FHI - I. Introduction and Country Context

A. Introduction

In 1987, the Government of Jamaica (GOJ) initiated an AIDS prevention campaign following a national conference on the epidemic. Although prevalence of HIV in Jamaica was low, it was believed that prevailing sexual behaviors, high rates of STIs and the large tourism sector could result in exponential rates of transmission if prevention measures were not taken immediately. The new program components included surveillance, control of STIs, condom promotion, counseling, laboratory facilities, management and evaluation. To support the GOJ in the implementation of its campaign, USAID and other donors provided financial and technical assistance.

Initiated in 1988, the USAID/Jamaica AIDS/STI Prevention and Control project was designed to address the growth in HIV/AIDS cases and the dramatic increase in STIs and expanded upon the previous USAID prevention activities. Under this project, AIDSTECH supported research on sexual decision making and indicators, provision of equipment and project development assistance. The USAID project was extended in 1992 for four additional years with a stronger emphasis on increasing access to and use of condoms, reducing the number of sex partners and decreasing the incidence of STIs. At this time, due to the factors cited above, AID/Washington selected Jamaica as one of the fifteen priority countries worldwide to receive technical assistance under the AIDSCAP project. In Jamaica, the epidemic was not yet believed to be overwhelming and prevention would have a significant impact. Funding levels were increased at this time from $2.5 million to $5.5 million with additional resources for program activities made available from the Latin America and the Caribbean (LAC) Bureau.

The goal of the Jamaica program was to reduce the rate of sexually transmitted HIV. To achieve this goal, the program aimed:

To decrease STIs through improved diagnosis and treatment;
To increase condom use by expanding and improving access and;
To reduce the number of sexual partners through behavior change communication (BCC) among the target groups.

The AIDSCAP/Jamaica project had three strategic components:

1. STI Prevention and Control: Epidemiological data indicated that STIs were a growing public health problem in Jamaica, in the late 1980s. Reported congenital syphilis cases increased between 1985 and 1990 from 8 to 60. Visits to public sector STI clinics increased nearly 27% from 1987 to 1990. In 1991, the MOH reported positive STIs in 3.6% of blood donors and 4.1% of women getting prenatal care. Proper diagnosis and treatment to interrupt the chain of transmission of STIs was planned to reduce the chances of HIV infection as well as improving the general health of the sexually active population.

2. Behavior Change Communication: Research in Jamaica showed that the existence of a number of sexual sociocultural beliefs and attitudes had significant implications for HIV/STI communication interventions. Included among these were the belief that:

Suppression of sexual activity is unnatural;
STIs are a natural correlate of sexual activity;
Virginity is not a positive value;
Infidelity is socially acceptable and;
AIDS is a homosexual disease and homosexuality is unacceptable.

An effective BCC component was essential if these beliefs were to be countered and behaviors affected.

3. Condom Distribution and Promotion: Although condom use for family planning was high, accessibility, both geographic and financial, and acceptability were identified as constraints to increased condom use in Jamaica. This component coupled with the BCC component was necessary to ensure correct, consistent use of condoms, especially by individuals practicing high risk behaviors.

The following pie chart shows the breakdown of subproject expenditures by strategy for the life of the AIDSCAP/Jamaica program.

Graph 1: Subproject Expenditures by Technical Strategy

Target Groups and Target Areas:

The primary target groups for the program were STI clinic attendees, commercial sex workers (CSWs), adolescents, adults with multiple sex partners, men who have sex with men (MWM) and persons who were HIV-positive. Intermediate target groups identified included policy makers and opinion leaders, medical professionals and commercial sector retailers.

Geographically, the program was comprised of seven subprojects with the Epi Unit of the MOH, six of these with a national focus and one working in targeted communities in the Kingston Metropolitan Area. In addition, there were eight subprojects with six NGOs. Three of these NGOs had island-wide targets. The remaining three focused on major metropolitan areas or tourist areas where populations of target groups such as MWM and CSWs are concentrated. The program also supported four subprojects with two private sector organizations and one with an international PVO, which implemented activities nationally. Finally, nine rapid response fund activities were implemented by seven organizations.

The following is the logical framework under which the AIDSCAP/Jamaica program was designed and implemented.

Jamaica Country Program Logical Framework

Narrative Summary Measurable Indicators Means of Verification Important Assumptions

Goal: Reduce the rate of sexually transmitted HIV in Jamaica 1.1 Stabilization or decrease in gender group and/or age-specific HIV prevalence and incidence 1.1 HIV sentinel surveillance (Goal to supergoal) Sexual intercourse is the primary mode of HIV transmission.

Purpose: Decrease of STIs, increase condom use, and reduce the number of sexual partners in selected target groups 1.1 30% decrease in gender and age-specific syphilis prevalence 1.1 Target population based surveys (Purpose to goal) 1.1 Reducing the number of sexual partners and STIs has an impact on HIV transmission.

1.2 70% increase in reported condom use among the target population in high-risk sexual encounters 1.2 Syphilis sentinel surveillance 1.2 Appropriate condom use reduces HIV/STI transmission.

1.3 10% decrease in congenital syphilis by EOP 1.3 Project narrative reports of major findings from focus group discussions and/or key informant interviews 1.3 Condoms are available and accessible to the target population.

1.4 STI diagnosis and treatment services are available and accessible to the target population.

Outputs: 1. Enhance communication interventions to promote behavior change in primary prevention target populations: STI patients, CSWs, adolescents, adults with multiple sex partners, MWM, and HIV+ individuals 1.1 90% of target groups name condoms as acceptable way of preventing HIV 1.1 KABP surveys 1.1 Accurate mobilization of target population to participate in project activities exist.

1.2 80% of target population(s) reached by communication activities, by target population, by gender 1.2 Project narrative reports of major findings from focus group discussions and/or key informant interviews 1.2 Communication activities lead to behavior change.

1.3 Communication strategies will be consistent with social, cultural, and religious norms for various segments of the population.

2. Increase access and availability of condoms in the commercial and public sectors 2.1 30 million condoms sold or distributed by EOP. (based on CPS at 20% use rate) 2.1 Provider assessments 2.1 Condom logistics infrastructure exists.

2.2 70% of target population(s) report condom use in high risk situations 2.2 KABP surveys 2.2 Constant and consistent supply of quality condoms is secure.

2.3 20% increase in condoms being purchased in the private sector 2.3 Process data/logistic reports/surveys 2.3 GOJ allows budget allocation for increased availability to the public sector.

2.4 Retail audits 2.4 Increased accessibility will increase use.

2.5 Information management System (if it's available and includes condoms) 2.5 Pricing structure allows purchase in the commercial sector by target population.

3. Increase access to improve STI prevention and treatment services in the public and private sectors
3.1 80% of target population with STIs receive treatment according to standard STI diagnosis and treatment protocols

3.1 Provider assessments. 3.1 Target population(s) will feel empowered to access STI diagnosis and preventive services.

3.2 Target population surveys 3.2 Laboratory and technical capabilities to manage effectively will improve with increased demand on STI diagnosis and treatment services.

3.3 Project narrative reports of major findings from focus group discussions and/or key informant interviews 3.3 STI service providers will want to work with target population.

3.4 Target populations are easily identified.

3.5 Sociocultural norms permit activities focusing resources on target population(s).

3.6 Physical, human, and financial resources will be available throughout the life of projects.

3.7 Private practice providers are willing to care for STI clients.

4. Strengthen the capacity of host country institutions to manage and implement effective HIV/AIDS prevention projects in the public and private sectors
4.1 All institutions funded by NHCP implement integrated HIV/AIDS prevention programs that include strategic and implementation planning

4.1 Pre- and post- institutional assessments that include both quantitative and qualitative methodologies 4.1 Institutions with appropriate mission statement/philosophy exist to implement USAID mandates.

4.2 Sociopolitical support for capacity building is constant throughout life of project.

5. Facilitate dialogue and collaboration among nonprofit, commercial, and public sector to positively address AIDS-related policy issues
5.1 400 policy makers/opinion leaders in all key sectors, representing public and private institutions, at the central and regional levels, involved in policy dialogue activities

5.1 Training curricula and attendance records 5.1 Multisector policy environment that is conducive to the development and implementation of comprehensive AIDS prevention activities is created.

5.2 Meeting Minutes 5.2 Government policies strongly influence effectiveness of intervention strategies.

B. Country Context

The island of which Christopher Columbus said " the fairest isle that eyes have beheld," Jamaica is a nation with a population of approximately 2.5 million inhabitants. First a Spanish colony, Xaymaca, as the indigenous people called it, became an English settlement in 1655 and was home to pirates and a thriving slave trade until the late 1830s. Prior to its destruction in a 1692 earthquake, the first capital city, Port Royal, was described as "the richest and wickedest city in the new world." Still known for its colorful culture and breathtaking topography, this island is now a favorite tourist destination.

The population of Jamaica is primarily of African, European, East Indian and Chinese origin thus the national motto "Out of many, one people." Nearly half resides in urban areas, with half of these urban residents living in the Kingston and St. Andrews metropolitan area. Literacy rates are 80% for women and 76% for men. Over 40% of Jamaican households are headed by women. One third of the population is under the age of 15 while 7% are over 65 years of age. Life expectancy is 69 years for men and 73 years for women. About one third of the population is living in poverty. One third of the poor live in urban settings where they lack affordable housing and land to grow food in addition to being victims of high crime rates.

The Jamaican economy relies heavily on the service sector, including tourism, with nearly 60% of its gross domestic product derived from this sector. Manufacturing comprises roughly 20% of GDP while construction, mining and agriculture total just over 20%. Government expenditures on health represent only 6.6% of the budget. Since 1993, the Government of Jamaica has increased its budget for HIV prevention and control by 53%. These funds absorb a share of the costs of mobile contact investigators and pharmaceuticals for STI treatment.

1. Epidemiology

The first diagnosed case of AIDS in Jamaica was in 1982. By 1993 there were over 500 known cases. One year later, there were over 800 cases, 64% male and 36% female with all parishes having reported cases. Current data show a total in December 1996 of 2,060 cases. According to the Ministry of Health's sentinel surveillance data, the number of individuals infected with HIV is estimated to be between 5,000 and 10,000. These cases are primarily (80%) among the heterosexual population and in urban areas. As of 1995, the parish of St. James had the highest AIDS case rate (189 per 100,000) followed by the parishes of Kingston and St. Catherine. The majority (59%) of AIDS cases occurs in people between the ages of 20 and 39, with 8% pediatric cases.

In 1993, HIV prevalence was estimated at 0.1% in the general population and 0.3% in urban areas. 1996 prevalence was calculated at between 0.3 and 0.4%. STI clinic attendees in Kingston and Montego Bay had a rate of 4% in 1994. While prevalence is relatively low in comparison with other Caribbean countries, the large commercial sex industry, high rates of alcohol and drug abuse, the sizable number of migrant laborers and high rates of STIs indicate the potential for the epidemic to have a devastating impact in Jamaica. Pervasive homophobia in Jamaica is also a barrier to reaching the homosexual population.

2. Policy

The government of Jamaica is highly aware of the HIV/AIDS epidemic and initiated support for intervention in 1987, through the Ministry of Health, EPI Unit and the National HIV/STD Control Program (NHCP) - now named National HIV/STI Control Program (NHCP). The National AIDS Committee (NAC) was established to advise on policy and address other issues related to HIV/AIDS. The NAC was comprised of representatives from the ministries of health, labor and education and the National Family Planning Board (NFPB) as well as insurance companies, several NGOs and private sector organizations. Additionally, various churches in Jamaica were actively involved in the NAC and in education efforts. Both the NAC and the NHCP had the support of the prime minister and the leader of the opposition and STI/HIV/AIDS was seen as a national priority. However, with the exception of mandatory HIV/AIDS case reporting to the MOH and the removal of tariffs on condoms in 1993, as of the end of this project no legislation or official government policy had been passed.

3. Donor Support

While USAID was the major donor for AIDS prevention, other multilateral and bilateral donors provided complementary assistance. Multilateral assistance included Pan-American Health Organization (PAHO) which worked with the NAC providing technical assistance and financial support for the development of a mid-term plan, prevention and control of blood and perinatal transmission, care for persons with HIV/AIDS and project management. Additionally, PAHO funded three staff positions with the MOH EPI Unit in the areas of communications, coordination and administration. The World Health Organization/Global Program for AIDS (WHO/GPA) provided some programmatic support through 1995. United Nations Development Program (UNDP) worked with school-based HIV education activities. United Nations Population Fund (UNFPA) worked in BCC targeting disenfranchised adolescents, developing radio programs and comic books as well as training peer counselors. The United Nations Educational, Scientific and Cultural Organization (UNESCO) developed a model curriculum to add AIDS/STIs to the national Family Life Education curriculum.

Bilateral assistance came from multiple sources. The European Union (EU) provided long-term technical assistance and support for the expansion of surveillance activities. German Technical Cooperation (GTZ) primarily supported assistance in the National Reference Laboratory in Kingston and the HIV Diagnostic Laboratory in Cornwall Regional Hospital. Additional support was provided for health care worker training, IEC and some sentinel surveillance activities. The Canadian International Development Agency (CIDA) purchased equipment for laboratories. The Dutch and Norwegian governments implemented HIV/AIDS/STI projects with selected NGOs. The Japanese government was exploring possibilities of working through JICA in primary health. Caribbean Epidemiology Center (CAREC) assisted Jamaica to be involved in Eastern Caribbean regional activities including workshops on materials development, training and policy development.

Program Activity Timeline - Jamaica

Final Report for theAIDSCAP Program in Jamaica: Country Program Description

Final Report for the
AIDSCAP Program in Jamaica: Country Program Description