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Final Report for the
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Table of Contents Executive Summary (See Below) I. Country Program Description C. Accomplishments and Outcomes D. Implementation and Management Issues E. Subproject Highlights II. Lessons Learned and Recommendations Executive Summary Introduction Family Health International (FHI) began its collaboration with the Ministry of Health's (MOH) Epidemiology Unit in 1992 when Jamaica became a priority country under the AIDSCAP project. At this time, The Ministry of Health/Jamaica developed a comprehensive HIV/STI control program of which AIDSCAP provided the major support between 1992 - 1996. Unlike the neighboring countries of Haiti and the Dominican Republic where the epidemic had already become significant and widespread in the general population, Jamaica was still in the very early stages of the pandemic. Nonetheless, Jamaica shared many of the characteristics of high prevalence countries including high rates of STIs, high levels of multipartnerism, migration and poverty. By emphasizing prevention and establishing a comprehensive intervention at this stage it was expected that the high rates of HIV prevalence experienced in other countries would be avoided. Program Accomplishments The Jamaica BCC strategy creatively used local culture, music, drama, celebrity endorsements and humor as effective means of communicating the safer sex messages to a wide cross section of the island. A coordinated effort reinforced the prevention messages of the national program which were: use a condom every time; abstain or delay sexual activity; stick to one faithful, uninfected partner; and seek early and complete treatment for STIs Since different implementing agencies focused on distinct target populations, each one developed and designed materials. As a result, in the four years of the AIDSCAP/Jamaica project, a wide range of print material and mass media communication were produced and distributed to all of the targeted risk groups. To ensure consistency within the campaigns, the EPI Unit Communication team formed a BCC team, including of all AIDSCAP subproject managers. This team worked to guarantee uniform messages countrywide. A total of 6,017 people were trained and over 760,000 were educated by the Jamaican subprojects. Through the public relations project, the program leveraged over US $1 million in sponsorship from the private sector and the media and in-kind contributions on behalf of the National HIV/STD Control Program. Most of the STI and HIV/AIDS materials produced in Jamaica from 1993 to 1996 were supported with AIDSCAP funding. These materials ranged from informational, promotional and celebrity endorsement posters, flyers and comic strips to newspaper articles and advice columns, pocket calendars, condom use prescription pads and bookmarks and workplace policy guidelines. Nearly 1.4 million copies of these materials were distributed during the project. In addition to print materials, the program supported television and radio public service announcements, a twelve-part radio series, video productions, music and drama presentations, puppetry, exhibitions at World AIDS Day and Safe Sex Week celebrations and installment of a confidential telephone Helpline. Some of the most successful slogans were, "You can't tell by looking," "Only you can stop AIDS," "Using a condom is the way to live" and "Keep on keepin' it on." Finally, a national resource center and a speakers bureau were established to provide high quality materials and qualified experts for speaking engagements to interested groups. The accomplishments in the STI technical area of the AIDSCAP/Jamaica program were numerous. At the outset, Jamaica had a well developed STI diagnosis and treatment system, including infrastructure in both public and private sectors which was a good base on which to build. In addition to reducing HIV transmission, the goal of the national program was to reduce the economic and psychosocial burden of STIs and their complications by decreasing overall morbidity and mortality. Not only were public STI clinics operating but the country had national case management guidelines. As a result of the AIDSCAP/Jamaica program, syphilis screening was decentralized, STI case management was strengthened, private practitioners were trained and studies on vaginal discharge and genital ulcer disease were conducted. However, there were constraints such as insufficient supplies including condoms, lack of trained personnel and limited data availability. The purpose of the condom component of the AIDSCAP/Jamaica program was to decrease the rate of HIV/STI infection through increased accessibility of condoms to specific target populations through nontraditional outlets and increased acceptability of regular, correct use of condoms by these groups. The primary target populations for this component were young, sexually active adults (15-30) and persons with multiple partners, including CSWs and STI clinic attendees. In general the Jamaicans were more favorably disposed towards use and more likely to use a condom in 1996 than before the AIDSCAP program. Since 1985, when condom use was estimated at about 2 million per year, consumption has increased to over 10 million. In the last three years alone, consumption doubled. AIDSCAP subprojects distributed more than 5.1 million condoms. The following table is overall process indicator data for all subprojects, including targets and level of achievement. Table 1: PIF Summary Table For Aggregate Country Program
Constraints The major constraints faced by the program were economic, fiscal and structural. Due to worsening economic conditions, the program's impact on changing the behavior of women, particularly low income women, was limited. Increasing numbers of women reported non-regular partners. This may have been due to increased willingness by women to report multiple sex partners. The program was forced to cut subprojects unexpectedly which resulted in the cancellation of BCC and condom activities and limited the expansion of other strategies. Additionally, subprojects found the AIDSCAP funding mechanisms lacked flexibility to respond rapidly to changes in the environment. Delays in amendments and disbursements made it difficult for implementing agencies to manage their projects. Specific constraints related to the BCC component included:
In the area of STI there were several constraints including:
Finally, the Condom strategy faced the following constraints:
Outcomes Data reported by the MOH at the end of the AIDSCAP program showed that primary and secondary syphilis prevalence decreased from 39 to 23.3 per 100,000. Incidence was down among both men and women. The number of cases of congenital syphilis declined from 62 in 1991 to 37 in 1996. Additionally, a survey conducted in the public sector reported that 100% of STI clinic attendees were treated for syphilis and gonorrhea according to national guidelines. A survey conducted of private sector physicians indicated that an estimated 61% were treating STI patients properly. Evaluation research has shown substantial increases in knowledge and risk prevention behaviors among the majority of the Jamaican population, despite a minority who continue to believe in myths of HIV transmission and engage in high risk behaviors. Knowledge levels, already at high levels in 1992, continued to rise as beliefs in incorrect transmission means declined. More than 95% of the general population correctly cited two methods of HIV prevention in 1996, an increase from 91% four years earlier. Increased knowledge of HIV prevention methods was most striking among 12 to 14 year olds. Among this group, only 70% of both boys and girls could cite two or more prevention methods in 1994 versus 96% in 1996. In terms of modifying risk behaviors to avoid HIV infection, risk reduction strategies varied considerably among men and women, and among different age groups. In general, men reported fewer partners and longer relationships, while women reported increased condom use. Adolescent boys reported decreased levels of sexual activity and delayed sexual debut, while younger adult men reported fewer multiple regular and non-regular partnerships. The percentage of boys 12-14 who become sexually active by age 15 declined from 58% in 1994 to 41% in 1996. The percentage of men 15-29 reporting non-regular partnerships declined from 42% to 25%. Men 20-49 dramatically decreased the rate of multiple regular partners as well, with decreases from approx. 60% to 30%. Condom use at last sexual intercourse with a non-regular partner among men, already among the highest rates in the world in 1992, at 77%, was unchanged in 1996. Women reported an increase in multiple partnerships, and increased condom use. The percentage of women reporting multiple partnerships increased from 6% in 1992 to 14% in 1996. Both of these numbers are likely to be significant underestimates of the actual number of women having more than one sexual partner. This is supported by focus group activity and local expert opinion. The underlying cause for this increase can be attributed to economic instability and vulnerability and is supported by the finding that low income women report twice the level (and are more likely to admit it) of non-regular partners of middle income women. Although this increase in multipartnerism represents increased risk behavior, the concurrent increase in condom use mitigates this risk. Only 37% of women reported using condoms during their last sexual intercourse with a non-regular partner in 1992, compared to 73% in 1996. Women reported increased frequency of condom use with non-regular partners as well, with 30% reporting every time use in 1992 versus 64% in 1996. Despite these positive trends in the general population, a small percentage of the population appears to have been little influenced by AIDSCAP's HIV prevention efforts. Ten percent of the population believes that HIV can be transmitted through social contact, and negative attitudes towards HIV+/PWAs persist. A small percentage of men report never having used a condom despite engaging in high risk behaviors. Drug and alcohol use among commercial sex workers has inhibited the consistent use of condoms with clients. Many men do not seek treatment for STI infections. Lessons Learned and Recommendations
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