPACT/Interaide): IMPACT targeted female sex workers and their clients in Haiti's largest cities with peer education and condom distribution using monitors trained in group facilitation and participatory techniques. It also improved referrals to high quality STI services.

• Groupe de Lutte Anti-SIDA (GLAS): This project conducted workplace-based education on HIV transmission and condom use in 30 large factories and parastatal businesses targeting low-income workers in Port-au-Prince and reaching over 8,000 workers a year.

• Centre de Promotion des Femmes Ouvrières (CPFO): CPFO targeted women factory workers living in poor neighborhoods in an effort to enhance the familial and social environment in which these women live. The project implemented educational activities and awareness campaigns targeting women and their families, as well as members of their larger communities.

• Volontariat pour le Développement d'Haïti (VDH): VDH targeted 14,000 youth at risk in the northern districts of Haiti with peer education and condom social marketing.

• Centre Haïtien de Service Social (CHASS): CHASS collaborated with community-based organizations and a volunteer youth network in targeting poor urban youth in one of the poorest neighborhoods in Port-au-Prince with peer education and condom social marketing.

(2) Increasing condom access through condom social marketing (CSM): Population Services International (PSI) received Aba SIDA assistance to expand its condom social marketing activity nationwide. PSI established links to several other Aba SIDA partners in order to expand and diversify its condom distribution coverage. This innovation, combined with the project's notably vigorous promotional campaigns, made condom social marketing an especially important component of the Haiti program.

(3) Increasing access to appropriate STI care: Three overlapping activities were critical for this program component: 1) operational studies, 2) support and participation in the development of national standardized guidelines for syndromic management of STIs, and 3) upgraded quality of care in various clinic facilities. The Centres pour le Développement et la Santé (CDS) and the Groupe Haïtien d'Etude du Sarcome de Kaposi et Des Infections Opportunistes (GHESKIO) were the main recipients of Aba SIDA financial and technical support for STI-specific activities. CDS provided clinic-based services and an extensive network of volunteer collaborators who made home visits to the urban poor; and GHESKIO provided training for field physicians and nurses, sponsored a national center of excellence and conducted research on STIs and HIV.

(4) Enhancing the social and policy environment to support behavior change: This program component was particularly important in STI policy development and women and AIDS issues, in addition to enhancing the social environment through increased awareness of AIDS. Specific policy interventions which resulted in the establishment of national STI guidelines and advancements in gender programming for women were combined with mass media productions and special events targeting the general population.

(5) Strengthening technical, management and evaluation capacity of Haitian NGOs: The technical and management capacities of all Aba SIDA partners were strengthened through training, technical assistance and support by the AIDSCAP Country Office. In addition, the Institut Haïtien de Santé Communautaire's (INHSAC) conducted training for Aba SIDA projects with the specific objective of enhancing NGO capacity. In order to meet the variety of training needs present among Aba SIDA projects, INHSAC developed project-specific training curricula. Save the Children helped build the capacity of nine NGOs in the Central Plateau Region and supported a coalition of community-based groups in this region. In addition to these two projects, Aba Sida and AIDSCAP provided training and technical support for behavioral research evaluation to CDS, IHE and PMS, and facilitated their support to other Aba Sida partners.

(6) Improving care and management for AIDS patients: Through the AIDSCAP AIDS Care and Management Small Grants Initiative, three hospitals in Haiti received support to improve hospital- and home-based care for AIDS patients, improve social support for AIDS patients and their families, provide economic assistance to affected families through income generation activities, and integrate AIDS prevention services into their care activities.

During the past four years, Haitian communities and grassroots organizations have made remarkable progress in raising awareness about STI/HIV/AIDS and encouraging behavior change. Despite the political and economic crisis that persisted in Haiti throughout most of the Aba SIDA project period, significant accomplishments were achieved:

• The capacity of 13 NGOs to plan, manage, and evaluate comprehensive STI/HIV/AIDS programs was substantially increased;
• More than 800,000 people were educated on how to protect themselves from HIV/AIDS and over 400,000 educational materials were distributed;
• More than 5,000 health workers, NGO personnel and community volunteers were trained in the skills they need to sustain HIV/AIDS prevention programs;
• More than 16 million condoms were sold or distributed through condom social marketing activities;
• Condoms were made available throughout the country with an innovative strategy that used a network of over 1,400 condom outlets, as well as itinerant salesmen;
• National guidelines for STI case management were developed through the collaboration of the three main STI programs in Haiti and was subsequently adopted by the Ministry of Health for nationwide use;
• The first forums on women and AIDS in Haiti were sponsored and dialogue initiated to ensure that women's concerns are addressed in the country's new plan of action for HIV/AIDS prevention.

Aba SIDA programs led to a significantly increased understanding of HIV/AIDS transmission and prevention methods in both high-risk target populations, and the overall Haitian population. Behavior changes were also reported. Three significant outcomes of the Aba SIDA program are evident from an analysis of baseline and post-intervention research in Aba SIDA target audiences: knowledge of AIDS has substantially increased; personal risk assessment skills have improved; and a high percentage of the population reported changing their behavior to reduce the risk of HIV infection.

Specific, documented outcomes for the general population between 1990 and 1995 include:

• The percent of the population who were aware of the sexual transmission of HIV increased from 60 percent to 90 percent;
• The percent of the population who knew of at least 1 prevention method increased to 95 percent;
• The percent of the population unable to assess their level of risk for HIV infection decreased from 18 percent to less than 1 percent;
• The percent of the population who knew of condoms increased from 69 percent of men and 54 percent of women, to 95 percent of both men and women;
• The percent of the population who knew of 1 or more sources to acquire condoms increased to above 90 percent; and
• The percent of the population having ever used condoms doubled, from 16 percent of men and 6 percent of women, to 32 percent and 12 percent respectively.

Official STI management guidelines were disseminated in June 1996 after extensive research, training and institutional development to build a consensus with public and private sector practitioners on STI diagnosis and treatment. Although no measurement of STI treatment according to national guidelines was feasible, a measure of the percentage of clinicians in an AIDSCAP-funded project correctly treating the most common STI syndrome increased from 10 percent to 69 percent between 1993 and 1995.

Evidence of increased managerial and technical capacity building of the Haiti implementing agencies was documented through a rapid assessment survey and in-depth interviews. Of the sixteen implementing agencies, program managers reported increased staff skills in a range of technical areas including: BCC (14), CSM (6), evaluation research (16), and STIs (5). Program management improvements were noted in the areas of: report writing (16), financial management (16), and strategic planning (9). In addition to improved staff skills, program managers uniformly mentioned improved management systems for finance, monitoring and evaluation. Three program managers mentioned improved condom distribution systems. Finally, all program managers cited improved networking with private and public sector organizations, and the development of coalitions.

There were many lessons learned from Aba SIDA's various interventions. Ten are highlighted as major lessons learned for the program as a whole:

• It is critical for program planners to recognize women's constraints in the realm of sexual decision making.
• Given the significance of men's sexual behavior for women's risk, it is important that the health community's concern for preventing AIDS in women does not divert programmatic attention away from men.
• Better conceptual models and demonstration projects that focus on influencing the interaction of sexual partners in the decision making process are needed for sexual risk reduction interventions.
• Youth need to be supported in designing and conducting their own behavior change activities, even at the risk of some degree of controversy.
• It is important to recognize that the programmatic distinction between "behavior change communication," "condom promotion," and "improving STI care," while conceptually useful for understanding intervention needs, has less value in actual program design and implementation. In high-level decision making caution should be exercised to avoid creating unnecessary programmatic fissures by dividing up organizational responsibilities too strictly along the lines of "technical areas."
• It is necessary to broaden the scope of "AIDS education" to include more consistent and aggressive attention to STIs other than HIV.
• HIV/AIDS programming can be designed, implemented and adapted in spite of political, economic and/or social instability and adversities.
• In the absence of a national HIV/AIDS infrastructure, the civil society, particularly the NGO sector, can play a crucial role to sustain and deliver HIV/AIDS prevention and control services to the population.
• HIV/AIDS prevention and control interventions can effectively achieve behavior change among target populations.
• Medical and public health interventions alone are insufficient to combat the HIV/AIDS pandemic.

Aba SIDA/AIDSCAP Process Quantitative Data Accomplishments

Process Indicators	Cumulative Totals
People Educated	821,741
People Trained	5,293
Materials Distributed	408,869
Condoms *	16,265,775
Condom outlets	1,456

* Condoms total includes condoms sold and distributed free. Cumulative condom sales are adjusted to avoid double counting introduced by the sale of condoms by PSI to implementing agencies, and their resale to customers.