Mid-term evaluation : HIV/AIDS/STI prevention and care project -- USAID/Dominican Republic

Midterm evaluation covers the period 1998-5/01. AccionSIDA and other USAID-supported projects have helped increase access to HIV/AIDS/STI prevention services, with some improvement of HIV/AIDS-related surveillance and reporting systems. A pilot project to promote STI pre-packaged therapy has also shown some success. Additional successes include the creation of an NGO/AIDS coalition and of the Dominican Republic Network of Persons Living with HIV/AIDS (REDOVIH+). NGO intervention projects targeted to at-risk populations have reduced high-risk sexual behavior; some of these projects have been identified as "best practices" and are replicable elsewhere in the country. Other successful interventions include projects that feature extensive involvement of beneficiary populations, such as men who have sex with men (MSM), youth, and commercial sex workers (CSWs). Recent national AIDS prevention and control strategies have demonstrably reduced the number of sexual partners and increased condom use in the general population. The Dominican Government has been less successful in increasing access to primary health care and incorporating HIV/AIDS/STI care into the public health system. Despite the Mission's proactive support for the National AIDS Commission/National Coordination for the Control of Sexually Transmitted Infections and AIDS (CONASIDA/DIGECITSS), situational constraints caused by changes in government and a corresponding redefinition of roles and responsibilities have delayed implementation of public health reform. In addition, some of the country's most vulnerable populations are in need of greater prevention and care services, e.g., MSM sub-populations (young MSM, male CSWs, transvestites), migrant workers, and prisoners. Although the stigma of HIV/AIDS has somewhat diminished, a high level of discrimination remains, and many health professionals at major public hospitals and clinics continue to resist caring for AIDS patients. In addition, physicians continue to request HIV tests from candidates for surgery without the latter's knowledge and to refuse assistance if the result is positive. Businesses use HIV tests in hiring and firing decisions without obtaining the employee's consent or offering pre- or post-test counseling. TV and radio spots often focus on condom use, but information, education, and communication (IEC)/mass media prevention messages also stress partner reduction/fidelity, abstinence/postponement of sexual debut, and dissemination of information on STI treatment/prevention. This strategy of combined messages has made an impact on HIV infection, but discrimination, stigma, and associated ignorance and misinformation about HIV/AIDS have not been adequately addressed. Mass media campaigns have not targeted MSM (young MSM in particular), migrant workers, and prisoners. Condom availability in Dominican Republic is limited by the purchasing capability of the population, thus severely restricting access among groups who are most vulnerable to HIV infection (i.e., youth and poor women). Persons living with HIV/AIDS also have limited access to condoms, thereby increasing their chance of transmitting HIV to uninfected partners. STI diagnosis and treatment services are generally available in the major cities targeted by AccionSIDA. Nevertheless, STI services are more commonly found in clinical units segregated from other health care units, reflecting high levels of stigma associated with STI treatment. Relatedly, it is expected that CSWs seek STI services at different hours than the population at large. Capacity building through short-term TA and study tours has improved DIGECITTS staff skills in STI management and program implementation. Specific capacity-building activities have included development of a national strategic plan for AIDS prevention and care, development of 12 provincial strategic plans, and NGO management workshops. AccionSIDA has revised its evaluation plan and related prevention and process indicators, and results evaluation studies are planned for 2002. However, no project situational analysis has been carried out. More specifically, no information is available about target populations or the social and cultural context related to STI and HIV transmission.