1. Introduction
During the four years of the AIDSCAP/Jamaica program, AIDSCAP support to the Ministry of Health Epidemiology Unit contributed toward the three goals of the HIV/AIDS strategy. Through efforts in both the public and private sectors, STI diagnosis and treatment was strengthened and STI incidence reduced. As a result of national campaigns, condom use continued to increase. Finally, surveys of the general population and specific target groups showed changes in behavior, especially among the young, toward fewer partners. This section of the report details the program's accomplishments with respect to the technical strategies and outcomes focusing on behavioral data. It also discusses the successes the program experienced in increasing local capacity.
2. Accomplishments and Constraints
Behavior Change Communication
The purpose of the AIDSCAP BCC component of the Jamaica program was to enhance communication interventions to promote behavior change in primary prevention target populations. These populations included STI patients, CSWs, adolescents, adults with multiple partners, MWM and HIV+ individuals. Purpose indicators for this technical area were the following:
- 90% of target groups name condoms as acceptable way of preventing HIV by the end of project (EOP)
- 80% of target populations reached by communication activities, by target population and gender by EOP
The behavior change communication strategy in Jamaica, coordinated by the MOH/Epi Unit Communications Team, encompassed all of the subprojects. This strategy was implemented primarily through projects with the Ministry of Health, EPI Unit's Face-to-Face and Targeted Community Outreach projects, ACOSTRAD, the Jamaica Red Cross and Jamaica AIDS Society with support from several other NGOs. A unique aspect of the Jamaica program was its collaboration with a public relations firm, Berl Francis Ltd. through which a PR campaign on HIV/AIDS was conducted.
Research in Jamaica has shown the existence of a number of sexual sociocultural constructs that have significant implications for HIV/STI communication interventions. These include but are not limited to the belief that suppression of sexual activity is unnatural; infidelity is socially acceptable; virginity is not a positive value; STIs are a normal correlate of sexual activity; AIDS is a homosexual disease and homosexuality is unacceptable.
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, consisting of all AIDSCAP subproject managers. This team worked to guarantee uniform messages, in both public and NGO sector materials and in the public relations activities. Additionally, the 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. This coordinated effort reinforced the prevention messages of the national program which were to:
- Use a condom every time
- Abstain or delay sexual activity
- Stick to one faithful, uninfected partner
- Seek early and complete treatment for STIs
Jamaica, with its high literacy rate was well suited for a public relations/mass media campaign. There are several national daily and weekly newspapers as well as newspapers targeted to specific regions and audiences. The island has two national television stations and a dozen radio stations which are popular sources of news, information and entertainment programming.
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. 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 initiation 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." The public relations project was able to leverage over US$1 million in sponsorship for the program's activities from the private sector and the media. Finally, a national resource center and a speakers bureau were established. The center is accessible to the general public and contains a wealth of information on HIV/AIDS/STIs for students, teachers, medical professionals and anyone looking to research this field. The speakers bureau provided speakers mainly from the National AIDS Committee for 140 speaking engagements reaching some 30,000 people.
The November 1995 mid-term evaluation of the USAID-funded HIV/AIDS/STI Prevention and Control project concluded that this strategy was successful in reaching target groups with sufficient information. The final KABP studies carried out under the AIDSCAP project confirmed this finding. Some 98% of both men and women had knowledge about condoms and condom sources. Additionally, knowledge of at least two preventive methods, including condoms, increased from 91% to 95% in 1996 in the general population. Increased knowledge levels among low-income adolescents (12-14) rose more dramatically from 70% in 1994 to 96% in 1996. The Jamaica STI/HIV/AIDS program with AIDSCAP assistance contributed to this almost universal knowledge about STI/HIV/AIDS and had begun to make the shift the focus from awareness to behavior change when the project ended.
Constraints in the BCC strategy were related to budgetary cuts. As a result of unexpected funding cuts the mass media campaign was eliminated. This campaign was to have been implemented through a private sector advertising agency. Some activities included in this campaign were implemented by the public relations firm. Other planned BCC activities had to be canceled or reduced for the same reason, e.g. promotion of the Helpline, planned expansion to reach CSWs in other regions and a mobile health center.
Another constraint, the initial lack of coordination/communication among subproject implementing agencies, resulted in a somewhat fragmented approach and some lost opportunities for collaboration early in the program. Additionally, the public relations campaign was hampered by the lack of flexibility within its subagreement and was unable to take advantage of unanticipated opportunities.
Evaluators of the AIDSCAP BCC component stated that the strategy was constrained by the selection of target groups based on demographic variables rather than on sociocultural and economic boundaries. They found that the interventions left out young males and therefore did little to understand this group's role as sexual decision maker.
Finally, it was found that for women in Jamaica condom negotiation is difficult at times, due to threats of violence to women and economic pressures, thus presenting further challenges to change high risk behaviors.
Sexually Transmitted Infection
The proper case management of STIs was a fundamental component of the AIDSCAP technical assistance to the Jamaica STI/HIV/AIDS program. Correct diagnosis and treatment interrupts the chain of transmission of STIs, reduces the chances of HIV infection during sexual contact and improves the general health of persons who are sexually active. Public sector epidemiological data indicate that STIs were a significant public health problem in Jamaica, with congenital syphilis and positive VDRLs increasing. Prior to AIDSCAP support, the MOH worked for years to improve STI case management but inadequate resources severely limited its effectiveness.
In spite of this, Jamaica had a well developed STI system, infrastructure in both public and private sectors and a good base on which to build. In Jamaica, a tradition of STI control efforts predated the HIV/AIDS epidemic. The goal of the national program was to reduce HIV transmission as well as 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. However, there were constraints such as insufficient supplies including condoms, lack of trained personnel and limited data availability.
The STI component of the AIDSCAP/Jamaica program aimed to increase access to improved STI services in the public and private sectors. To accomplish this the program included biomedical and behavioral interventions for diagnosis, treatment and prevention of STIs, institutional strengthening for capacity building and STI-related research. The outcome indicator of the Strategic and Implementation Plan was the following:
- 80% of target population with STIs receives treatment according to standard STI diagnosis and treatment protocols by EOP
The accomplishments in this technical area were numerous. The indicators were achieved or exceeded. Management of STI cases was improved as a result of operations research. The services provided by laboratories were improved. Syphilis screening was decentralized. Finally, the interventions strengthened contact investigation services.
During the AIDSCAP program, guidelines for STI case management and counseling were revised in the form of a manual and 2,000 copies distributed to service providers including all 13 public STI and 13 antenatal clinics. This manual was adapted for primary health care centers, providing a systematic approach to STI case management, diagnostic tools, prescription of the correct treatment and counseling of the patient/partner. More than 100 clinics were following manual guidelines by EOP. The reporting of clinic data was improved and a new STI software database was developed and implemented. All clinics had supplies of condoms. In addition, more than 500 public and 1,200 private sector health care workers received STI training. The program was also responsible for training and deploying a cadre of peer counselors in 16 clinics.
As a result of the program all 13 STI clinic laboratories and 13 major antenatal clinics are now providing RPR testing. Training and skills upgrading for 18 laboratory technicians was provided. Public screening for syphilis was decentralized from two laboratories in 1993 to over 90 STI and antenatal clinics in 1996. Due to the shortage of laboratory technicians in public clinics, non-laboratory technicians were also trained and were performing immediate, on-site screening and serologic tests. By EOP, the number of STI clinic attendees receiving diagnosis and treatment for gonorrhea according to the national guidelines increased from 74% to 100%. In addition to clinic-based services the program initiated a comprehensive program including drop-in centers for CSWs in Kingston and Montego Bay.
The STI component experienced several constraints to its implementation, including resistance to change, funding limitations and a lack of understanding of the link between STI and HIV/AIDS. First, clinicians remained reluctant to change their procedures and begin to use algorithms in STI management subsequent to their training. Second, funding constraints affected this component. For example, the strategy of linking CSM to STI clinics was dropped. The budget limitations also resulted in the cancellation of plans to extend the STI program to reach CSWs in Negril and other tourist areas and launch a mobile project targeted for areas with high levels of transactional sex. Finally, the link between STIs and HIV/AIDS is not well understood by some members of the government, medical community or general population. STIs are still viewed as a normal part of sexual activity. Nearly half do not seek treatment for STIs, and were not reached by project efforts.
Condoms
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. A secondary target was the condom distribution/sales infrastructure consisting of retailers, potential retailers, importers/distributors and public sector policy makers. The indicators proposed were:
- 70% increase in reported condom use among the target populations in high risk sexual encounters by EOP
- 30 million condoms distributed/sold per year by EOP
- 20% increase in condoms being purchased in the private sector by EOP
At least fifteen brands of condoms are available in Jamaica through well established commercial outlets, an ongoing USAID-supported condom social marketing program - mainly through pharmacies, supermarkets, and government and NGO health centers. These brands include private sector, USAID-donated and socially marketed condoms. Prices range from $0.06 to $1.36 for a packet of three for those condoms which are sold. Estimates were that in 1991 at least 60% of condoms were purchased by the consumer. Over 90% of pharmacies and 70% of supermarkets stock condoms. These are the major channels for condom distribution. The public and NGO sectors distribute condoms free of charge. AIDSCAP strategies focused on making the product both accessible and acceptable.
During the AIDSCAP support to the Jamaica program, condom use increased and knowledge and attitudes about condom use improved. In the general population, 97% knew about condoms and where to acquire them. All CSWs surveyed had condoms on hand at their work sites. Although there are differences by gender, in general the Jamaicans are more favorably disposed towards use and more likely to use a condom 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. However, it should be noted that the program was unable to reach the initial goal of 30 million condoms. Achievement was only half the 20 million that the MOH, Epi Unit conservatively estimated would stem the spread of HIV.
The following graph shows the increase in condom distribution from 1991 to the end of the project.
Graph 2: Condom Distribution
(Total Condom Market Units)
The 1996 KABP surveys found that many fewer respondents mentioned that unavailability of condoms was an issue. These surveys also found fewer men reporting that condoms are difficult to use. While there is still some resistance to condom use, especially with regular partners, the target populations reported increased use with non-regular partners. Condom use was more frequently mentioned as a prevention method for STI/HIV than monogamy.
Nevertheless, there were numerous constraints to the condom component of the AIDSCAP Jamaica program. First, a prevailing negative image of condoms among wholesalers and distributors was an obstacle the condom social marketing (CSM) subproject was unable to overcome and resulted in failure to expand the number of nontraditional outlets as projected. At EOP, the nontraditional outlet market, including bars, small shops and "self-serves," remained relatively unexploited.
Supplementing the KABP surveys, as an element of its condom strategy, AIDSCAP/Jamaica supported quarterly condom audits. The goal of these audits was tracking the extent to which condoms of all types were available nationally in both traditional and nontraditional retail outlets and to monitor pricing of the products. These periodic audits started in the final quarter of 1993 and continued through the end of the Jamaica program. The surveys included all retail brands from the socially marketed Panther brand to the Contempo and Durex lines of product. Over time these audits indicated a decrease in the number of both traditional (from 67% to 58%) and nontraditional outlets (from 25% to 14%) distributing condoms. Availability of the Panther Regular, the most affordable condom, declined in both types of outlets.
Graph 3 : Percentage of Traditional and Nontraditional Outlets
Distributing Condoms (1993-1996)
One possible explanation for these declines is that in 1994, AIDSCAP/Jamaica support for condom social marketing was curtailed. This project was working to expand condom social marketing to nontraditional outlets that would be accessible to the program's target populations. Although the project had limited success and did not reach its objective of adding 5,000 new retail outlets to its program, the media campaign and promotional activities did contribute to increased condom distribution/sales. Since the termination of this project, both the number of retail outlets selling condoms and those including the condom social marketing condom in their stock have fallen off. This cut also resulted in cancellation of the planned linkages of the CSM project with the 13 STI clinics.
Physical/cultural barriers still impact accessibility of condoms. Condoms are often displayed out of the customer's reach especially in pharmacies and thus the customer must request the product, which is still a cause for discomfort. This was especially evident among adolescents (12-14) who mentioned shyness or fear related to accessing condoms. Only 54% of young women and 88% of young men stated that they could obtain condoms.
The quarterly condom distribution audits conducted by Hope Enterprises over a three year period generated useful information about the availability of condoms in different outlets. However, these surveys did not provide explanations of the trends they recorded. Thus, it is more difficult for the program to respond and react.
Summary Process Indicator Accomplishments for Aggregate Country Program
The following table contains overall process indicator data for all subprojects, including targets and level of achievement.
Table 2: PIF Summary Table For Aggregate Country Program
| Indicator |
Persons Trained |
Persons Educated |
Materials Distributed |
Condoms Distributed |
| Target |
2,417 |
287,785 |
1,213,447 |
3,809,073 |
| Accomplished |
6,017 |
760,286 |
1,381,352 |
5,135,893 |
3. Project Outcomes
Biologic Impact
HIV/AIDS
Current estimates indicate that between 5,000 and 10,000 Jamaicans are HIV-positive. Whereas hard data have been available on the number of AIDS cases over the fifteen years of the epidemic, these data do not reflect the number of individuals infected with HIV or among which population groups the virus is spreading most rapidly. Sentinel surveillance in Jamaica was conducted in six parishes with 11,000 blood samples drawn from ten subgroups. These subgroups were male and female CSWs, STI clinic attendees, antenatal clinic attendees, informal commercial importers (higglers), food handlers, prisoners, MWM, drug abusers, hotel workers and marginalized community residents.
HIV seroprevalence among STI clinic attendees increased between 1993 and late 1994/early 1995 from 4.3% to 4.5% in the Kingston/St. Andrew (KSA) area and from 7.0% to 8.8% in St. James. The 1995 prevalence among this population in the parishes of St. Ann and St. Catherine was found to be 4.7% and 5.6% respectively. This target group remains a challenge, and the problem could be exacerbated by the fact that half of men with STIs do not seek proper treatment. Future programs should continue to try to reach this group to increase appropriate treatment to a higher proportion of people with STIs.
The sentinel surveillance of CSWs and MWM showed the following. CSW prevalence varied widely by parish. In KSA, where prevention interventions began in 1991, the percent has declined from 12.7% in 1989 to around 8% in 1996. In St. James, where interventions started in 1995, the percent is also decreasing. Estimates show that between 1993 and 1996, prevalence dropped from 25% to about 21%. It should be noted that the earlier samples included only female CSWs and the later samples include male and female.
Surveys of antenatal clinic attendees in five parishes showed an increase in HIV prevalence from 0.4% to 1.0% between 1992 and 1995. However, the rate for KSA was 3.2%. Blood donor prevalence was stable at 0.4%.
STIs
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 19 in 1996. Additionally, the public sector reported that 100% of STI clinic attendees were treated for syphilis and gonorrhea according to national guidelines. A survey conducted in 1995 of private sector physicians indicated that an estimated 61% were treating STI patients properly. The following table summarizes STI incidence and prevalence data collected during the AIDSCAP program.
Table 3: STI Cases/Rates Reported
| Disease/Condition |
1994 |
1995 |
1996
(6 mos.) |
| Syphilis (all forms) |
2,018 |
2,414 |
932 |
| Syphilis (primary and secondary) |
835 |
715 |
291 |
| Congenital syphilis (< 1 year) |
68 |
45 |
10 |
| Reactive VDRL/RPR in pregnant women tested |
4.8% |
5.8% |
4.2% * |
| Reactive VDRL in blood donors |
2.1% |
1.8% |
1.5% |
| Reactive VDRL/RPR in CHC/STI clinic attendees |
15% |
17% |
Not avail. |
| Gonorrhea (all cases) |
10,620 |
5,056** |
3,246** |
| Non-gonococcal (Chlamydia) infections (all cases) |
12,219 |
7,369** |
4,713** |
| Ophthalmia neonatorum |
347 |
414 |
162 |
| Pelvic Inflammatory Disease (PID)*** |
1,835 |
2,490 |
N/A |
| Trichomonas |
7,093 |
8,108 |
N/A |
| Chancroid |
609 |
624 |
N/A |
| Genital Herpes |
304 |
408 |
N/A |
| AIDS |
359 |
505 |
233 |
* one antenatal clinic only
** reporting format changed to genital discharge. Data based on results of prevalence studies and is not comparable with 1994.
*** data from STI clinics only, which represent 22% of the caseload in 1994 and 25% in 1995.
(N.B. Increase in cases in consecutive years may be due to improvement in case-finding, surveillance and health promotion.)
Outcomes
Overview
Evaluation research has shown substantial increases in knowledge and risk prevention behaviors among the majority of the Jamaican population from 1992 to 1996. Nonetheless, there remains a small minority who continue to believe in myths of HIV transmission and continue to engage in high risk behaviors.
Knowledge of HIV prevention, already high in 1992, continued to rise as beliefs in incorrect transmission means declined. Risk reduction strategies were adopted by a majority of men and women since hearing of HIV/AIDS, although these varied considerably by gender and age group. In general, men reported fewer partners and longer relationships. Women reported increased condom use with non-regular partners.
Despite overall positive trends in HIV prevention knowledge and risk behavior, a small percentage of the population appears to have been little influenced by AIDSCAP's HIV prevention efforts. Ten percent of the population believe that HIV can be transmitted through social contact, and negative attitudes towards HIV+/PWAs are widespread. Ten percent of men also report never having used a condom with non-regular partners. 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. Economic instability and vulnerability is causing women to seek multiple partners for support.
Knowledge of HIV Prevention Methods and Perception of Risk of HIV Infection
Knowledge levels have risen sharply in the last four years (see Graph 4, below). Knowledge of HIV as a sexually transmitted infection which is preventable with the use of condoms is understood by greater than 90% of the population. Knowledge of two or more prevention methods has risen dramatically among women and youth: for example, 71% of male adolescents 12 to 14 were capable of citing two or more prevention methods in 1994, compared to 99% in 1996. Only 34% of women aged 40-49 could cite two or more methods in 1992, versus 92% in 1996.
Graph 4 : Knowledge of HIV Prevention Methods
(General population, two or more methods, prompted)
When asked how to prevent HIV infection, a greater number of both men and women report "using condoms" (92% of men, 93% of women) than report "having one faithful partner." This latter response has decreased since 1994, particularly among men (from 95% among men, and 92% among women in 1994 to 78% among men, and 87% among women in 1996). Qualitative research has found that men thought fidelity to be "unrealistic" and women thought believing in a partner's fidelity to be "unreliable".
Beliefs in incorrect transmission methods such as mosquito bites, public toilets, and touching someone with AIDS, have been decreasing as knowledge of correct methods improves. In 1992, 42% of men and 31% of women cited mosquito bites as a means of HIV transmission. By 1996 this figure had decreased to 26% among men, and 21% among women. The belief that "touching someone with AIDS" could transmit HIV decreased from 20% among men and 12% among women to 9% among both over the same time period. Decreased fears of social transmission of AIDS are essential to insure compassion towards PWAs among the increasing percentage of the population who report personally knowing someone with AIDS.
Since 1989, as the Jamaican population has become more knowledgeable about the risks of HIV, and as individuals have changed their behaviors to reduce their risk, the percentage of the population perceiving themselves at risk for HIV has declined from 63% to 22% among men, and from 50% to 18% among women (Graph 5).
Graph 5 : Perception of Risk
Since 1992, however, an important percentage of the population has emerged that state that they are unable to assess their risk for HIV infection. This population, which has grown to 10% of men and 14% of women in 1996, may represent individuals that previously engaged in high risk behaviors and are uncertain of their present risk or HIV status (46% report having changed their behavior to avoid infection). Alternatively, this population may be unwilling to admit or examine their risk status (48% report never using condoms in high risk situations). Regardless of the explanation, it is clear that this population represents a special concern for HIV prevention program managers, and should be targeted for counseling and educational programs to assist in self-risk assessment.
Target Populations
Among Male STI Clinic Attendees (STICAs) knowledge of the use of condoms as a method of HIV prevention was very high and had significantly (p=.01) increased from baseline (97% endorsed condoms as a prevention method in 1994 vs. 100% in 1996). Beliefs in inaccurate means of HIV transmission also significantly (p<.001) declined in terms of mosquito bites (43% vs. 28%), public toilets (29% vs. 4%), sharing food with someone with AIDS (21% vs. 3%) and touching someone with AIDS(20% vs. 0.5%).
Despite the high levels of knowledge of HIV prevention methods, a majority of STICAs maintains attitudes which hinder their ability to perceive themselves at risk for HIV infection. A majority believes that most men have been infected with an STI more than once (64%), and that you can always tell when you have caught an STI (90%). A significant (p=.004) increase in STICAs feel that they have "no chance" for HIV infection (39% vs. 53%) while the percentage believing themselves to have "some chance" or unsure has declined (from 40% to 35%, and 18% to 11%, respectively).
One hundred percent of CSWs surveyed knew of at least two methods of HIV prevention. All of the CSWs cited condom use, while 98% cited using clean needles. However, twenty-six percent of CSWs thought that HIV infection could be prevented by practicing only oral sex, 13% by not touching an infected person, 11% by avoiding mosquito bites, and 9% each for having a good diet, avoiding public toilets and not sharing food with an infected person.
Forty-five percent of CSWs reported that they believed themselves to be at "no chance" for HIV infection, 31% at a "moderate chance," 13% a "good chance," and 11% were uncertain of their risk. The overwhelming majority of those at "no chance" claimed to always use a condom (84%). Other reasons for not feeling at risk, included, no homosexual contact (9%), condoms used sometimes (9%), clients do not have HIV (4%), do not do oral sex (2%), and know clients well (2%).
Knowledge of at least two HIV prevention methods increased significantly (p<.001) among adolescent (12-14 year old) boys and girls (see Graph 6, below). No difference was seen by location (urban vs. rural). Ninety-six percent of boys, but only 74% of girls, (p<.001) reported receiving any information on HIV/AIDS in the last 12 months. Information was reportedly received from schools (68%), media (34%), parents/grandparents (16%), street (7%), and youth/community clubs (4%). Rural adolescents reported significantly higher rates of information received from the school (76% vs. 58%, p=.000) and from parents/grandparents (21% vs. 12%, p=.01) than did urban adolescents.
Graph 6 : Knowledge of HIV Prevention Methods
(Adolescents 12-14 years old, two or more methods, prompted)
While 97% of boys knew that HIV is preventable, only 82% of girls knew (p<.001). Myths of HIV transmission showed considerable decline between baseline and follow-up, but remained quite high among girls. While only 8% of boys believed sharing food with an infected person was a means of HIV transmission (down from 25% in 1994, p<.001), 23% of girls maintained this belief. Overall, only 37% of the sample could correctly explain the meaning of the term "STI." Only one-half of all adolescents were aware that HIV could be transmitted by asymptomatic individuals. Knowledge of this type of transmission had declined from 62% to 55% (p=.09) among boys and from 64% to 46% among girls (p<.001).
Knowledge of at least two prevention methods was quite high in the targeted community intervention (TCI) population of residents of an inner-city red light district, increasing from 97% to 100% (p=.009) among men, and from 95% to 97% among women. Unprompted knowledge of two prevention methods was much lower, however (21% overall), reflecting perhaps a lack of assurance in the information.
An increasing percentage of men (49% to 61%) and women in the targeted community (45% to 54%) reported they believed there was "no chance" that they were infected. Those perceiving a "good/moderate chance" declined among men (40% to 23%) while increasing among women (35% to 39%). Sixteen percent of men and 7% of women were unsure.
In the MWM population significant increases in knowledge of two correct prevention practices were noted between 1993 and 1996. More substantial increases were noted among men who reported bisexual behavior (81% to 96%) than men who reported only homosexual behavior (89% to 95%).
Unlike all other target populations, a substantial increase was noted among MWM who perceive themselves to be at risk or are uncertain of their risk status. The percentage reporting "no chance" of HIV infection decreased from 55% to 25% while the percentage reporting a "good/moderate chance" increased from 46% to 54% and those uncertain increased from 0% to 20% over the study period. Eleven percent of the 1996 sample reported being HIV+.
Sexual Behavior and Partner Networking
Behavior change strategies varied considerably among different age groups and genders. Overall, between 1992 and 1996, Jamaican men reported a small decrease in multiple partnerships (from 49% to 44%, p=.08). Between 1994 and 1996 however, we note a large decrease in non-regular partnerships among men (from 35% to 26%, p<.01). Women reported a small increase in non-regular partnerships
The overall changes among men and women mask contradictory trends within different age groups. Among men, 15-19 year olds reported decreased non-regular partners, but increased multiple regular partners. Men 20-29 and men 30-39 reported decreased non-regular partners and regular partners, while men 40-49 reported an increase in non-regular partners and a decrease in regular partners (Graphs 7 and 8).
Graph 7: Percentage of Men Reporting Non-Regular Partners
(1994 vs. 1996, by age)
Among men aged 15-19, the percentage reporting non-regular partners has been cut in half from 28% in 1994 to 14% in 1996. This decline is offset however by an increase in the percentage reporting more than one regular partner in the last 12 months which rose from 45% in 1992 to 69% in 1996. These results may indicate that young men, while not decreasing overall sexual activity are becoming more selective in terms of sexual partners, and having longer relationships.
Graph 8: Percentage of Men Reporting > 1 Regular Partner
(1992, 1994, 1996, by age)
Men over 20 report significant decreases in multiple regular partnerships, but smaller (and statistically insignificant) changes in non-regular partnerships between 1994 and 1996.
Another perspective on trends in sexual partner networking can be viewed from examining the percentage of men reporting only non-regular partnerships, both non-regular and multiple regular partnerships, only multiple regular partnerships, and only one regular partnership.
The percent of women reporting multiple partnerships was much lower than men, however it has more than doubled from 6% in 1992 to 14% in 1996. Women from lower socioeconomic levels report twice the level of non-regular partners (20% in 1996) than the national average.
Graph 9: Patterns of Sexual Behavior - Women
(General population, last 12 months)
Target Populations
A significant decrease was found between baseline and follow-up in the percentage of STICAs reporting one or more non-regular partners in the past 12 months (50% vs. 32%). Multiple regular partnerships increased however, from 50% to 73%. This changing profile of STICAs indicates a high level of risk for STI infection in regular partner relationships as well as non-regular partnerships and a greater acceptance of referral and treatment of STIs from regular partners. STICAs continue to be a high risk population however, with sixteen percent reporting engaging in transactional sex (vs. 5% of the male general population).
Many more adolescent boys reported sexual experience and recent sexual activity than girls. However, declines were reported in boys sexually experienced (59% to 41%) and sexually active in the past 12 months (40% to 33%). Ten percent of girls reported being sexually experienced (from 11%), and 7% being sexually active (from 6%). No difference was seen between urban and rural adolescents.
Among the TCI targeted population, a slight increase was reported in the percentage of men (31% to 35%) and women (14% to 20%) reporting non-regular partners in the past 12 months. Thirteen percent of women (versus 2% in a national survey) reported engaging in transactional sex in the last 12 months. Among these women this represented a doubling of the figure reported in 1995 (6.5%). Whereas in 1995, 43% of women reporting non-regular partners also reported transactional sex, in 1996 this figure was 63%. The high rate of transactional sex in these communities, and the increasing number of women involved in it, were confirmed in qualitative research and explained in light of the difficult and deteriorating economic climate. A higher percentage of men in this study also reported engaging in transactional sex than in the national survey (9% vs. 5%). Between the baseline and follow-up studies multiple regular partnerships increased significantly among men (21% to 31%).
In the post study, 59% of MWM reported at least one non-regular partner over the past 12 months, while 12% reported multiple regular partners, 22% reported a single regular partner, and 8% reported no partners. Qualitative research found that the high incidence of multiple relationships involving early sex is seen by members of the target group as the social norm, and that the high level of homophobia in the Jamaican society discouraged stable, long-term, regular partnerships.
Condom Use
Reported condom use among Jamaican men and women is extremely high. Among men 15-49, 74% report using condoms during their last sexual intercourse with a non-regular partner. Rates were higher among men 20-39 (79%) than among men 40-49 (64%), and are virtually unchanged from 1992. Among women with non-regular partners, condom use has increased tremendously. Only 37% of women reported using condoms during their last sexual intercourse with a non-regular partner in 1992, compared to 73% in 1996.
Although last time condom use figures were virtually unchanged among Jamaican men, the frequency of condom use with non-regular partners increased between 1992 and 1996. Fifty-five percent of men reported "every time" condom use with non-regular partners in 1992, and 59% in 1996.
Graph 10: Frequency of Condom Use - Men
(with non-regular partners, last 12 months)
Among women, the percentage of the population reporting never using condoms was cut in half (from 45% to 23%) while the percentage reporting using condoms "every time" more than doubled (from 30% to 64%).
Graph 11: Frequency of Condom Use - Women
(with non-regular partners, last 12 months)
Both graphs demonstrate a dwindling percentage reporting condom use "most times" with non-regular partners. This phenomenon was also reported in focus group discussions. Program managers expected to find a small minority that use condoms consistently, a small minority that never use condoms, and a majority that report using condoms sometimes. Instead, men and women both reported that individuals were either dedicated condom users or not.
Among those not using condoms, explanations for lack of use have shifted from structural reasons to personal ones (see table below). Qualitative research indicates that among the main reasons for the dislike of condoms are: its lack of sensitivity during intercourse; the likelihood of its "getting lost in the woman"; allergic reactions; and the "unpleasant" smell. Dislike of condoms was more commonly mentioned by women (67%) than men (46%.)
Table 4: Reasons for not using condoms in high risk behavior, 1994 vs. 1996
| |
1994 |
1996 |
| Structural Reasons: |
| Unavailable |
46% |
19% |
| Other contraceptive used |
19% |
0% |
| Unplanned sex |
8% |
0% |
| Personal Reasons: |
| Dislike condoms |
23% |
51% |
Target Populations
As might be expected, STICAs use condoms significantly less than the general population (59% report last time use with a non-regular partner vs. 74% of the general population). This figure though represents an increase from 25% in 1994. The most important reason given for the nonuse of condoms in high-risk situations was their unavailability (77%). This is also in stark contrast with the general population (19%) reporting no access. In terms of general attitudes towards condoms, a significant decline was seen in the percentage of STICAs agreeing to the statement that "condoms are difficult to use" (from 11% to 3%).
Ninety-five percent of CSWs reported last time condom use with a client, while 76% reported consistent condom use in the last three days with paying clients. Nonuse of condoms was related in qualitative research, to either the threat of violence, or the desperate need for money. Seventy-six percent of CSWs reported getting condoms from MOH sources, and 100% had condoms (an average of 12) on hand during the interview.
Among youth, 93% of the respondents were able to recognize a condom. Eighty-eight percent of boys, and 54% of girls reported that they could access condoms, with rates significantly higher among 14 year olds than among 12 year olds. Of those unable to access a condom, 56% did not know of a source of condoms, and 8% stated that they were too embarrassed to buy condoms. Among sexually active adolescents, an increase in the number reporting consistent (every time) condom use was reported, both among boys (16% to 29%) and girls (21% to 35%). Those reporting never using condoms also decreased, although not significantly (58% to 48% among boys, 52% to 42% among girls). Among those reporting condom use, rural adolescents were most likely to get condoms at a shop (58% vs. 33%) while urban adolescents were most likely to get condoms from a relative or friend (48% vs. 11%).
In the TCI population, last time condom use with non-regular partners increased among both men (68% to 85%) and women (46% to 59%). Among regular partners, condom use increased only slightly among men (37% to 41%) but significantly among women (26% to 41%). Men report very high rates of condom use with paying partners (94%). Alarmingly rates for women with paying partners are much lower (56%). Clinics were the most frequently mentioned location for getting condoms (30%). While shops and supermarkets were well known sources of condoms (50% and 21%), they were only rarely mentioned as the location where condoms were acquired (12% and 2%). This may reflect the cost of condoms, and again, the economic conditions present.
Condom use increased significantly among men reporting receptive anal sex (51% to 78%) and showed a small, though not significant increase among insertive partners (81% to 87%). Among bisexual men, only 50% reported consistent condom use with female partners.
STIs
Appropriate STI treatment seeking behavior is a critical problem in Jamaica. Qualitative research has indicated improvements in the population's attitudes and approach to STI treatment. Program managers and staff from the TCI subproject stated "There has also been a change in the whole attitude towards going for treatment for STI. Before people were treating themselves; ignoring it; not aware that they could be infected if there were no signs. And now more people are seeking treatment and are more aware of the whole thing of STIs and health care." Despite these observations, the 1996 national KABP found that of the six percent of men who reported at least urethritis and the 2% of men who reported genital sores over the past year, only 54% reported having sought appropriate treatment. A third reported doing nothing while 9% sought inappropriate treatment.
Some 37% of CSWs reported having had an STI within the last year. A higher percentage of CSWs reported having been infected by a regular partner than by a client. CSWs reporting crack cocaine use reported lower rates of consistent condom use than non-drug users (67% versus 88%) and significantly higher rates of STI infection (64% versus 22%) in the last 12 months.
Attitudes
Attitudes towards sexuality, STIs and HIV/AIDS have shifted noticeably in Jamaica during the AIDSCAP program. These changes have been noticed not only in the target populations but in the media and among opinion leaders and people of influence in the communities and nationally. Women became more open to discussions about sexuality. Churches have begun discussions about HIV/AIDS, including the topic in sermons, offering treatment/counseling for PWA and asking for congregation support. Several pastors wrote articles on care and support for PWA. Leading entertainers openly endorsed messages about safer sex, participated in public service announcements and recorded songs with prevention messages.
While the percentage of the population who know someone with HIV/AIDS has increased steadily from 1992 to 1996 (see Graph 12 below), there continues to be a great fear among HIV+ individuals to disclose their HIV status publicly. HIV+ individuals often reported that they were uncertain of revealing their status even to their immediate family, for fear of being ostracized and abandoned. The majority of those surveyed (63% of men and 50% of women) responded that HIV+ individuals should be forced to reveal their HIV status to the public.
Graph 12: Percentage of Population Knowing Someone with AIDS
Sample Methods
The Jamaica National KABP used a repeated cross-sectional survey design with a structured questionnaire to collect three waves of data from general population adults (15-49) in 1992, 1994 and 1996. Sample size averaged 1190 in each wave, and used a stratified multistage sample based upon selection of census enumeration districts (EDs), using PPS, and the random selection of households within Eds. Same sex interviewing was used with respondents chosen with a random numbers grid.
Target Population Surveys
One hundred male STI clinic attendees (STICAs) were randomly surveyed at each of Jamaica's two main STI clinics in Kingston and Montego Bay in 1994 and 1996.
A cross-sectional survey was conducted in 1995 among 100 CSWs in Kingston, Montego Bay, and Ocho Rios working in locations where the ACOSTRAD intervention had been conducted. Ninety-five percent reported contact with an HIV/AIDS intervention and 82% reported having used outreach facilities of the Ministry of Health. CSWs were intercepted while soliciting at these locations and invited to participate in the survey.
A total of 556 (283 boys, 273 girls) interviews were conducted in 1994, and 561 (288 boys, 273 girls) interviews were conducted in 1996, with adolescent students between the ages of 12 and 14 from 15 schools in Kingston and St. Catherine parishes. Students were primarily from lower socioeconomic backgrounds.
Four hundred and forty-six (220 men, 226 women) interviews were conducted in 1996, and 438 (234 men, 204 women) interviews were conducted in 1995 with inner city residents in three communities covered by the TCI project. Individuals were selected using a two-staged stratified sample.
A convenience sample of 101 MWM at baseline (1994), and 174 MWM at follow-up (1996), drawn from the constituency of the Jamaican AIDS Support organization (83% of respondents reported that they had participated in sessions relating to HIV/AIDS).
4. Capacity Building
Technical Skill Building
Over the life of the AIDSCAP/Jamaica program, project staff efforts focused on increasing the technical skills of implementing agencies in the areas of BCC, STI and sentinel surveillance. A total of more than 176 person weeks of technical assistance (TA) in these areas resulted in enhanced program management capabilities and strengthened technical capacity by the end of the project.
The Program for Appropriate Technology in Health (PATH) provided technical assistance in BCC to the Jamaica program with additional input from Ogilvy Adams and Rinehart (OAR). TA included the development of a BCC strategy; a workshop on developing material for a low literate audience and the use of pre-testing material; and a workshop on developing condom promotion material. The development of a detailed BCC strategy with target groups, messages and desired outcomes was the first for AIDSCAP and became a model for other countries. As a result of the assistance provided by PATH, local counterparts were able to expand on the strategy and more effectively develop materials. The use of the BCC strategy created a more cohesive team within the NHCP as Epi Unit staff and NGOs had a clearer sense of where their activities fit into the bigger picture. Later, several Jamaican counterparts were invited to present at international meetings on the development and use of a BCC strategy.
The workshop on developing low literate material was especially successful in that program managers and technical staff acquired a full appreciation for the process of material development. The necessity of pre-testing material was emphasized and was reinforced with hands-on experience. Theories and practical methods presented at the workshop were successfully used during the material development process for example, pre-testing of material became a required component of material development.
The University of North Carolina (UNC) provided continuous TA in STI control both in the public and private sector. STI TA included training medical staff in the diagnosis and treatment of STIs; conducting research on the use of algorithms versus laboratory testing for vaginal discharge; conducting an audit on genital ulcer disease; assisting in the decentralization of syphilis screening by institutionalizing the use of RPR tests in all 13 parish health clinics; on-site training in laboratory techniques and clinical case management; and establishing a continuing education program through the MAJ. Additional technical assistance in program management and evaluation, data management and analysis strengthened the public sector STI program.
The successful transfer of technical skills in STIs was demonstrated in several areas. The adjustment of the patient flow in the 13 health centers allowed for the consistent use of RPR tests prior to seeing a doctor and ensured treatment at the point of first contact. Another successful transfer of skills was demonstrated by the MAJ in their continuing education series. Towards the end of the series, the MAJ took on more of a leadership role in planning and implementing educational activities. In addition, the MAJ used data from the pre and post-tests to lobby for continuing education as a requirement for maintaining a medical license.
As part of the overall strategic and implementation plan, CDC provided ongoing support to the Epi Unit in Sentinel Surveillance. CDC provided computer TA in accessing previously irretrievable data and creating a user friendly database, as a result the Epi Unit was able to develop a more reliable reporting system which later they maintained themselves.
Organizational Development
AIDSCAP's participation in the NHCP assisted both the public and private sector by improving their capacity to implement more strategic AIDS prevention efforts. The process of development of subagreements provided opportunities to develop longer term strategic plans; develop appropriate evaluation indicators, and identify needed resources. The final subagreements provided readily available documentation to share with counterparts which greatly enhanced coordination. The use of subagreements proved to be particularly useful in the Epi Unit as there was a multitude of activities happening simultaneously.
AIDSCAP assisted NGOs to become more mature organizations in structure and function. For example, when JAS initiated project activities they functioned informally with committed volunteers assisting PWAs and conducting AIDS prevention activities as requested. The subagreement structure and planning assisted them to evolve into an institution with an organizational structure, staff with job descriptions, a Board of Directors and a strategic fund raising plan. On the other hand, the MAJ had a well established organizational structure for all its members but lacked managerial expertise in developing their own educational programs. Over the course of the project, the planning and implementation of the six continuing education programs moved from AIDSCAP with assistance from UNC directly to the MAJ. Hope Enterprises gained technical expertise in conducting quantitative and qualitative research, especially KABPs through working closely with staff from the Regional Office. The technical skills they gained has enhanced the companies other research activities.
By increasing the capacity of organizations to conduct more strategic AIDS prevention activities, other internal systems were improved especially in the area of financial management. Technical assistance and training related to the FHI/AIDSCAP accounting system strengthened the financial capacity of several implementing agencies. In other cases, organizations such as the Epi Unit and the MAJ, opted for using the financial services of an external organization to ensure full compliance of financial requirements. To assist in enhancing internal systems, AIDSCAP and CATC conducted a program management workshop for all implementing agencies. This three-day workshop focused on internal procedures from the use of a Board of Directors to filing systems.
Network Enhancement
The AIDSCAP/Jamaica program significantly expanded the efforts of the NHCP creating opportunities for a broader network of AIDS prevention practitioners. The involvement of the private sector in annual meetings allowed for input into the National Annual AIDS Prevention Plan as well as review of progress building a more cohesive national team which carried on after AIDSCAP's support terminated.
Further evidence of the establishment of networks by AIDSCAP/Jamaica was provided in a study of 49 care givers from a variety of backgrounds including: nurses, doctors, social workers, contact investigators, clergy, municipal officials, etc. Nearly four-fifths (78%) of the care givers had received training from the MOH. Care givers were asked to which organizations they most frequently referred to in search of more information. Two-fifths of the care givers reported seeking information and help from the Jamaica AIDS Support (JAS), followed by one-fourth reporting seeking help from the Helpline. Other AIDSCAP supported institutions were also mentioned, including ACOSTRAD, Red Cross, and the MOH/Epi Unit.
