Evaluation of the USAID AIDS help project

The evaluation focuses on project assistance to the Government of Peru's (GOP) Program for Control of Sexually Transmitted Diseases (PROCETSS). In the last 3 years, PROCETSS has developed a sexually transmitted disease (STD)/HIV prevention program that represents a model for the Andean region. Peru was one of the first Latin American countries to adopt syndromic management of STDs and begin zidovudine prophylaxis to prevent perinatal HIV transmission. The program strategy is guided by epidemiological data; interventions are evidence-based and scaled up to cover most medium-sized cities by the end of the year 2000. The program uses peer educators (PEPs) who work with men who have sex with men (MSM) and female sex workers (FSWs), and, in Lima, Callao, and Iquitos, with youth, to promote condom use and the prompt use of strengthened STD/HIV prevention services. The behavior change communication (BCC) materials produced are of high quality and are widely used. Behavior change interventions have focused on promoting condom use and encouraging use of STD services among highly sexually active persons. These interventions have been technically sound, have included the use of printed media and videotapes, and have demonstrated an impressive capacity to deliver face-to-face education/motivation and condoms by both peers and trained counselors. Evidence to date suggests that this approach has improved condom use behavior and lowered STD rates in high-risk groups, though further analysis is needed. PROCETSS' efforts to stimulate a favorable policy environment seem to have helped increase budgetary support by the Ministry of Health (MOH), but not to have reached other key political and business leaders. The most effective NGOs working with HIV/AIDS prevention are either based in Lima or focus their activities there, although the importance of building community-based programs in other cities of the country is recognized. PROCETSS has funded several NGO operational research activities, using them mainly to develop BCC materials for high-risk groups. NGO staff collaborated with PROCETSS to train peer educators and STD counselors and were to some extent included in PROCETSS' training activities. The HIV/STD service delivery system appropriately focuses on primary prevention of transmission and on secondary prevention of opportunistic infections among those infected with HIV. Funds from the social security and military systems provide antiretroviral treatment for a limited number of persons (300) with AIDS. The potential cost of antiretroviral drugs for treating 1,000 individuals with AIDS in Peru probably ranges from $7 to 10 million per year for drugs alone, depending on the type of therapy used. The current system of syndromic management of STDs can cut costs considerably by eliminating treatment for cervical infection from the vaginal discharge algorithm. Financial and institutional sustainability is evidenced by steady increases in GOP funding, which has leveraged considerable regional and local support. Centro de Referencia de Enfermedades Transmision/Unidad de Atencion Medicas Periodica (UAMPS) services are provided free to FSWs and MSM who voluntarily seek care. The Peru program emphasizes civil liberties but not cost recovery. The World Bank has stressed the negative externalities of STD and HIV infection that result from the failure of market forces to ensure delivery of services to those who should receive them. The public good resulting from rendering an infected person less infectious warrants and dictates the use of public funds for STD treatment throughout the world. The current channeling of USAID support for HIV/AIDS/STD activities via the VIGIA project (Addressing Threats of Emerging and Re-Emerging Infectious Diseases) shifts the locus of control dynamics for USAID support for HIV/AIDS/STD. VIGIA interacts closely with Oficina General de Epidemiologia (OGE) and the National Institute of Health, as well as with PROCETSS. There is a need to develop an overall consensus between USAID, VIGIA, and PROCETSS on mutual goals and objectives. Also needed are criteria and processes for prioritizing activities and mechanisms to encourage and coordinate other USAID program activities (e.g., in policy, human rights, youth, women's health, and reproductive health) involving HIV/AIDS/STD prevention and care.