Jamaicans Begin to Embrace Safer Sex

A comprehensive, well-coordinated program to control HIV/AIDS and other sexually transmitted diseases is helping Jamaicans change their individual behavior and the way society views safer sex.

Give me the woman with the wickedest slam.
The one who know how fi love up she man.

This hit song about a man seeking a partner with exceptional sexual technique became the vehicle for an important public health message on Jamaican television. "The wickedest slam is the one that don't give you an infection," says Beenie Man, a popular performing artist. "So remember: don't slam without protection."

The warning hits home in a society where rates of sexually transmitted diseases (STDs) are high and risky sexual behavior appears to be the norm for much of the population. During the past decade, studies in Jamaica have revealed widespread acceptance of sex outside of marriage or other stable relationships and a common perception that STDs are a natural and easily curable outcome of sexual activity.

But recent survey results suggest that these attitudes -- and behaviors -- are beginning to change. Jamaican men who once thought nothing of having five or more sex partners within a year are choosing their partners more carefully and staying in relationships longer. Men and women report having fewer sexual partners. And young adolescent boys are waiting until they're older to start having sex.

"I think we have begun to influence normative behavior," said Dr. Peter Figueroa, principal medical officer in Jamaica's Ministry of Health (MOH) and head of its HIV/STD control program. He attributes the program's success in influencing social norms to its comprehensive, systematic and sometimes unorthodox approach to HIV/AIDS prevention.

The program began in 1987 and soon attracted substantial support from international donors, particularly the U.S. Agency for International Development (USAID). With an overall HIV prevalence of less than 1 percent despite rates of 10 percent or higher in some groups and an epidemic fueled primarily by heterosexual transmission, Jamaica was seen as an opportunity to contain the epidemic's spread among the general population.

The USAID-funded AIDS Control and Prevention (AIDSCAP) Project took up that challenge in 1992. In most countries AIDSCAP works primarily -- and sometimes exclusively -- with nongovernmental organizations (NGOs). But in Jamaica, USAID decided to provide AIDSCAP's technical and financial support primarily to the MOH through an existing agreement between the U.S. and Jamaican governments.

AIDSCAP staff and technical consultants worked closely with MOH staff to carry out the program from 1993 to 1996. "This linkage made it possible to combine our joint resources, expertise and efforts to reach more people with HIV/STD prevention resources," said Dr. M. Ricardo Calderón, who is director of AIDSCAP's Regional Office for Latin America and the Caribbean.

STDs a Priority

From the beginning, the MOH integrated HIV/AIDS prevention into its STD program. For Dr. Figueroa, this decision typifies the willingness of program staff to flout the conventional wisdom and do what they believed was necessary to slow the epidemic in Jamaica.

"A majority of people coming into HIV/AIDS felt that was wrong -- that STD programs were completely lifeless, bureaucratic and failures," he said. "But we built on the foundation we had here, and now world opinion has come around."

Combining STD and HIV prevention in one program helped ensure that messages about STDs were prominent in educational materials and outreach efforts. It also made improving STD services a high priority for the program.

Jamaica's STD program suffered from shortages of drugs, supplies and trained staff, long waits for laboratory results and increasing drug resistance. Researchers from AIDSCAP and one of its subcontractors, the University of North Carolina (UNC), worked with MOH staff to train health workers, upgrade clinics and laboratories, and study ways to improve STD services.

More than 5,000 public health care workers from government STD clinics in Jamaica's 13 parishes (districts) were trained in syndromic management of STDs, which enables them to prescribe prompt, effective treatment without expensive and time-consuming laboratory tests. During the summer of 1996, a study conducted by researchers who observed the management of patients with gonorrhea found that all the patients were treated correctly -- up from 74 percent in 1991.

Most program efforts have focused on improving STD prevention and treatment in government-run facilities. But recognizing that only about half of the STD cases in Jamaica are treated in public clinics, the MOH and AIDSCAP worked with the Medical Association of Jamaica to organize five continuing education seminars on STDs and HIV for private physicians. More than 55 percent of Jamaica's 1,100 practicing private physicians attended at least one seminar.

Physicians were impressed by the results of studies conducted by the MOH, UNC and AIDSCAP in Jamaica that demonstrated the effectiveness of syndromic management. Two months after the seminars, the number of participants reporting that they used this approach to treat urethritis and genital ulcer disease rose above 80 percent. Presentations of local drug resistance data also seem to have had an impact: before the seminars, more than 43 percent of participants had prescribed ineffective drugs to treat gonorrhea, compared to only 3.6 percent two months later.

A Bold Move

The most dramatic improvement in STD services in Jamaica resulted from the decentralization of syphilis screening. Before decentralization, pregnant women and STD clinic clients who were screened for syphilis had to wait at least a week and typically up to six weeks for results to return from the two central government laboratories in Kingston and Montego Bay. "By that time, patients were gone, and women had delivered," said Frieda Behets of UNC, a technical consultant to the project.

Delays in diagnosis and treatment resulted in further transmission of the disease by people with symptomless syphilis and contributed to increases in the number of infants born with the disease. One study in Jamaica showed that fetal loss, stillbirth or infant death were almost twice as likely to occur when the mother had untreated syphilis.

The decentralization effort began at the Comprehensive Health Centre in Kingston and was gradually expanded to other health centers and clinics. Laboratory aides and assistants with little laboratory experience learned how to perform syphilis blood tests at the clinics.

Many people were reluctant to endorse decentralization at first because they believed syphilis tests should be conducted only by laboratory technicians, according to Behets. However, a quality control assessment at the national reference laboratory showed that on-site testing was accurate: more than 96 percent of the results of syphilis tests performed by laboratory aides were confirmed.

Syphilis screening is now available at 76 antenatal clinics and 17 STD clinics in Jamaica. As a result, 68 percent of those who test positive for syphilis are treated the same day and 85 percent receive treatment in less than one week. More efficient and effective diagnosis and treatment contributed to a significant decline in infectious syphilis from 1994 to 1996.

A Strategy That Works

Another strength of the Jamaica program was the MOH communication team. "Jamaica established one of the most comprehensive behavior change communication (BCC) campaigns we have seen," Dr. Calderón said. "This is a country that clearly defined the specific messages they wanted to convey to the population through public, private and NGO initiatives."

Communication team members used research results and lessons learned from previous communication campaigns to identify target groups and develop strategies and messages for each group. A message designed to help adolescents delay sexual initiation was supportive: "You are not alone." STD clinic clients' resistance to condom use was countered with "Increase the skills, increase the pleasure." And young adults with more than one sexual partner learned "Your partners' other partners are your partners too."

Every part of the communication strategy was well articulated and narrowly focused. For example, the target group of sexually active young adults was divided into men and women entering new relationships, women in need of condom negotiation skills, men with STDs and women with STDs. Messages were developed for each of those audience "segments."

What made the strategy work, though, was the careful coordination of all communication messages and activities, notes Donna Flanagan, AIDSCAP's associate director for behavior change communication. "The communication team met with implementers, media people and evaluators regularly, and they planned together what their strategies should be and how they could complement each other," she said. "It seems that this approach encouraged a national outlook and a climate of sharing that serve Jamaica well."

The communication team met every week. In addition to MOH staff, the team included a representative of Berl Francis and Company, Limited, the local agency MOH and AIDSCAP hired to carry out a public relations campaign targeting opinion leaders, young adults and adolescents. Making the agency representative a full member of the communication team ensured that the messages communicated through the media were consistent with those conveyed by outreach workers, peer educators and project materials.

Monthly meetings of a larger group known as the BCC team, with representatives from all the organizations involved in the HIV/STD program, enhanced that coordination. These meetings also provided opportunities to devise joint strategies for counteracting rumors and misinformation.

Flanagan explained that the BCC team "knew how to put out fires." "They could spot a trend in the early stages," she said. "Someone would say, 'We've been hearing a rumor in this parish,' and someone else would say, 'We've begun to hear that too -- what can we do?' "

Good communication and regular meetings also helped program and project managers use evaluation data to guide implementation. Annual meetings brought together representatives from the MOH, AIDSCAP, USAID, the collaborating NGOs and Hope Enterprises, the local firm that provided evaluation support, to discuss evaluation data and refine program and project strategies.

Technical assistance, training and oversight by the communication team ensured the quality and consistency of all educational materials and outreach efforts. Program activities reached almost three-quarters of a million people.

Getting Through

One of the innovative features of the program was its use of public relations to influence youth and opinion leaders from the media, churches, the music industry and communities. Berl Francis staff wrote articles for Jamaican publications, including a weekly "Safer Sex" advice column, briefed opinion leaders and organized events.

Through its contacts with the Jamaican media and private sector, the Berl Francis agency was able to leverage U.S.$181,818 worth of cash and in-kind contributions to the public relations campaign. During the two-year campaign, the agency generated or assisted in the production of 64 radio and television programs and 421 newspaper and magazine articles about HIV/AIDS, including 167 articles written by Berl Francis staff.

"We realized we were getting through when the media managers became receptive," said Berl Francis, agency director. "We didn't have to bang on doors anymore. In fact, they started initiating requests for interviews, wanting to have further discussion on certain issues."

Dance hall disc jockeys helped the program gain access to the media by contributing their time to videotape and record public service announcements (PSAs) that aired on television, radio and the sound systems of dance halls. These performing artists have become wildly popular with Jamaican youth, primarily through live performances.

"Dance hall disc jockeys wield immense influence in the society," Francis explained. "Their lyrics both reflect social attitudes as well as influence ideas and behavior."

Beenie Man, who is particularly popular among young men, promoted condom use in two PSAs tied to his "Wickedest Slam" song. Lady Saw, whose explicit lyrics have earned her a large following among men and women, appealed to men not to mistreat women who ask them to use condoms. She also taped a PSA aimed at women who resist condom use with the message, "It's not a matter of trust, it's reality."

The creativity of Jamaican musical stars, actors, comedians -- and community members themselves -- was an important ingredient of the communication strategy's success. Many of the projects that were part of the HIV/STD program incorporated drama, songs, games and other forms of entertainment into their activities.

The Targeted Community Initiative (TCI) enlisted the help of a famous Jamaican comedian to introduce sensitive topics such as HIV and condom use to inner-city communities. "The use of comedy was very effective," said TCI Project Manager Audrey Wilson Campbell. "It was non-threatening, but we were getting to the root of the issue."

Other talented artists performed in musical road shows for youth and at community gatherings. Projects also encouraged community members to develop and perform their own HIV/AIDS dramas.

Teens participating in the Jamaica Red Cross's peer education project provided the story line and other ideas for a radio drama about HIV/AIDS that aired twice a week, reaching an estimated audience of 60,000. And the MOH shot a video called "FRAIDS" in the inner-city neighborhood of McIntyre Lands that featured members of the community. "FRAIDS" and several other MOH-produced videos were shown on both local television stations.

Face to Face

The mass media coverage generated by the program reinforced the messages Jamaicans received from thousands of outreach workers, counselors, other public health staff and peer educators. The HIV/STD program worked with employers to establish prevention programs in dozens of workplaces and with social service workers to build HIV counseling skills. Its "Face-to-Face" Project filled rural communities with peer educators and its "Helpline" counselors provided advice over the telephone to thousands of callers. And TCI outreach workers used a community development approach in Kingston's disadvantaged inner-city neighborhoods, asking community members what kind of prevention services they needed.

Program staff emphasized the need to listen to members of the target audiences and remain flexible enough to adjust projects to meet their needs. The Jamaica Red Cross did this by involving young people in every aspect of its "Together We Can" project, including materials development. For example, the peer educators helped design a workbook with interactive instructional exercises to use in sessions with other teens.

The project's peer education sessions are popular with the target audience. "In many cases, going to a session has become a status symbol," Project Director Lois Hue said.

This popularity bodes well for the efforts of "Together We Can" and the MOH to make abstinence an accepted prevention option for young teens. Surveys suggest that more adolescents are abstaining from sex -- particularly 12- to 14-year-old boys. From 1994 to 1996, the percentage of boys in this age group reporting sexual experience dropped from 59 to 41. One-third said they had been sexually active during the past 12 months, down from 40 percent.

Jamaica AIDS Support (JAS) also seeks to create a more supportive environment for behavior change. A grassroots NGO, JAS offers peer education and other prevention activities to marginalized groups, including gay and bisexual men, and provides counseling, support groups, testing, and home and hospice care to people living with HIV/AIDS and their families.

Many Jamaicans react to homosexuality with discomfort, contempt and sometimes even violence. These attitudes inadvertently promote HIV-risk behavior because they discourage stable, long-term partnerships between men. In response, JAS prevention efforts go beyond education and condom promotion to build self-esteem.

"We preach a message to counter the one that says you are dirty and evil," said JAS Executive Director Ian McKnight. "It says, 'You can be a productive member of society, and because of that you need to protect yourself.'"

The message seems to be having an impact. A comparison of surveys conducted in December 1995 and August 1996 revealed a 40 percent increase in condom use among men who have sex with men and a 30 percent reduction in self-reported high-risk behavior.

For JAS, which began as an informal network of gay and bisexual men helping friends with AIDS-related illnesses, responsiveness to its target audience is simple. "We were already part of the community," McKnight said. "Over the years we have been able to establish a trust."

To reach two of the other groups hardest hit by the epidemic in Jamaica -- STD clinic clients and female sex workers -- the program turned to another local organization that had earned the trust of those target populations. The Association for the Control of Sexually Transmitted Diseases (ACOSTRAD), a Jamaican NGO founded in 1978, provided education at all parish STD clinics and other health centers as well as special outreach efforts to sex workers and their clients in the red light district of downtown Kingston.

ACOSTRAD opened drop-in centers in Kingston and Montego Bay to provide a more confidential, convenient place where sex workers could receive STD treatment, counseling and HIV testing. More than 500 sex workers were reached at centers and during visits to bars, clubs and brothels.

Like many other target groups, sex workers seem to be taking the outreach workers' messages to heart. Reported condom use with the most recent client has increased dramatically to 95 percent. Three out of four of the women report consistent condom use.

New Directions

AIDSCAP's collaboration with the MOH in Jamaica ended as scheduled in August 1996, leaving behind an experienced HIV/AIDS prevention team and improved STD services. USAID now funds the MOH HIV/STD program directly and expects to continue this assistance through the year 2001.

During the years of AIDSCAP support for HIV/AIDS prevention in Jamaica, knowledge of HIV prevention methods increased among all target groups. For the first time, lack of access is not the major reason cited for failure to use condoms, suggesting that the program's reliance on the private sector and targeted free condom distribution has been effective. And a majority of the population now reports some behavior change to avoid HIV infection.

Although people are changing their sexual behavior and HIV prevalence remains below 1 percent in Jamaica, Dr. Figueroa sees no reason for complacency. HIV prevalence is as high as 20 to 30 percent among some of the target groups, and surveys conducted by Hope Enterprises in 1996 identified continuing problems and new challenges for the HIV/STD program.

The results show, for example, that a growing proportion of the population is unaware that HIV/AIDS can be symptomless for many years and half of the men with STD symptoms seek inappropriate treatment or no treatment at all. The surveys also revealed widespread negative attitudes toward people living with HIV/AIDS, low rates of condom use among unemployed men and sex workers who use illegal drugs, and an increasing number of women and girls in inner-city neighborhoods turning to sex work or seeking additional partners in response to a decline in the Jamaican economy.

Perhaps the most important challenge for the program will be to support continuing changes in the social norms that influence individuals' sexual behavior. "We need to sustain the message, to help sustain the behavior," McKnight said, "but also to create an environment in which safe behavior is acceptable."

-- Kathleen Henry