AIDS technical support program (ATSP) technical review (project no. 936-5972)

The evaluation covers Phases I (1987-1991) and II (1992-6/96, vs. a PACD of 8/97) and summarizes experience and lessons learned for use in designing Phase III. Phase II has supported HIV prevention and control through three major types of interventions -- efforts to reduce sexually transmitted infections/diseases (STIs/STDs), condom social marketing, and behavior change communication -- and several supporting interventions: behavior research, policy reform, monitoring and evaluation, capacity building, and women's status/empowerment. Field experience with STI/STD reduction demonstrates the following: syndromic management (a simplified approach to the clinical management of curable STIs, which recommends treatments based on symptoms rather than clinical or etiologic diagnoses) is an effective approach in resource-poor settings; sufficient supplies of drugs are critical; the targeted intervention research (TIR) approach is an effective tool for improving service quality and creating additional demand for STI services; provision of STI services along with condoms to high-risk populations is cost-effective; and integration of STI/HIV prevention and control with family planning and maternal/child health programs is feasible. There is a critical need to identify simple, inexpensive surveillance systems for STI/HIV, develop improved female-controlled barrier methods (e.g., microbicides), and develop rapid, simple, low-cost diagnostics. Condom social marketing (CSM) has been very successful in preventing HIV/AIDS. The special needs of those who continue to practice high-risk behaviors must continue to be addressed, however, as well as societal norms and values that make CSM more effective. There is a great need to include female-controlled barrier methods in CSM programs as they become available. Experience with communications to promote behavioral change teaches that mass media can quickly raise awareness and change attitudes and behavior. Mass media are most effective when coupled with interpersonal communication and community participation/ownership (e.g., peer-to-peer support). Many findings from U.S. behavior research could likely be applied in international settings (e.g., findings concerning the effects of social structures and community values on individual vulnerability and behavior). Addressing policy is essential: policy reform can create a favorable environment for behavior change, e.g., Thailand's 100% condom' brothels. A supportive policy environment is essential to the success of many programmatic interventions, such as allowing youth access to sex education and condoms, allowing nonmedical personnel to provide STD drugs, using syndromic management, or eliminating fees and regulatory obstacles to wider distribution of STD drugs and condoms. For Phase III, USAID should consider the following strategies: (1) policy reform at the donor and country levels, focusing on development of international standards; (2) TA in designing and implementing improved programs, accompanied by manuals, guidelines, and case studies demonstrating proven interventions; and (3) research on immediate programmatic needs (short-term) and on awareness of promising new developments. Efforts should continue to focus on men and women who practice high-risk behaviors, but should be expanded to other groups who are increasingly vulnerable to the virus (women and youth aged 15-29). Condom social marketing and STD reduction strategies should be scaled up during Phase III, as should communication programs that have been proven to change behaviors; more behavior research is needed, however. Finally, as the HIV/AIDS epidemic continues, the most effective response shifts toward activities that integrate prevention with nonclinical care. In several countries where sero-prevalence is high, the project is already supporting small, community-based social-psychological care and support for HIV positive groups and those living with AIDS. USAID should also consider supporting community-based social mobilization programs.