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The HIV/AIDS Prevention and Control SYNOPSIS Series

Latin America and Carrebean Regional Office
AIDSCAP/Family Health International

Family Health International (FHI) is a non-governmental organization that works to improve reproductive health around the world, with an emphasis on developing nations. Since 1991, FHI has implemented the AIDS Control and Prevention (AIDSCAP) Project, which is funded by the United States Agency for International Development (USAID). FHI/AIDSCAP has conducted HIV/AIDS prevention programs in more than 40 countries, and the Latin America and Caribbean Regional Office (LACRO) has implemented interventions in 14 countries within the region.

November 1997

For further information, contact:

Latin America and Caribbean Regional Office
AIDSCAP/Family Health International
2101 Wilson Blvd, Suite 700
Arlington, VA 22201
Telephone: (703) 516-9779
Fax: (703) 516-0839

Series Editor:

M. Ricardo CalderBLOCKQUOTE>

AIDSCAP/Family Health International Arlington, VA, USA

Prepared by:

Irving Hoffman

University of North Carolina Chapel Hill, NC

Bea Vuylsteke

Institute of Tropical Medicine Antwerpen, Belgium

Project Coordinator:

Mary L. Markowicz

AIDSCAP/Family Health International Arlington, VA, USA

Published by the Latin America and Caribbean Regional Office of
The AIDS Control and Prevention (AIDSCAP) Project
Family Health International

The opinions expressed herein are those of the writer(s) and do not necessarily reflect the views of USAID or Family Health International. Excerpts from this booklet may be freely reproduced, acknowledging FHI/AIDSCAP as the source.

ACRONYMS

AIDS	acquired immune deficiency syndrome
AIDSCAP	AIDS Control and Prevention Project
CBO	community-based organization
CSW	commercial sex worker
FHI	Family Health International
GUD	genital ulcer disease
HCP	health care provider
HIV	human immunodeficiency virus
IGND	intracellular gram-negative diplococci
LAC	Latin America and the Caribbean
LACRO	Latin America and Caribbean Regional Office
MOH	Ministry of Health
NACP	National AIDS Control Program
NGO	non-governmental organization
NGU	non-gonococcal urethritis
PID	pelvic inflammatory disease
PVO	private voluntary organization
RPR	rapid plasma reagin
STD	sexually transmitted disease
USAID	United States Agency for International Development
WHO	World Health Organization

ACKNOWLEDGEMENTS

We would like to acknowledge and recognize the contributions, work and efforts of the Implementing Agencies — NGOs, PVOs, CBOs, NACPs/MOH, Social Security Institutes, and private sector enterprises — with whom LACRO has worked and for all that we have learned and accomplished together in HIV/AIDS prevention and control.

We are especially grateful to Irving Hoffman, Research Instructor in the Division of Infectious Diseases at the University of North Carolina at Chapel Hill, and Bea Vuylsteke, Research Fellow at the Institute of Tropical Medicine in Belgium, for preparing this booklet. In addition, we thank Gina Dallabetta, Director of Technical Support at AIDSCAP/Family Health International, for reviewing the document.

We take this opportunity to also thank all the staff members of AIDSCAP/LACRO, including former staff members, for their overall support and assistance to LACRO activities: Joseph Amon, Lee Arnette, Mimi Binns, Oly Bracho, Marianne Burkhart, Rebecca Coleman, Mark Chorna, Genie Liska, Cathy Mamedes, Mary L. Markowicz, Robert Martz, Mary Kay McGeown, Steve Mobley, Manuel Mongalo, Polly Mott, Sara Padilla, MarvelParsons, Amparo PinzLuis Rodrez, Melissa Rosenberger, Diana Santos, Isabel Stout, Molly Strachan, and Oscar Vigann addition, we express our appreciation to the AIDSCAP LAC Resident Advisors: Catherine Brokenshire, Jamaica; Martha Butler de Lister, Dominican Republic; Eddy GcHaiti; Gale Hall, Jamaica; Jorge Higuero Crespo, Honduras; and Maria Euga Lemos Fernandes, Brazil; and other AIDSCAP staff for their insights and contributions. We are grateful to Peter Lamptey, FHI Senior Vice President of AIDS Programs and Project Director of AIDSCAP, and Tony Schwarzwalder, Deputy Project Director of AIDSCAP, for their continued support of LACRO activities.

Finally, we wish to extend our gratitude and appreciation to the USAID Global Bureau's HIV/AIDS Division, field Missions in Latin America and the Caribbean, and to the Population, Health and Nutrition Team in the Office of Regional Sustainable Development of the LAC Bureau, particularly James B. Sitrick, Jr., for the support and funding of the Information Dissemination Initiative and other LACRO programs.

PROLOGUE

The HIV/AIDS Prevention and Control SYNOPSIS Series is a summary of the lessons learned by the Latin America and Caribbean Regional Office (LACRO) of the AIDS Control and Prevention (AIDSCAP) Project. AIDSCAP is implemented by Family Health International (PHI) and funded by the United States Agency for International Development (USAID). The series is a program activity of the LACRO Information Dissemination Initiative and was created with several goals in mind:

- to highlight the lessons learned regarding program design, implementation, management and evaluation based on five years of HIV/AIDS prevention and control experience in LAC countries

- to serve as a brief theoretical and practical reference regarding prevention interventions for HIV/AIDS and other sexually transmitted infections (STIs) for program managers, government officials and community leaders, non-governmental organizations (NGOs), private voluntary organizations (PVOs), policy and decision makers, opinion leaders, and members of the donor community

- to provide expert information and guidance regarding current technical strategies and best practices, including a discussion of other critical issues surrounding HIV/AIDS/STI programming

- to share lessons learned within the region for adaptation or replication in other countries or regions to advance new technical strategies that must be taken into consideration in order to design and implement more effective prevention and control interventions

- to advocate a holistic and multidimensional approach to HIV/AIDS prevention and control as the only way to effectively stem the tide and impact of the pandemic

AIDSCAP (1991-1997) was originally designed to apply the lessons learned from previous successful small-scale prevention projects (1987-1991) to develop comprehensive programs to reduce the sexual transmission of the virus, the primary mode of transmission. AIDSCAP applied three primary strategies — Behavior Change Communication (BCC), STD Prevention and Control, and Condom Programming — along with supporting strategies of Behavioral Research, Policy Development and Evaluation.

The success of this approach, based on the combination of strategies and targeted interventions, has been widely documented. The AIDSCAP Project, in fact, has been recognized as among the best and most powerful international HIV/AIDS prevention programs to date.¹ AIDSCAP has worked with over 500 NGOs, government agencies, community groups and universities in more than 40 countries; trained more than 180,000 people; produced and disseminated some 5.8 million printed materials, videos, dramas, television and radio programs, and advertisements; reached almost 19 million people; and distributed more than 254 million condoms.²

However, the pandemic continues to escalate at a rate that outpaces our successes. Thus, we need to build upon these successes, learn from our experiences, and determine what has worked and what is missing in order to respond with added effect in the future. The magnitude and severity of the HIV/AIDS pandemic calls for boldness, flexibility, wisdom and openness. The world cannot afford to continue to fight HIV/AIDS only with current thinking and tools. We must look toward new thinking and strategies that complement and carry the current state-of-the-art approaches forward in the fight against HIV infection.

Therefore, LACRO endorses, promotes and elevates Gender Sensitive Initiatives (GSIs), Civil-Military Collaboration (CMC), Religious-Based Initiatives (RBIs), and Care & Management (C&M) as the new prototype of technical strategies that must be incorporated on par with the strategies that have been implemented to date. Walls, barriers and biases have to come down in order to unlock the strengths, benefits, potential, synergy and/or resources of GSIs, CMC, RBIs and C&M.

More importantly, approaches that compartmentalize strategies can no longer be justified. Despite the efforts to integrate and coordinate amongst and between technical strategies and different sectors of society, prevention programming is barely scratching the surface of what a real comprehensive effort should be. One of the most important lessons learned about HIV/AIDS is that it is not only a medical problem, nor is it exclusively a public health problem. Rather, the pandemic is in addition a socioeconomic problem and, as such, threatens the sustainable development of developing countries and challenges the ethical foundations of the developed world. HIV/AIDS has become a challenge to health, development and humanity.

For lasting success, a genuine multidimensional approach is urgently needed. One that demands new forms of wealth distribution, educational opportunities and development; attempts to resolve the inequalities in gender and power; acknowledges the individual, environmental, structural and superstructural causes of and solutions for the pandemic; and aims to balance the disparity between the "haves" and the "have-nots," resulting in more sustainable, equitable, effective and compassionate efforts.

Therefore, the SYNOPSIS Series reaffirms that current HIV/AIDS prevention and control strategies work, and contends that new technical strategies are needed and can be effective and complementary. The Series also strongly advocates for, and will discuss in a separate issue, the Multidimensional Model (MM) for the prevention and control of the pandemic. This model must guide national, regional and international planning and programming in order to achieve measurable and significant gains that can truly effect changes at the individual, societal, environmental and structural levels.

We trust the reader will be open to our futuristic thinking and will contribute to the further development of the strategies presented here as well as others. We hope the SYNOPSIS Series will stimulate discussion and reflection, propel continued dialogue, and encourage the pioneering of new combinations of innovative approaches.

M. Ricardo CalderMD, MPH, FPMER.
Regional Director
Latin America and Caribbean Regional Office
AIDSCAP/Family Health International