ASSESSMENT OF THE NATIONAL HIV/AIDS PROGRAM OF THE DOMINICAN REPUBLIC Prepared by Magdalena Rathe Alejandro Moliné Laura Rathe
FINAL REPORT October 2004
Prepared for the Caribbean Health Research Council (CHRC), under the Project “Strengthening the Institutional Response to HIV/AIDS/STIs in the Caribbean” funded by the European Union and managed by CARICOM, in collaboration with CAREC, CHRC, CRN+, UNAIDS and UWI
Assessment of the HIV-AIDS Program of the DR _____________________________________________________________________________________________________
TABLE OF CONTENTS ACKNOWLEDGEMENTS EXECUTIVE SUMMARY I. INTRODUCTION 1.1 Background 1.2 Purpose of the Assessment 1.3 Scope and Limitations 1.4 Methodology II. ASSESSMENT OF THE NATIONAL HIV/AIDS PROGRAM 2.1 General Information on the Dominican Republic 2.2 The health sector 2.3 The HIV/AIDS Situation in the DR 2.4 Legal Framework for the response to HIV/AIDS in the DR 2.5 Institutional Framework 2.5.1 The Presidential AIDS Council (COPRESIDA) • Structure and Functioning • Inter‐institutional Agreements 2.5.2 Ministry of Public Health and Social Assistance (SESPAS) • General Office for the Control of Sexually Transmitted Diseases and AIDS (DIGECITSS). 2.5.3 International cooperation 2.5.4 The role of the NGOs • The network of people living with HIV/AIDS 2.5.5 The role of the private sector 2.6 National Strategic Plan 2.7 National policies on HIV/AIDS 2.8 Prevention 2.8.1 Information, Education and Communication (IEC) 2.8.2 Condom distribution program 2.8.3 Prevention and control of STIs 2.8.4 Prevention and control of mother to child transmission 2.8.5 Laboratory and blood bank control 2.9 Care and Treatment 2.9.1 National program for integral care 2.9.2 Voluntary Counseling and Testing 2.9.3 Laboratory tests __________________________________________________________________________________________________ Caribbean Health Research Council
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2.9.4 Antiretroviral therapy (ARVT) 2.9.5 Opportunistic Infections 2.9.6 Home care and orphan support Financing the response to HIV/AIDS Stigma and discrimination Monitoring and Evaluation Epidemiological Surveillance Research The Core Caribbean Indicators
2.10 2.11 2.12 2.13 2.14 2.15
III. SUCCESSES AND CHALLENGES OF THE NATIONAL HIV/AIDS PROGRAM IV. CONCLUSIONS AND RECOMMENDATIONS BIBLIOGRAPHY ANNEXES Annex I: List of persons interviewed Annex II: Basic Care Units and day centers Annex III: Main projects with international financing Annex IV: NGOs working in HIV/AIDS Annex V: Matrix of core Caribbean indicators
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ACKNOWLEDGEMENTS The Plenitude Foundation wishes to express its gratitude to the Caribbean Health Research Council (CHRC) for entrusting us the task of conducting an Assessment of the National HIV/AIDS Program in the Dominican Republic. The summary presented herein, was possible thanks to the generous support and the information provided by each of the persons interviewed. Particularly valuable were the contributions of key staff members of the Presidential AIDS Council (COPRESIDA), the institution responsible for outlining the policies on HIV/AIDS in the Dominican Republic. Our special thanks to Mr. Antonio de Moya, for his orientation to conduct this work, facilitating part of the bibliography, and for his kindness in revising meticulously several draft versions of our paper. Also to Dr. Fátima Guerrero and Dr. Mayra Toribio, components’ coordinators of the Prevention and Control of HIV‐AIDS project in the Dominican Republic, who offered their time and actively collaborated during all the phases of the work. Finally, to Dr. Alberto Fiallo Billini, COPRESIDA’s Executive Director, for his appropriate comments on the draft version and his support in the final phase of the evaluation. We would also like to thank key members of the General Office for Sexually Transmitted Diseases and AIDS (DIGECITSS) and the CONECTA project, funded by the United States Agency for International Development (USAID), for their enthusiastic collaboration. Our thanks also to some persons who kindly read the paper and sent written comments, particularly to Ansari Ameen, our coordinator from CHRC, to María Castillo, from USAID‐DR, to Patricio Murgueytio, from Abt Associates‐Redsalud and to Tirsis Quezada, from Idesarrollo. Finally, we wish to thank all the persons interviewed, whose names are listed in Annex I, for offering us their valuable time and their insights on the national response to the epidemic.
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EXECUTIVE SUMMARY The Caribbean Health Research Council (CHRC), based in Trinidad & Tobago, is one of the regional institutions participating in a project financed by the European Union entitled, Strengthening the Institutional Response to HIV/AIDS/STI in the Caribbean (SIRHASC). The purpose of this project is to support the capability of regional institutions to coordinate, plan, implement and monitor the regional response to the HIV/AIDS epidemic in the Caribbean. The global objective of the project is to reduce the spread of the disease and its impact on the countries of the subregion, especially those mostly affected, by strengthening the regional capacity to plan and coordinate an effective response, to HIV/AIDS as well as other sexually transmitted infections. One of CHRC’s main commitments is to conduct assessments of the national HIV/AIDS programs in eight Caribbean countries that are already engaged in a multisectorial approach, even though they may be in different stages of implementation. These assessments intend to establish a baseline to measure the countries´ progress in their fight against the epidemic. In addition, they mean to facilitate the collection of standardized data in the eight countries, thereby contributing to measure the progress in the region as a whole. In this respect, CHRC has contracted the services of the Plenitude Foundation, a research center based in the Dominican Republic, to conduct a quick assessment of the country’s National HIV/AIDS Program. Thus, CHRC does not attempt to gravitate excessively on the staff of the national HIV/AIDS program in the country. The quick assessment of the HIV/AIDS program in the Dominican Republic has the following objectives: • Document the Dominican Republic’s response to the HIV/AIDS epidemic. • Describe the interventions that have been implemented, both ongoing and planned, in the areas of prevention, control and treatment. • Present the real status of the collection process for standard quantitative indicators of the national program’s results, which can in turn serve as a basis for future assessments. • Identify success stories, lessons learned and barriers of the National HIV/AIDS Program in the Dominican Republic. The methodology used to conduct this assessment consisted of collecting and synthesizing data from the following sources: __________________________________________________________________________________________________ Caribbean Health Research Council
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Existing literature on the National HIV/AIDS Program. Available data on quantitative indicators adopted by the Caribbean countries in different programmatic areas. Semi‐structured interviews with selected key informants.
• In view of the fact that this is a quick assessment, conducted in a very brief time limit, it was not intended to delve deeply into the actual effectiveness of the programs or any specific interventions. It does, however highlight the most outstanding issues that may lead to more in‐depth evaluations. Any assessment of the national response to HIV/AIDS in the Dominican Republic would verify that, although many gaps and barriers need yet to be overcome, important successes have been achieved and the general outlook is hopeful. The following are some of the most significant achievements: • Political will and the incorporation of many social actors in the expanded national response to HIV/AIDS. • General planning to face the epidemic. • Launching of the program for antiretroviral treatment. • Probable reduction of the national HIV/AIDS prevalence. • The formation of an organization of PLHAs. • Awareness among high‐risk groups of their vulnerability and the need to change their sexual behaviors to prevent the spread of HIV. • Sensitization regarding PLHAs. • High level of information on HIV/AIDS among the population. • Development of an epistemological community with human resources and managerial assets specialized in HIV/AIDS. As indicated in the preceding paragraphs, the successes achieved in the response to HIV/AIDS are considerable. This, however, has not been an easy process. There are still many obstacles in the way, and a lot of conscientious efforts need to be made to overcome them. Some of these are the following: • Lack of integration of the National Program of HIV‐AIDS to the process of health sector reform. • Low level of coordination in the sector. • Overlapping of institutional functions, duplication of activities and leadership discrepancies. • Insufficient resources allocated in the National Budget. • Institutional weaknesses. • Lack of monitoring and evaluation systems. • Deficiencies in the legal system and lack of initiative on the part of PLHAs to demand their rights and the enforcement of the AIDS Law.
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Poor access to organized information. Very limited community participation in the search and implementation of solutions.
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The balance of achievements and challenges described in the previous section, leads to the conclusion that the DR has made considerable advancements with respect to similar assessments made on previous periods. At the institutional level, the creation of COPRESIDA and DIGECITTS, although both still require greater budgetary support and institutional strengthening. These institutions have contributed to the mobilization of significant external resources that have made possible the startup of the National Integral Care Program. Important efforts have been made in the area of prevention, which possibly account for a decrease in the prevalence rates and the increased awareness of the problem in all levels of society. Important advancements have also been made in terms of strategic planning as well as research, although there is still some deficiency in monitoring and evaluation. The next paragraphs provide some recommendations to consolidate the National Response to HIV/AIDS in the Dominican Republic, and to overcome the barriers confronted. These recommendations are based in most part on the consultations made to key informants from the National HIV/AIDS Program. • Integrate the National Program of HIV‐AIDS to the process of reform of the health sector. The long term sustainability of the National Program of HIV‐AIDS depends on its integration to the process of reform of the health sector and, particularly, of the social security system. Although it is certain that the National Program has a multisectorial character, that extends the health sector, it is not less certain that the bulk of the resources that the country will assign to it in the next years, will correspond to the program of care to patients. The inevitable transformations in the health sector as a consequence of the reform will have an important impact in the technical and financial viability of the HIV‐AIDS program, reason why it is not advisable that it stays like an isolated effort. • Reinforce COPRESIDA´s core functions. In coordination with other state institutions, COPRESIDA should have clearly defined roles, demand an increase in its budgetary resources, and build the organizational structure that is contained in its constitutional decree. This will encompass an important process of institutional strengthening, particularly with respect to its capacity to manage the bulk of international resources that have been committed. • Improve the coordination of projects, programs and donors. The State should assume with stronger authority its coordination and general leadership roles in the national response to HIV/AIDS. To this effect, it is essential that donor meetings are continued to be held, under the leadership of COPRESIDA. In fact, all projects with international funding should follow the guidelines that will be designed in the National Strategic Plan and COPRESIDA. • The formulation of the NSP 2004‐2008 should be concluded. The NSP 2004‐2008 will be a valuable tool that will incorporate the experiences and lessons learned in previous planning exercises; therefore, completion of the ongoing process is very important for future actions. __________________________________________________________________________________________________ Caribbean Health Research Council
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Set forth a monitoring and evaluation system for the national response to HIV/AIDS. In order to verify the appropriateness between planning and implementation, and to ascertain the level of the national response, the authorities must create a unit for M&E that includes external assessments of the national response to HIV/AIDS. The unit would be in charge of the selection and design of indicators and report the data to the CRIS, UNGASS and UNAIDS. In addition, it is indispensable to include the M&E component in all projects, programs and units in the sector. Likewise, M&E systems should be user friendly to facilitate its use. Establish the production of National HIV/AIDS Accounts as a permanent activity. A systematic and permanent production of national HIV/AIDS accounts is required in order to monitor the spending and the financial resources available in the sector as well as the shifts in resource allocation, and to ensure the funds are used to meet the local needs. Improve epidemiological surveillance. A revision of the HIV/AIDS epidemiological system would be convenient to improve the entire structure, from data collection to processing, as well as the presentation, dissemination and use of the information. Guarantee the access to integral care including ARV treatment and the efficiency of the national program. The Integral Care Program with the provision of antiretrovirals is a great achievement and a hopeful event for PLHAs. In terms of the TARV, a guarantee of continued and regular access is imperative. It is also essential to provide adequate information and to stress the importance of treatment adherence. Financial resources should be identified ahead to ensure program sustainability, as the cost of ARVs is high and the treatment is long and should not be interrupted once initiated. The Basic Care Units should be incorporated into the health system, and efforts made to avoid overlapping with other structures. Set the basis to guarantee the sustainability of the national response to HIV/AIDS. Until now, the fight against HIV/AIDS has relied considerably on the international cooperation. To avoid a traumatic separation in the future, the country should begin to seek alternative operational modalities and resources to guarantee the sustainability of the activities once the international sources are depleted. Improve the management capacity of the STI program, the program for MTCT, laboratory and blood bank control, etc. Basic management of the various specialized programs must be improved in order to enhance an effective response to HIV/AIDS. Situation analysis of each program should be conducted, and proposals for improvement should be designed and implemented. Promote changes in the sexual behavior among vulnerable populations. The main deterrent barriers against HIV infection are healthy sexual practices. Dominicans are provided with a lot of information on HIV/AIDS, but the real challenge is to shift over this information and education to actual behavior changes. Guarantee continuous access to condoms for the poorest population groups. Together with increased campaigns to promote condom use, effective distribution channels should be identified to ensure that free condoms are regularly provided to the population groups that are unable to purchase them. Efforts to promote regular condom use should be continued.
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Guarantee respect for the human rights and social integration of PLHAs. Stronger efforts must be made to reduce stigma and discrimination against people living with HIV/AIDS. Means should be sought to guarantee their right to work and the access to integral health care. Special emphasis should be made on the empowerment of PLHAs and their participation in the country’s social life. Ensure the approval in Congress of the modified AIDS Law. After a revision process of the Law 55‐93, which was carried out with the active participation of the main actors in the issue of HIV/AIDS, a draft bill is being submitted to the national congress. This process should successfully culminate in the approval of the reformed law, which includes amendments for its pertinent application. Increase community participation in decision‐making processes. Until now, communities have played a passive role in the response to HIV/AIDS. To improve the efficiency of the actions, community participation must be increased, both in decision‐making and implementation processes. Create an HIV/AIDS Documentation Center. The national authorities should create a documentation center specialized in HIV/AIDS related issues, to facilitate research and to document the historic memory of the process.
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ASSESSMENT OF THE NATIONAL HIV/AIDS PROGRAM OF THE DOMINICAN REPUBLIC I.
INTRODUCTION
1.1
Background
The Caribbean is one of the regions most affected by the HIV/AIDS epidemic worldwide, ranking second after the Sub‐Saharan Africa. It is estimated that approximately 430,000 people are currently infected in the region and that 80% of these live on the island of Santo Domingo, occupied by the Dominican Republic and Haiti (ONUSIDA, 2004). All the Caribbean countries have recognized the need to become actively involved in the development of effective national programs to address the fight against the disease. The Caribbean Health Research Council (CHRC), based in Trinidad & Tobago, is one of the regional institutions participating in a project financed by the European Union entitled, Strengthening the Institutional Response to HIV/AIDS/STI in the Caribbean (SIRHASC). The purpose of this project is to support the capability of regional institutions to coordinate, plan, implement and monitor the regional response to the HIV/AIDS epidemic in the Caribbean. The global objective of the project is to reduce the spread of the disease and its impact on the countries of the subregion, especially those mostly affected, by strengthening the regional capacity to plan and coordinate an effective response, to HIV/AIDS as well as other sexually transmitted infections. The majority of the Caribbean countries are building their national HIV/AIDS programs based on the success stories and lessons learned by the African countries, adopting a multisectorial approach in the fight against the epidemic. Although numerous components of these programs have been particularly evaluated, a specific assessment of the global effort of these programs is not available. One of CHRC’s main commitments is to conduct assessments of the national HIV/AIDS programs in eight Caribbean countries that are already engaged in a multisectorial approach, even though they may be in different stages of implementation. These assessments intend to establish a baseline to measure the countries´ progress in their fight against the epidemic. In addition, they mean to facilitate the collection of standardized data in the eight countries, thereby contributing to measure the progress in the region as a whole. In this respect, CHRC has contracted the services of the Plenitude Foundation, a research center based in the Dominican Republic, to conduct a quick assessment of the country’s National HIV/AIDS Program. Thus, CHRC does not attempt to gravitate excessively on the staff of the national HIV/AIDS program in the country. __________________________________________________________________________________________________ Caribbean Health Research Council
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1.2
Work Objectives
During this phase of its work, CHRC wishes to rely on a preliminary assessment of the HIV/AIDS situation in each of the countries consulted and an overview of the interventions that are in place to address it. The quick assessment of the HIV/AIDS program in the Dominican Republic has the following objectives: • Document the Dominican Republic’s response to the HIV/AIDS epidemic. • Describe the interventions that have been implemented, both ongoing and planned, in the areas of prevention, control and treatment. • Present the real status of the collection process for standard quantitative indicators of the national program’s results, which can in turn serve as a basis for future assessments. • Identify success stories, lessons learned and barriers of the National HIV/AIDS Program in the Dominican Republic.
1.3
Methodology
The methodology used to conduct this assessment consisted of collecting and synthesizing data from the following sources: • Existing literature on the National HIV/AIDS Program. • Available data on qualitative indicators adopted by the Caribbean countries in different programmatic areas. • Semi‐structured interviews with selected key informants. The first step consisted of a bibliographic analysis of the different components of the National HIV/AIDS Program, provided in principle by key personnel of the Presidential AIDS Council (COPRESIDA), the entity responsible in the Dominican Republic for outlining policies, addressing inter‐sectoral coordination and negotiating external funding. Important documents were obtained, such as the legal basis of the Program, various projects with external funding, action plans of various institutions, the National Strategic Plan on STI/HIV/AIDS 2000‐2003, progress reports for ongoing activities, international agreements of which the country is signatory, among others. The complete bibliography is shown in the Annex. After a thorough revision of all the documentation, key informants were selected to be interviewed. In developing the guide for the semi‐structured interviews, the main concern was obtaining a response to the following questions: • To what extent has the country been affected by HIV/AIDS? • What has been the national response in the following areas? __________________________________________________________________________________________________ Caribbean Health Research Council
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Strategic Planning Financial commitment Assistance of external institutions Treatment Prevention Capacity building Legislation What are the main achievements of the national program? What are the main barriers/challenges? What are the plans to address these challenges?
• • • A list of the people interviewed is shown in the Annex. In some cases, the interviews were made with individuals, others were made in groups and in most cases, the relevant institutions were visited. Numerous interviews sought information on the actual or non‐existent collection of quantitative data of the indicators for monitoring and evaluation. CHRC, in collaboration with representatives of national programs in various Caribbean countries, identified a set of key indicators for each of the main programmatic areas in order to monitor the joint progress made to fight the epidemic in the region. As a result, a guide entitled Caribbean Indicators and Measurement Tools (CIMT) was developed to evaluate the National HIV/AIDS Programs. The guide identifies and defines the key programmatic areas (policies, prevention, care, support and treatment, human rights and socio‐economic impact). This task consisted in filling out a matrix that identifies which key indicators in the Caribbean are currently available for each program, the period covered by the information and the estimated time for the data collection, in case it was unavailable. The information obtained is described in a special section of this report.
1.4
Scope and limitations of the assessment
The scope of this report is to identify the successes and challenges of the National HIV/AIDS Program in the Dominican Republic, based in principle on the bibliographic analysis and the opinion of experts in the area. In view of the fact that this is a quick assessment, conducted in a very brief time limit, it was not intended to delve deeply into the actual effectiveness of the programs or any specific interventions. It does, however highlight the most outstanding issues that may lead to more in‐depth assessments
II.
ASSESSMENT OF THE NATIONAL HIV/AIDS PROGRAM 2.1
General Information on the Dominican Republic
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The Dominican Republic is located in the Caribbean, occupying two thirds of the island of Hispaniola, which it shares with Haiti. The Dominican Republic owns 48,442 Km2 of the total island extension of 77,914 Km2. It was colonized by the Spanish on December 5 1492, and in a few years exterminated its native people, the Taino Araucanian aborigines. Subsequently, the Spanish brought African slaves to the island to work the land, a decisive influence on the mixed ethnicity that is seen today among its people. In 1822 the Dominican Republic was occupied by the Haitians, who had become independent from France at the turn of the century. The country regained its independence in 1844. Until recently, the national economy relied on traditional agricultural products such as sugar cane, coffee and cocoa. Since the early 1980s, a change in the traditional model began to take place, and lately the economy has seen a transformation towards the service area. Tourism, the free zones and cash remittances from Dominicans living abroad, estimated to be approximately one million, are the main sources of income. During the last decade, the nation achieved high growth rates, for several years the highest in the Latin American and Caribbean region, with low levels of inflation. This contributed to an enhanced standard of living for the population and a reduction of poverty. However, during the first years of the present decade this tendency has been reverted, due mainly to an unprecedented banking crisis. During 2003, as a result of an increase of almost 300% in the exchange rate of the American Dollar, the Gross National Product (GNP) registered a decrease of 0.4% and an inflation rate above 40%. In addition, the unemployment rate has increased from 12 to 16%. The population of the Dominican Republic is over 8.5 million, 65% living in urban areas and a rather proportional ratio between men and women. 62% of the population is within the 15 ‐ 64 age group, 34% is under 14 and the remaining 4% is over 64 years of age. 16% of the population is white, 11% is black and 73% mulatto. The literacy rate among those over 15 is 82.1% and 95% of the entire population is catholic.
2.2 The Health Sector Traditionally, the health service system has been mixed and comprised of institutions from the public, private and non‐governmental sectors. The public sector consists of a group of institutions such as the Ministry of Public Health and Social Assistance (SESPAS), the Dominican Social Security Institute (IDSS), the Program for Essential Drugs/Logistic Support Center (PROMESE/CAL) and the new structures developed after the start‐up of the New Dominican Social Security System, which is currently in its implementation process. According to its 2002 Annual Report, the MOH (SESPAS) had six specialized hospitals, eight regional hospitals, 107 municipal hospitals, 22 provincial hospitals, 615 rural clinics, 90 clinical consulting sites, 30 sanitary centers and 159 consulting rooms. __________________________________________________________________________________________________ Caribbean Health Research Council
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The country’s private sector is sustained mainly by direct payments. In recent years, a system of prepaid medical services has been developed through insurance plans and medical contracts. Approximately 160 clinics are affiliated to the Dominican Association of Private Clinics (ANDECLIP) and many more are known to exist. Likewise, the Non Governmental Organizations (NGOs) play an important role in the health care service provision, particularly in primary care, sexual and reproductive health, child survival (AIEPI) and HIV/AIDS. Currently, the Dominican Republic is in the midst of a reform process of the health sector and its social security system that began in the 1990s, principally geared at expanding the coverage, improving equitable access to care and increasing the quality of the services provided. The legal and regulatory framework of the reform process is based primarily on the General Health Law, approved on March 8, 2001 and the law that creates the New Social Security System, which was approved on March 9, 2001. The new system, its implementation merely starting, consecrates among its fundamental principles the decentralization of management, financing, insurance and service provision. Thus, a group of new institutions is being developed, under the coordination of the National Social Security Council. This body governs the Health Superintendence, the Social Security Treasury and the Affiliates Information and Service Office. (Only the SST is part of the NSSC) The MOH (SESPAS) is in charge of directing the sector as a whole, with the mandate of separating its management functions from the provision of services. The service providers are organized in networks, and the people join the Health Risk Administrators (HRAs). A public HRA is created to affiliate persons with lower incomes, through a subsidized system. This system was started in November 2003 but only to some extent, with very low coverage and in one of the country’s most impoverished regions. In the near future, a contributory family health insurance plan will be in effect, the price and coverage of this service are currently being debated. The prevention of mother to child transmission of HIV/AIDS is among the services to be included in this social security package. Individuals and organizations of people living with the disease are contesting the plan, in an effort to widen the scope of its HIV/AIDS‐related care services. Without the inclusion of HIV‐AIDS interventions in this package it is very unlikely that their financing will be sustainable in the long run.
2.3 The situation of HIV/AIDS The health situation in the Dominican Republic has been characterized by an epidemiological medley, with an abundance of several infectious diseases, although at present, chronic degenerative illnesses and accidents are having a significant impact. According to the 2002 Demographic and Health Survey (ENDESA), the infant mortality rate is 31/1,000 and maternal mortality is 183/100,000. This fact is astounding, since the same __________________________________________________________________________________________________ Caribbean Health Research Council
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source indicates that 98% of the births are institutional, which probably reveals the inherent problems in the quality of the services provided. According to the World Health Organization (WHO), the five main causes for seeking medical care in the DR are Acute Respiratory Infection (ARI), Acute Diarrheic Illness (ADI), hypertension, pregnancies and dermatitis. The life expectancy is about 69 years. With respect to HIV/AIDS, it must be pointed out that the Dominican Republic shares the island with Haiti, the country with the highest seroprevalence rates in the Caribbean and in the entire western hemisphere. The significant migrant flow from Haiti into the Dominican Republic has increased its vulnerability to the spread of the disease. According to the ENDESA 2002, the rate of prevalence in the country is 1% within the population group with ages 15 ‐ 49, which would yield an estimated total of 50,000 people with HIV/AIDS in that population range for 2002; the total prevalence in males is 1.1% and 0.9 in females. The population group identified with the highest prevalence rates (5%) was those living in settings near sugar cane plantations or bateyes, where there is a large number of Haitian immigrants. According to the same source, the Health Regions with the highest incidence rates in the country are regions V, VII and II, representing the sector of tourism, the sugar industry and the free zones, all pillars of the Dominican economy (ENDESA, 2002). The first AIDS case in the Dominican Republic was diagnosed in 1983. During the first years of the infection, the majority of HIV/AIDS cases were found in homosexual males and commercial sex workers, both male and female. Presently, 70% of all new cases are found in the heterosexual population, having become a generalized epidemic that has transcended the high‐risk groups. Estimates for the year 2001 taken from sentinel surveys conducted anonymously among pregnant women, female sex workers and people attending the STI clinics, point to a prevalence of 8% in female sex workers and 15% in men who have sex with other men. The Report on the Current HIV/AIDS Situation in the Dominican Republic presented in March 2004 by the General Directorate for the Control of Sexually Transmitted Infections and AIDS (DIGECITSS) indicates that the total number of reported HIV/AIDS cases until October 2003 was 15,446, of which 7,180 had already acquired AIDS. The most frequent mode of transmission identified was sexual, 75.7% of the accumulated cases being heterosexual and 7.1% in homosexuals and bisexuals. Prenatal transmission accounted for 2% of all cases, and intravenous drug use was close to 4.1%, mainly among Dominicans who lived abroad. Blood transfusion accounted for 5.5% during the five‐year period between 1993 and 1997 and 1.2% between 1998 and 2003. Likewise, 79.6% of the total number of cases corresponds to the 15‐44 age group. Of this total, 62.9% of the cases reported are males, and the male to female ratio is 1.7:1. According to a specialist, under reporting is more than 50% in the country (DIGECITTS, 2004).
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After a participatory process that involved various sectors of the Dominican society and with the support of international cooperation agencies, on December 31, 1993 the Executive Branch endorsed the AIDS Law (Law 55‐93), the first of its kind in the Latin America and Caribbean region. At the time of its official enactment, this legislative piece represented an advanced legal regulation that placed special emphasis on information and prevention of the disease, recognition of the rights of people living with HIV/AIDS, and the sanctions for discriminatory actions. However, the law has not been widely disseminated among the population, its complete enforcement has been deficient, and the weaknesses of the country’s judicial system in no way promote the defense of the human rights of PLHAs. The legal text consists of four chapters: the first refers to diagnosis, the prohibition of mandatory testing, its exceptions, confidentiality issues, and the obligatory provision of care and counseling services; the second deals with prevention, its importance and the general responsibility of nationwide dissemination, prohibits the reuse of needles and syringes, establishes a mandatory supply of condoms in short‐stay hotels and motels, and instructs the MOH to arrange for the tax exemption of condoms, muzzles and protective glasses that are used to uphold the biosecurity standards in the prevention of STI and AIDS; the third deals with the rights and duties of people living with HIV/AIDS (PLHA) and the health care they are entitled to receive, the obligation of HIV‐positive individuals to inform their status to their sexual contacts and to report previous partners, the labor rights and the prohibition for PLHA to donate blood, semen, maternal milk or organs, fostering research in the field and its regulations, as well as the obligation of blood banks and health care centers to follow the existing biosecurity standards; and the fourth establishes a set of penalties according to the nature and seriousness of the violations perpetrated. Currently, a process is underway to modify and improve the original content of the Law, and a proposal has already been drafted by consensus to be submitted to the national congress. The amendment to the present legal framework in HIV/AIDS is justified by the social changes that took place in the country during the early 1990s, the lack of action by the national authorities and non‐compliance with some the legal mandates contained therein, and the need to adjust the document to the new national and international guidelines to address the pandemic. More specifically, these could be outlined as follows: • The need to correspond its contents with the General Health Law (Law 42‐01) and with the law that creates the New Dominican Social Security System (Law 87‐01). • Reinforce issues of confidentiality and the respect for the human rights of people living with HIV/AIDS (PLHAs). • Include penalization for discriminatory behaviors against people infected with HIV/AIDS. • Ratify the banning of mandatory testing. • Acknowledge the right to integral care, including ARV treatment.
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• Disregard the tentative conviction of murder for those who, being aware of their HIV‐positive status, infect others through sexual transmission without previously informing their partners of their condition. In addition, as a means to consolidate the institutional functioning of the unit that is ultimately responsible for the coordination and implementation of the national response to HIV/AIDS, this amendment to the AIDS law intends to enforce the legal establishment of the Presidential AIDS Council (COPRESIDA) so that it may receive direct funding from the national budget. It is important to point out that the law may be modified and improved, but this does not necessarily imply its absolute enforcement. To become a true model that would generate genuine social changes in the country, it requires the proactivity and full empowerment of PLHA.
2.5 The institutional framework of the response 2.5.1 The Presidential AIDS Council (COPRESIDA) After the presence of HIV/AIDS in the country was evident in 1983, the Dominican Republic began to take formal actions to address the epidemic, creating in 1985 an HTLV‐III Surveillance Unit within the MOH (SESPAS). The National AIDS Program (PROCETS) was established in 1987, and subsequently the National AIDS Commission (CONASIDA). PROCETS was set up as a department of the Ministry of Health, and CONASIDA as a multisectoral coordination unit. The mission of the CONASIDA was to design the national policies for prevention and control, as well as to obtain national and international resources to finance the fight against the epidemic. Sometime later the Commission became a Council but never reached full operational level, for which reason PROCETS had to assume many of its responsibilities. In August 24, 2000 the Presidential AIDS Commission was established by decree No.596‐00 of the Executive Branch, being accountable for the submission within ninety days of a full report on the national situation, potential response actions and recommendations to address the epidemic. As a result of this report, on January 8, 2001 the Presidential AIDS Council (COPRESIDA) was established by presidential decree No. 32‐01. The establishment of this high‐level institution responds to the need of securing the country’s political support at the highest level, and to have a coordinating unit that brings together the main stakeholders involved in the fight against an epidemic that has surpassed the boundaries of the health sector. Decree 596‐00 defines the primary function of COPRESIDA as: “To safeguard the strict compliance with the AIDS Law 55‐93 and to design the policies that will enforce the fight against the HIV/AIDS epidemic at the national level, utilizing for its implementation and operational activities all the official departments and existing NGOs that are operating in the country and others to be __________________________________________________________________________________________________ Caribbean Health Research Council
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developed”. In addition, it establishes that COPRESIDA would develop a national master strategic plan to fight HIV/AIDS, with short and long term goals and objectives. COPRESIDA is comprised of representatives of nine public institutions, including the Armed Forces, Non Governmental Organizations (NGOs), the private sector and people living with HIV/AIDS. The Executive Director is appointed by the President of the Republic. Table 1 MEMBERS OF COPRESIDA Public Sector 1. Minister of Public Health and Social Assistance (SESPAS) (President) 2. Director of Dominican Social Security Institute (Vice‐President) 3. Technical Secretary to the Executive Branch 4. Minister of Education 5. Minister of Superior Education, Science and Technology 6. Director of the Health Corps for the Armed Forces and the National Police Private Sector 7. President of the National Council for Public Enterprise NGOs 8. President of the Coalition of Non Governmental Organizations Against AIDS People Living with HIV/AIDS 9. Representative elected by people living with HIV/AIDS The establishment of COPRESIDA is an important milestone in the fight against the HIV/AIDS epidemic in the country, and until now, its participation has been key to achieving the following results: • Social awareness of HIV/AIDS as a crucial obstacle to the development of contemporary Dominican society, which transcends the boundaries of public health and acquires multisectoral characteristics. • Negotiation and procurement of international funding to fight the epidemic. COPRESIDA has played an essential role in securing financial resources from the World Bank, the Global Fund and the Clinton Foundation, as well as the coordination of many other donors. • Bilateral agreement between the Dominican Republic and Haiti to address the HIV/AIDS epidemic. • Signing agreements for the prevention of HIV/AIDS with a group of Dominican public and private institutions. • Originating meetings with donors, to coordinate and articulate various initiatives to address HIV/AIDS in the Dominican Republic. __________________________________________________________________________________________________ Caribbean Health Research Council
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• Financing and support for the new National Strategic Plan on HIV/AIDS. All the key actors in the area of HIV/AIDS recognize the importance of COPRESIDA. However, there has been some criticism, basically by those who claim that COPRESIDA should focus more on its mandate to coordinate and manage the National AIDS Program and allow for other units the implementation of specific projects. In this respect, the institutional roles should be clarified in order to avoid conflicts between the COPRESIDA and DIGECITSS. Likewise, it has been pointed out that the platform of social participation of COPRESIDA should be expanded to allow the integration and participation of more stakeholders. The existence of COPRESIDA represents a significant advancement in the expanded national response to the epidemic. Nonetheless, once acknowledged and valued, proper measures should be taken to allow the development of true leadership within the sector, with a representative and visionary discourse, a reliable and coherent proposal, as well as being capable of implementing a sound management and accurate direction of the process. Structure and Functioning of COPRESIDA The decree on the constitution of the COPRESIDA establishes that its Executive Direction would receive a core budget from the Executive Branch and that both the MOH (SESPAS) and the Social Security Institute (IDSS) would provide the office space, staff and equipment required for its operation. It also indicates that the Executive Direction would have three basic support units: a) the Medical and Research Office; b) the Prevention Office; and c) the Administrative and Planning Office. Likewise, it establishes that DIGECITSS, the Under ministry of Primary Care of the MOH, and the STI/AIDS Prevention Program (PROPRESID) of the IDSS would be the basic operational branches of the health sector in the fight against the HIV/AIDS epidemic. Until now, COPRESIDA has been unable to develop the operational structure conceived in the original decree due to insufficient budgetary allocation, as it only receives a small funding from the central government. To be operational, it has had to obtain financial support from the HIV/AIDS Prevention and Control Project that is funded by the World Bank (WB). It is important to point out that COPRESIDA has an Advisory Committee, comprised of representatives from the international cooperation agencies. In addition, various specialized commissions have been created in areas such as: drug supply, condoms and training (in process). However, these commissions have no regular operational capacity and have very little participation in the decision‐making process. The Executive Council of the COPRESIDA should convene every two moths; however these meetings are not being held as established, having met only once during 2002, __________________________________________________________________________________________________ Caribbean Health Research Council
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twice in 2003 and only once during the first semester of 2004. Also, the official representatives often do not attend the meetings and send substitutes who rarely have the authority to make decisions and to assume serious institutional commitments. Inter‐institutional Agreements One of the objectives in the creation of the COPRESIDA was to organize a multisectoral participation in the national response to the HIV/AIDS epidemic. In this respect, it has been able to involve a group of institutions that represent important national sectors, whose commitments are registered in a series of collaboration agreements. These agreements are in line with the specific mandate of COPRESIDA to act as a coordinating unit and transfer all the pertaining actions to fight HIV/AIDS to other implementing agencies. Integration of both public and private institutions in the fight against HIV/AIDS should secure the continuity and sustainability of all the actions once the international financial sources are depleted. The signed agreements have not ensured the total participation and integration in the fight against HIV/AIDS, and in some cases the initiatives taken by the institutions have been minimal. In the particular instance of public institutions outside the health sector, the lack of political will to address the epidemic has been evident by the insufficient allocation of specialized budgetary lines for HIV/AIDS, with the exception of the Ministry of Education, the Ministry of Superior Education, Science and Technology, and the Armed Forces. In other public institutions, some of the activities as well as the salaries for the staff working in HIV/AIDS are covered with resources that are not allocated as specialized financing. COPRESIDA has signed collaboration agreements with a large number of institutions from the public sector, employers, NGOs, workers unions, sports and religious sectors. Below is the list of signatories (abbreviations by initials have been left in Spanish): • Ministry of Public Health (SESPAS) • General Office for the Control of Sexually Transmitted Infections and AIDS of the MOH (DIGECITSS) • Ministry of Education (SEE) • Ministry of Superior Education, Science and Technology (SEESCYT) • Ministry for Women’s Affairs (SEM) • Ministry of Youth (SEJ) • Ministry of Labor (SET) • Ministry of Tourism • Ministry of the Armed Forces • Dominican Institute of Social Security (IDSS) • Sugar State Council (CEA) • National Housing Institute (INAVI) • The National Police (PN) • General Office for Civil Defense (DGDC) • Office of the Attorney General (PGR) __________________________________________________________________________________________________ Caribbean Health Research Council
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• • • • • • • • • • • • • •
General Prisons Program Dominican Red Cross (CRD) Coalition of NGOs Against AIDS National Evangelic University (UNEV) Christian and Evangelic Churches (PROSOLIDARIDAD) Youth Pastoral Employers Confederation of the Dominican Republic (COPARDOM) National Association of Hotels and Restaurants (ASONANOREST) Vicini Group‐IDDI Institute of Vocational Training (INFOTEP) Punta Cana Group National Syndicates Unity Council (CNUS) Dominican Olympic Committee (COD) National Union of Private Lay Schools (UNACOPRIL)
All these agreements include a connection between the institution and COPRESIDA, and they encompass the implementation of joint promotion and prevention activities. The agreements signed with the MOH (SESPAS), the Social Security Institute (IDSS) and the Armed Forces foresee additional activities in treatment and epidemiological surveillance. Based on these agreements, various managerial sensitization campaigns have been carried out in coordination with COPRESIDA, as well as training of the staff working in the proposed activities. The planning of all HIV/AIDS related activities is made annually in coordination with COPRESIDA, and each counterpart institution provides the funding of most of the programs. The decree that created the COPRESIDA explicitly establishes the formation of departments oriented to address the epidemic in: the Ministry of Education and Culture, the Ministry of Tourism, the Armed Forces and the National Police and the National Council for Superior Education (now the Ministry of Superior Education, Science and Technology). COPRESIDA is also responsible for providing these departments with logistic support and training. At present, the following institutions have specialized units in HIV/AIDS: the MOH (SESPAS), the Social Security Institute (IDSS), the Ministry of the Armed Forces, the Ministry of Education, Ministry of Youth, Ministry of Labor, and the Ministry of Superior Education, Science and Technology. All of these have received the support of COPRESIDA through the Project for Prevention and Control of HIV/AIDS, financed by the World Bank. 2.5.2 The Ministry of Public Health and Social Assistance (SESPAS) As pointed out previously, the MOH (SESPAS) is the implementing unit of all policies related with HIV/AIDS within the health sector. The Program for the Control of Sexually Transmitted Diseases and AIDS (PROCETS) was created in February 1987 under the Epidemiology Division of the MOH. The main function of this program was to implement national policies on prevention and control of the HIV/AIDS epidemic in the Dominican Republic. One of its achievements was the early implementation in 1991 of the Epidemiological Surveillance System, one of the first established in the region. __________________________________________________________________________________________________ Caribbean Health Research Council
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In view of the widespread of the HIV/AIDS epidemic and its impact on national social and economic development, the General Program for the Control of Sexually Transmitted Infections and AIDS (DIGECITSS) was established in 2002, with the purpose of expanding the action scope of the PROCETS. Its mission was to reduce the spread of HIV/AIDS and STIs in the Dominican Republic and contribute to mitigate the impact of the epidemic. Its main lines of action are the following: • Epidemiological Surveillance and Research: Organize and strengthen epidemiological and research activities to generate data regarding the status of the HIV/AIDS epidemic in the country. Makes projections and estimates on the evolution of the disease and carries out regular seroprevalence surveys. • Laboratories and Blood Banks: Strengthens the National Laboratory Network and provides support for the diagnoses and monitoring of STI/HIV/AIDS. Promotes guidelines and monitors all aspects related with the screening of safe blood for transfusions. • Information, Education and Communication: Provides IEC to promote responsible sexual behavior in the population, in collaboration with local NGOs and GOs. Informs on risk behaviors and the preventive measures to avoid the spread of STI/HIV. In addition, increases the knowledge and skills for the use of condoms, with an emphasis on young people and high‐risk groups. • Planning, Management and Administration: Oversees actions and required resources to respond to each of the action lines. • Control of the STIs as a measure to prevent HIV/AIDS. Standardizes the services provided at the national level according to the STI care guidelines and the existing care model. • Control of the Mother to Child Transmission of HIV/AIDS: Standardizes and develops actions for the prevention of vertical transmission of HIV. • Pre and post Test Counseling: Guarantees pre and post HIV test counseling and other STIs in those health centers where diagnostic tests are prescribed and/or carried out, according to the national guidelines. • Integral Care of HIV/AIDS. Coordinates actions that guarantee the integral care provided to PLHA within the public service network, adapting integral care procedures to the different care levels and the technological and pharmacological updates. • Networks and support groups: Coordinates various formal and non‐formal, public, private and non‐profitable organizations, to provide support in STI/HIV/AIDS prevention activities through exchange and mutual learning. 2.5.3 International Cooperation The international cooperation has been essential in the expanded response to HIV/AIDS. Most of the interventions that are currently in place are financed with external funds provided by international organizations. __________________________________________________________________________________________________ Caribbean Health Research Council
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The international cooperation agencies operate in different ways, particularly through direct interventions, providing resources to support public actions and institutional strengthening, and implementing activities through non‐governmental organizations. As described in the following section, most of the NGOs mobilize resources with international cooperation. Several United Nations agencies in the country are supporting different interventions. These include UNAIDS, UNDP, WHO/PAHO, UNICEF and UNFPA. The United Nations Agency for International Development (USAID) has a long history providing support to the country’s response to HIV/AIDS through various projects. Currently, the bulk of its CONECTA project funds are allotted to these activities. Another USAID funded project, REDSALUD supports the decentralization of DIGECITSS within the framework of the health system reform. It supports local SESPAS offices in Region V (East) and civil society organizations in the preparation of evaluations, capacity building and implementation of priority interventions.The European Union and other bilateral agencies have had some participation. Since the year 2002, the country has been receiving funds from a US$25 million World Bank loan to finance the HIV/AIDS Prevention and Control Project. In 2004, a $49 million contract was signed with the Global Fund, and the funds for the first two years have already been guaranteed. Also this year, an agreement was signed with the Clinton Foundation to finance a national program of integral care, including the procurement of antirretrovirals. The CONECTA project is managed by a USAID contract group, under the leadership of Family Health International. A summary of the main components of these projects is provided in the Annex. In addition, a table with essential data on the contributions made by other cooperation agencies is included in the Annex. The main ongoing projects, administrated by COPRESIDA, are summarized in the following table. Table 2 MAIN COPRESIDA PROJECTS PROJECT
FINAL GOAL
OBJECTIVES
EXPECTED OUTCOMES
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Reduce HIV transmission and the AIDS impact on the human development in the Dominican Republic.
‐Reduce the spread of HIV/AIDS epidemic by increasing programs and activities focused on high‐risk groups. ‐Increase awareness of HIV/AIDS among the general population. ‐Strengthen the institutional capacity to ensure the effectiveness and sustainability of the national response.
‐Reduce the HIV infection rates. ‐Reduce the impact of HIV/AIDS on health and the socioeconomic development both in individual households and the community. ‐Improve the knowledge on factors involving the spread of the disease and the trends of the epidemic ‐A strengthened institutional capacity for an expanded response to HIV/AIDS.
National Response to HIV/AIDS COPRESIDA Global Fund 2004‐2009
Reduce HIV transmission and the AIDS impact on the human development in the Dominican Republic.
‐Create an improved political and human rights environment. ‐Increase the access and use of prevention services and improve the management of STIs. ‐Integral management and access increase to treatment for PLHAs.
National Initiative for the Integral Care of PLHAs Clinton Foundation (CHAI)
Increase longevity and improve the quality of life for people living with HIV/AIDS in the Dominican Republic.
‐Improve and expand the efforts in prevention, especially in VCT, MTCT, syndromic management of STIs and reducing the stigma, by providing integral treatment and prevention. ‐Provide complete integral care, primary and effective to those individuals requiring the services. ‐Strengthen general health services provided in the DR to ensure sustainable provision of integral care to HIV/AIDS patients.
‐All sexually active individuals who wish to know their HIV status can be tested and are able to assess their own risks of HIV infection in order to make positive behavior changes. ‐Reduced mother to child transmission. ‐Adoption of safer sexual practices. ‐Improved access to condoms. ‐Access to ARV treatment to those who need it (6,000 PLHAs) ‐Enhanced support to PLHAs and their families. ‐Access to integral care and antiretroviral treatment for all Dominican PLHAs according to the standards. ‐All individuals who are HIV+ are capable of knowing their serological status. ‐Reduce the risks for mother to child transmission. ‐Increased knowledge on epidemiological data among vulnerable groups.
2.5.4 The Role of the NGOs The non‐governmental organizations (NGOs) and the community‐based organizations participating in the national fight against AIDS play an important role in the prevention and treatment efforts. They have an active participation in policy design and formulation, the development of intervention models for behavior change and the __________________________________________________________________________________________________ Caribbean Health Research Council
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production of educational materials, among many other activities. The NGOs are extremely motivated and enjoy a high credibility within the sector; they have contributed their values and experience, have maintained a solid presence throughout time and have been crucial to the growth of a national leadership in the fight against HIV/AIDS. The NGOs began their work in HIV/AIDS in the country with the creation of the Foundation for the Fight against AIDS in 1986. Currently, 50 organizations are actively working in HIV/AIDS activities, 6 of which are exclusive in the area. In addition, several NGOs working in other areas have included specific HIV/AIDS related programs. Those in the HIV/AIDS arena receive technical and financial support from international agencies, the government and some additional funding from the general society. Most of the NGOs working in HIV/AIDS are part of the Coalition of NGOs against AIDS. This organization, created in February 1997, brings together close to 30 of the most important NGOs that are involved in the fight against HIV/AIDS in the country. The Coalition pursues the following objectives: a) to strengthen and develop actions that may influence public policies; b) to promote institutional strengthening and development for an effective integration of its members and social positioning; c) to obtain and distribute funding that can ensure the Coalition’s sustainability and self‐sufficiency; d) to promote the unity of different sectors in the fight against HIV/AIDS; e) to create strategic alliances with other NGOs, international cooperation agencies and the government to enhance the response to HIV/AIDS; f) to advocate for increased financial resources from the State and international cooperation for the fight against AIDS; and g) to develop regular publications. Another important organization to be highlighted is the National Health Institute (INSALUD), that groups NGOs working in the health sector, some of which address the issue of HIV/AIDS and in some cases are also members of the Coalition. In addition to the important role played by the NGOs in HIV/AIDS prevention, their participation in the integral care model is being contemplated, particularly in the areas of counseling, ARV treatment and day care centers. This is described in greater detail under the section on treatment. The contributions made by the NGOs for the fight against HIV/AIDS in the country are diverse, including some of the following: • Participating in decision‐making, planning and strategic venues. Since the establishment of the CONASIDA, the NGOs have actively participated in all the relevant decision‐making, planning and strategic processes. • Creating awareness on the HIV/AIDS issue. For years, the NGOs have been promoting the respect to and acceptance of PLHA among the different actors and levels of Dominican Society. • Contributing to the empowerment of vulnerable actors. The NGOs have contributed significantly to the participation of the most vulnerable groups, particularly commercial sex workers, men who have sex with men and residents of the bateyes. __________________________________________________________________________________________________ Caribbean Health Research Council
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• Participating in the sector’s legal framework. The formulation of the AIDS Law and its amendment proposal has included the active participation of the NGOs in the area. • Integrating various stakeholders. The work of the NGOs has lead to the incorporation of a vast number of individuals and stakeholders in the fight against the epidemic. • Participating in the development of intervention models for behavioral change. The NGOs have a long history in bringing about the exchange of experiences for behavioral change, especially among the high‐risk groups. • Developing high‐quality educational tools and materials. In their work, the NGOs have developed a large number of educational tools and materials for the fight against HIV/AIDS, some of very high quality that has been used in other countries. • Follow‐up of the programmatic agenda. The NGOs have kept a close watch on the compliance of institutional commitments in the sector, thereby contributing also to the development and general continuity of the process. The NGOs working in AIDS also face institutional and managerial weaknesses that affect their performance, but a generalized assumption cannot be made since there are disparities in their levels of development, depending on the resources, their experience and the quality of their staff members. Some ONGs lack the necessary tools for a sound management, such as plans, a monitoring system, evaluations, financial and administrative systems and others. It is also important to continue promoting the exchange and communication between the existing NGOs to avoid overlapping, and to increase monitoring of their activities and accountability system. The Organization of People Living with HIV/AIDS It must be highlighted that the organization of people living with HIV/AIDS has been instrumental in the national response to HIV/AIDS. The Network of People Living with HIV/AIDS (REDOVIH) is defined as “an organization aimed at providing emotional and legal support” and “to promote the empowerment of and the respect of the human rights” of PLHA. REDOVIH is a network of self‐support groups and individuals living with HIV/AIDS that began operating in 1997 and a membership of over 2000. The network promotes the participation of its members and focuses on producing consensual and institutionalized responses. Its work includes providing emotional support to its members, IEC, and striving to make people who are HIV‐positive to become agents of change and part of the efforts in HIV prevention. REDOVIH has played an important role at the international level, and its members have held relevant positions in the Caribbean Network of People Living with HIV (CRN+), the World Council of Women Living with HIV and the Global Network of People Living with HIV/AIDS. __________________________________________________________________________________________________ Caribbean Health Research Council
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An important example of the benefits REDOVIH offers to its members, is the legal suit submitted before the Interamerican Human Rights Court, claiming integral care for PLHA, which initiated and accelerated the implementation process of a care program, including the provision of antiretroviral treatment (ARV). Recently, a new NGO was created, the Alianza Solidaria para la Lucha contra el SIDA (ASOLSIDA), which also groups PLHA. 2.5.5 The Role of the Private Sector As part of its multisectoral response to HIV/AIDS, COPRESIDA has been gradually incorporating important sectors of society in the fight against the epidemic. One sector that COPRESIDA has worked more closely with is the business sector, having signed a series of agreements, some of which include: • Between COPRESIDA and the Punta Cana Group, which consists of several tourism enterprises located on the Eastern coast. This agreement was signed in 2003 and has already undergone various levels of implementation. The project has joint funding from COPRESIDA and the Punta Cana Group, implemented by the Punta Cana Foundation. • A Multisectoral Collaboration Agreement for the Prevention of HIV/AIDS at the Workplace, signed on July 2, 2002 between the National Council of Workers Unions (CNUS), the Dominican Republic Employers Confederation (COPARDOM) and the Ministry of Labor (SET), the MOH (SESPAS), the National Institute for Vocational Training (INFOTEP), the Social Security Institute (IDSS), the Coalition of NGOs Against AIDS, the Program Smart Work1 and the COPRESIDA. The main pledge made by the signatories was the immediate development of a Sectoral Plan to fight HIV/AIDS in the workplace. The implementation of the activities foreseen in the Plan requires a global investment of approximately US$26 million over a five‐year period. It was programmed to begin in 2003, but the funds have still not been disbursed by the COPRESIDA. • COPRESIDA and the National Association of Hotels and Restaurants (ASONAHORES), signed an agreement to implement a prevention project in the area of tourism. The action plan is still in its development phase. • COPRESIDA and the Vicini Group, signed recently to carry out activities to fight HIV/AIDS in the bateyes (sugar cane workers), the main risk area in the country. This also is in its initial phase. These agreements show the interest of the business sector in HIV/AIDS and the government’s concern to join new partners in the response to the epidemic. However, the 1Smart
Work is the Dominican version of a project from the Academy for Educational Development,
SMARTWORK (Strategically Managing AIDS Responses Together in the Workplace), funded by the United States Labor Department.
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agreements have met some setbacks in their implementation. The main obstacle has been the funding, both with the financial contribution required from the business sectors as well as the national counterpart from the government, in the case of projects with external funding.
2.6 Strategic Planning of the National Program The ongoing changes in terms of development and the response to HIV/AIDS require the continuous and regular revisions of the strategies and planning for the national response to the epidemic. The first planning exercise at national level was the National Plan for the Prevention and Control of AIDS, developed for the period 1997‐2001. This Plan identified three basic components: a) prevention of sexual transmission; b) prevention of blood transmission; and c) prevention of prenatal transmission. It sought the coordination of actions between the public sector and the civil society organizations, and the interventions were prioritized based on the national HIV/AIDS/STI situation. In addition, the guidelines for the development of integral care for people infected with HIV/AIDS were completed, including segments on managerial and administrative development for the implementation of the Plan. Once the proposed period had concluded, an assessment was made to verify the implementation of some of the foreseen actions in both the public and private sectors, but these had not been totally accomplished. Subsequently, the CONASIDA, in coordination with PROCETS, drafted the National Strategic Plan for STI/HIV/AIDS for the period 2000‐2003. The development of the Plan was a multisectoral exercise of national scope that succeeded in the integration and participation of government institutions, non‐governmental organizations, international cooperation agencies and civil society institutions. This effort was made in accordance with the Guide for the Strategic Planning Process published by UNAIDS in 1998, which includes four phases: a) situation analysis; b) response analysis; c) strategic plan formulation; and d) resource mobilization. The final result was a Strategic Plan that included: a vision for the next three years, a definition of principles and purposes, and the identification of three strategic areas and thirteen lines of action. The strategic areas and their objectives are the following: Strategic Area 1: Policies, Decision‐making and Social Mobilization. To formulate and implement policies for the creation of a favorable environment to foster the prevention and care of STI/HIV/AIDS, as well as sponsoring social participation to address HIV/AIDS/STI. Strategic Area 2: Prevention. Increase the provision of HIV/AIDS prevention services. Strategic Area 3: Care. Increase the provision of efficient care services. Now that the implementation time frame of the NSP 2000 – 2003 has concluded, it is important to point out a series of general remarks: __________________________________________________________________________________________________ Caribbean Health Research Council
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• The NSP 2000‐2003 was a good planning and coordination exercise, with a high level of participation of individuals from different institutions and levels. • The NSP was a good document that lacked a solid budget and a proposal for monitoring and evaluation. • The NSP was only partially used as an operational guide in the national response to HIV/AIDS. At present, the country is preparing a new strategic plan for the period 2004‐2008. A qualitative assessment of the NSP 2000‐2003 is underway and a methodological proposal has been drafted, not as ample and participatory as the previous, but one that will yield a final document in a shorter period of time. Also, the new NSP will be based on the previous plan, it will use as reference the updated version of the UNAIDS strategic planning guide, it will include national strategic lines, will be adapted to the reform process of the health sector and social security, and will contain measurable results and indicators for the design of a new system for monitoring and evaluation.
2.7 National Policies on HIV/AIDS Policies represent the statements that define and summarize the contents of all actions and the main results these actions should generate. In the Dominican Republic, there is no specific policy formulation for the national response to the HIV/AIDS epidemic. However, most of the actions carried out have defined a series of guidelines, which, in practice, have become what could be called the sector’s implicit policies. Some of these were identified in this assessment, namely: • A progressive integration of the majority of stakeholders and social classes in the national response to the epidemic. The extent in which the problem of HIV/AIDS has acquired a multisectoral dimension and required initiatives of higher levels of complexity, wider participation of different stakeholders and different levels has been sought. • The creation of a legal framework that may contribute to fight the disease and guarantee the rights of PLHA. Due to the dimension of the problems involved, the formalization of legal regulations and principles to which society should respond, have become necessary. The laws, regulations and legal dispositions are seen from a dynamic perspective, thus they should be revised and updated regularly. • Selection of clearly defined courses of action for the response, through the formulation and implementation of specific plans. Due to the level of complexity and the lack of sufficient resources to support a costly process, the response actions should not be spontaneous but part of an organizational structure in the form of implementation chronograms. • Progressive specialization and rationalization of all response actions. The augmented complexity of the HIV/AIDS situation has required higher levels of specialization and technology in the national to the epidemic. The development of work methodologies, the standardization of operational methods, the regulation of __________________________________________________________________________________________________ Caribbean Health Research Council
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•
•
analytical tools and the protocol procedures, are more frequently becoming part of a rich and diverse managerial guarantee. Integral articulation of treatment procedures. There has been a progressive transition from isolated and specific treatment to expanded responses that combine and concentrate numerous procedures, aimed at providing an integral care. Choice of cost‐effective actions. The high costs involved in the different interventions against HIV/AIDS impose pressure on the decision‐makers at management levels, in order to choose actions that minimize costs and maximize results.
2.8 HIV/AIDS Prevention 2.8.1 Information, Education and Communication (IEC) The objective of the Information, Education and Communication Program (IEC) is to contribute to increase the knowledge on the modes of HIV transmission and the protective measures, as well as to promote safer sexual practices and acceptance of the human rights of people living with HIV/AIDS. In 1993, CONASIDA developed with the support of the PROCETS, a National Strategy on Information, Education and Communication (NSIEC). Afterwards, in 1999, the strategy was reformulated, stressing that the epidemic “warranted a multisectorial approach, with programmatic interventions focused on specific and priority target audiences”. The new NSIEC, still in effect, seeks to generate changes in the patterns of risk behaviors among priority populations, namely: • Adolescents • Sexually active adult women • Sexually active adult men • Health staff • Groups with social influence • Special groups In the Dominican Republic, the IEC activities for HIV/AIDS prevention have been carried out under three main strategies: a) the mass media, by providing general information on radio and television; b) intermediate channels, by disseminating information through other means such as billboards, newspapers, posters, educational materials, caps, buttons, stickers and signs; and c) direct interventions with a specific audience, by providing information and/or education through specific activities such as workshops, courses and lectures. The first HIV/AIDS prevention campaign in the country was made in 1989 and it was focused on promoting faithfulness and protective measures among the general population. The initial campaigns were addressed to the general public and were not segmented by audiences. Recent ones have carried specific messages addressed to target audiences. Most of the work made has been directed to young people. __________________________________________________________________________________________________ Caribbean Health Research Council
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Numerous mass media campaigns with different objectives have been carried out in the country, with the participation of national public figures in the fields of communications media, sports and arts. Many of these campaigns have been monitored to verify the frequency of diffusion, but very few appraisals have been conducted to know their effectiveness. The broadcasting is free of charge, in compliance with article 9 of the AIDS Law which establishes that “the General Telecommunications Bureau, in coordination with the MOH and the Ministry of Education, will broadcast the messages, free of charge, on the mass media channels, to inform the population and to prevent the transmission of Sexually Transmitted Diseases (STDs) and AIDS”. The radio and television stations air the spots on HIV/AIDS with relative frequency, particularly during non‐prime time. Through the communications media, the HIV/AIDS prevention messages reach all segments of the population on a regular basis. Many IEC activities have been conducted on a permanent and diverse manner through intermediate channels. The same applies to the strategy on direct interventions, very frequently carried out in the country. The work done by NGOs with female sex workers and men who have sex with men is particularly remarkable. The results of the IEC strategy can be partially assessed from the knowledge that on AIDS has the Dominican population. According to the ENDESA 2002 less than 1% (0.7%) of the individuals interviewed had never heard about AIDS, and 2.7% of the women and 2.4% of the men believed there is no way to prevent AIDS. Table 3 KNOWLEDGE ON WAYS TO PREVENT AIDS Ways to prevent it Women Men Using condoms Having only 1 sexual partner/being faithful to partner Reduce number of sexual partners Avoid sex with prostitutes Avoid sex with people who have multiple partners Avoid sex with homosexuals
73.3%
82.5%
42.9%
33.4%
5.6% 4.5% 3.3% 0.7%
3.9% 20.6% 3.1% 2.1%
92.8% (89.5% in 1996) of the women and 92.2% of the men said that a person who looks healthy could have AIDS. __________________________________________________________________________________________________ Caribbean Health Research Council
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Additionally, Population Services International (PSI), an USAID contractor, conducted an impact evaluation of a campaign conducted by Gallup, DR. The universe were youngsters of both sexes, from 13 to 24 years, who belonged to different socioeconomic statuses. Among the main activities in direct prevention information are those carried out by the Program for Emotional and Sexual Education (PEAS), under the Ministry of Education, whose general objective is: “Establish the integral training of the students by providing basic knowledge on human sexuality, and developing values that build on their awareness of the socio‐ cultural reality and their capacity to make conscientious and responsible decisions”. The Program is envisioned for implementation at the primary, intermediate and basic levels in public schools throughout the country. It began in 2003 with the participation of teachers who had been trained by specialized facilitators. The program includes an HIV/AIDS component at the intermediate level, which intends to generate values and healthy and responsible attitudes to deal with sexuality and HIV/AIDS. Presently, 4,787 teachers have been trained (46%) and 5,713 (54%) are pending training. The Program is underway in 100% of the schools in the capital of the country, and in an undetermined number of schools nationwide. It is presently being evaluated using the LQUAS methodology by a team of representatives from the General Appraisal for Monitoring and Evaluation Team (GAMET)2 with the support of the Plenitude Foundation. 2.8.2 Condoms The use of condoms was initially introduced in the country as a contraceptive method for family planning through the Population and Family Council (CONAPOFA). This was a national wide program channeled through SESPAS facilities. Afterwards an agreement was signed with the Social Security Institute, which provided condoms in the free export industrial zones. Additionally, with the support of the United Nations Population Fund (UNFPA), the condoms began to be distributed in the “bateyes”, with which the purpose of the intervention was widened to STI prevention. The objective of the condom program in the prevention of HIV/AIDS is to increase the access and general use of condoms, especially in the most impoverished populations and those who are sexually active. The first time the country purchased condoms for the specific purpose of HIV/AIDS prevention was in 1995 (2 million units) and were distributed by the PROCETS. Subsequently, in 2003 the HIV/AIDS Prevention and Control Program purchased 2 million units, and 2 additional million units in 2004. The main distribution channels employed by the prevention program are: free supply among vulnerable populations such as prisoners and residents of the bateyes, social marketing and IEC activities. Several NGOs participate in the social marketing activities, such as ADOPLAFAM, Dominican Churches Social Services, MUDE and CASCO, among Conjunct group of UNAIDS and the World Bank.
2
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others. Article 16 of the AIDS Law states: “Establishments such as: “reservados”3, short‐stay hotels and motels, and other locations with beds for rent, should provide clients a minimum of two (2) condoms and place them somewhere visible”. A recent study found that 69% of the short‐stay hotels and motels provided condoms in their rooms, and a 31% condom use rate. The private market in the country offers an increasingly large variety of options and attractive package presentations. Condom advertising has become regular and its frequency has increased in the communications media. The country has a Condom Commission that has been in operation for several years. In 2001, a process was started to develop a National Condom Policy, with the technical assistance of the United Nations Population Fund (UNFPA). In this respect, numerous meetings and consultancies have been conducted, and the process is currently in a very advanced level. This policy aims to establish a regulation for the prevention of HIV/AIDS through the use of condoms. This policy will be of national scope, including both the public and private sectors, and will consist of the following components: a) policies to increase the access to condoms; b) policies to promote condom use; c) policies to ensure funding; d) policies to ensure the quality; e) policies to ensure the supply; and f) policies to provide the services. The results of this policy can be partially assessed by the knowledge of condoms by the Dominican population, although their use is not so extended, particularly with cohabitant partner, as can be seen in the following table, with data from ENDESA 2002. Table 4 KNOWLEDGE AND USE OF CONDOMS Knowledge Women Men Knows source of condoms Is able to obtain condoms
Used a condom in last sexual encounter With cohabitant partner With non‐cohabitant partner With any partner
76.7% 67.7%
91.3% 43.8%
Women
Men
2.1% 25.2% 5.9%
1.2% 50.3% 20.2%
3
“Reservados” are special private cubicles found in some local Chinese restaurants, which are presumably
reserved to eat and/or drink, but are used instead for casual sex.
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2.8.3 Prevention of Mother to Child Transmission The objective of the National Program for the Prevention of Mother to Child Transmission (NPMTCT) is to reduce the infection in children born to positive mothers. The NPMTCT started as a pilot on May 15, 2000 in four maternities throughout the country. Three hospitals were selected in the National District and one in the province of Puerto Plata. The decisive factor for selection was the coverage, as these four hospitals account for more than 60% of the deliveries in the country. Subsequently, the program was extended to other health facilities and by the end of 2003 it was being implemented in the 33 (100%) public maternity hospitals and in 82 (82.8%) of the 99 municipal hospitals; the Program is also implemented in 8 (44.4%) of the 18 hospitals managed by the Dominican Social Security Institute (IDSS) providing maternity services. The implementation procedure of the NPMTCT includes seven basic steps: a) pre and post test counseling for pregnant women, b) screening of pregnant women with rapid HIV tests; c) post test counseling; d) administration of antiretroviral drug to the positive mother (one tablet of Nevirapine 200 Mg) eight hours before the caesarean section; e) a caesarean section; f) administration of antiretroviral drug to the newborn (oral solution of Nevirapine 2 Mg per Kg of weight) between 8 – 72 hours after birth; and g) maternal formula for the newborn. In case of natural birth, the antiretroviral drug is administered once the labor process begins. Earlier in the Program, the antirretroviral used was AZT but it was too costly. The NPMTCT receives a donation of Nevirapine (Viramune) from the La Rioja government (Spain), through an agreement existent from 2000. In 2003 Axion International, under agreement with Boehringer Laboratories, made a donation of the drug. Experience with the above program has determined certain parameters of effectiveness in the prevention of mother to child transmission, namely: a) 50% effectiveness in cases of Nevirapine + maternal formula; and b) 70% effectiveness in cases of Nevirapine + caesarean section + maternal formula. An important and difficult aspect of the treatment is ensuring the supply of formula, a setback in the country due to lack of funds and distribution problems. This issue must be on the agenda of the decision‐making processes and when setting priorities. Another inconvenience with the Program is the fact that occasionally, some hospitals have no reagents for the rapid HIV tests. Counseling is another aspect of the procedure that is carried out with certain degree of difficulty, both in pre and post HIV testing. There is no clear protocol established for pre test counseling, and in some cases it is provided by unqualified staff and usually in groups, which is not convenient. In general, the process is followed but with low effectiveness in terms of providing adequate information. In post test counseling, negative results are given in groups and positive results are given individually. There are problems with the lack of __________________________________________________________________________________________________ Caribbean Health Research Council
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space and privacy for giving out positive results, which should be done by specialized psychologists. In addition, it should be pointed out that during the first years of program implementation, many gynecologists were reluctant to perform cesarean sections on women who were HIV+, although this situation has now changed. During 2003, 156,967 women assisted to a first antenatal visit in the health institutions where the PNRTV is at work. In each one of those serologic tests were indicated and a total of 78,118 (49.7%) HIV tests were performed with 1,606 (2%) positive results. Additionally, 48,129 (61.6%) pre‐test counseling sessions were conducted, and 22,985 (29.4%) post‐test; 83.9% of the mothers and 93.3% of the newborns were administered Nevirapine. The previous information makes clear that a great difference exists between the indicated tests and the actually performed. This gap has different explanations, among which we could mention: (a) some pregnant women do not return after the first visit until the delivery date; (b) sometimes they do not know that the tests are free; (c) there are deficiencies in the pre‐test counseling quality; and (d) lack of reactive laboratory supplies in some places. It is important to point out that HIV‐AIDS tests are always performed on women who attend health services for delivery. A pilot project has recently begun implementation in order to reduce the gap between performed and indicated tests. Prior to the first visit, pregnant women receive pre‐ test counseling and sign test consent. After the visit they receive the test results and post‐test counseling. 2.8.4 Blood Banks The Blood Banks Program aims to increase the diagnostic capacity of the laboratories in order to minimize the risks of HIV infection by blood transfusions. Work in this field began with the formulation of rules and guidelines by PROCETS in 1987, and subsequently undertaken by the DIGECITSS. In the Dominican Republic there are approximately 300 laboratories and 60 blood banks and/or blood transfusion services that perform HIV testing, and 3 reference laboratories to confirm positive results. Article 3 of the AIDS Law prohibits blood transfusions without proper screening for HIV and viral hepatitis. It is estimated that 10% of the early HIV infections were caused by blood transfusions; however, the March report presented by DIGECITSS indicates that the rate of infections due to blood transfusions was 1.2% over a five‐year period (1998‐2003). Nonetheless, in the opinion of expert professionals, this rate has increased recently. __________________________________________________________________________________________________ Caribbean Health Research Council
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In 2002, DIGECITSS coordinated a quality assessment in 289 laboratories and blood banks. The study was conducted with a quality scale of 0 to 5 with the following score equivalents: 5 = Excellent; 4 = Very Good; 3= Good; 2 = Regular (less than adequate); 1= Bad; 0 = Non‐existent. The general score was 3.35, which reflects an adequate level of quality. However, from the previous figure it is presumed that a large number of laboratories are working with bad and regular standards of quality. The following table shows the results by sector. Table 5 QUALITY RATING IN LABORATORIES AND BLOOD BANKS SECTOR SESPAS (MOH) IDSS (Social Security) Red Cross Armed Forces Private
RATING 3.27 3.68 3.77 3.61 3.59
The referenced study points out the aspects with the lowest scores, which were basically equipment, furnishing, biosecurity, administrative staff, documentation and glassware. 2.8.5 Other Sexually Transmitted Infections (STIs) The STI program began as part of the Epidemiological Division of the MOH and was later transferred to the DIGECITSS. Traditionally, the STI section has had insufficient budgetary allocation, regardless of the fact that their treatment is one of the most cost‐ effective approaches for the prevention of HIV, since having an STI may increase up to 9 times the risk of HIV infection. In recent years, the strategy to tackle the spread of STIs has included two components: the syndromic management and the pre‐packed therapy kits. The syndromic management is used as a method of detection and diagnosis. The pre‐packed therapy is a kit that is distributed depending on the diagnosis and includes drugs (to treat symptomatic vaginitis, genital ulcers and inflammatory pelvic illnesses), condoms, educational materials and other supplies. Recently, efforts have been made to strengthen the capacity of the provincial departments to supervise the STI services, providing training on syndromic management. However, the work has been limited and many difficulties have arisen in the distribution of the pre‐packed kits, thus the implementation of this new strategy is still very poor in the country. Regarding STI, the preliminary report on Health Situation Analysis prepared by the General Direction of Epidemiology indicates: “The syndrome associated with syphilis and gonorrhea show a clearly defined descending tendency. They have probably been impacted by the actions taken to prevent HIV‐AIDS. Some case studies document that there has been __________________________________________________________________________________________________ Caribbean Health Research Council
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an increase in the resistance to gonococcic uretritis antimicrobials as well as an increase in inflammatory pelvic disease cases in women. Data from the DHS 2002 show that 9% of sexually active women suffered from an STI in the year prior to the survey. Prevalence is higher in adolescents and young women (15‐29 years), residents in rural areas and with basic education from fifth to eighth grades. The majority of them, 75%, sought medical assistance.
2.9 Care and Treatment During the first years of the HIV infection, the country was not capable of giving an effective response. Society was faced with a new situation, and no options for providing an integral response to the pathology of this disease. The first cases were treated by the health system in the habitual manner as for any opportunistic infection. There were no specialized care facilities, and patients with HIV were referred to the Sanitary Center of the MOH. The treatment of persons with HIV/AIDS began in a reactive and spontaneous form, and the procedures for testing, counseling and care were divided between the following official institutions: the National Laboratory Dr. Bernardo Defilló, where the first HIV tests were performed in 1986, the Human Sexuality Institute (HSI) and the Sanitary Center. With time, the high costs of treatment and the lack of a health service structure capable of providing an efficient response led to a reformulation of the approach. In an effort to incorporate the services, an Integral Service Unit was created in 1993 in the Sanitary Center. Basically, the Unit provided care and treatment for opportunistic infections and emotional support, becoming the first attempt to provide integral care to HIV/AIDS patients in the Dominican Republic. The Unit at the Sanitary Center served at the time as a training center where the health staff concerned with HIV/AIDS completed an internship without a formal training program. During the 1990´s, the first HIV patients were treated at the Padre Billini Hospital, the Children’s Hospital Robert Read Cabral, the Dermatology Institute in Santo Domingo, among others, but there were no integral care units. In 1999 the MOH launched a national program for the prevention of mother to child transmission. Although the description of this program is included under the section on prevention in this report, it must be mentioned as a component of treatment, because the provision of ARV drugs to positive mothers and their newborns is initiated under said program. Up until 2002, antiretroviral therapy in the country was provided informally depending on the financial possibilities of the patients, their families and donations. 2.9.1 National program for integral care __________________________________________________________________________________________________ Caribbean Health Research Council
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The Coordination Unit for Integral Care was established in 2003 by the DIGECITSS. The Unit is responsible for the design and monitoring of the National Program for the Integral Care of HIV/AIDS at all levels of the health system. This program combines prevention, care and treatment, contributing to tackle the spread of HIV/AIDS and mitigate its impact. The Unit´s mission is to coordinate efforts in providing quality care services and equal access to PLHAs. It receives financial and logistic support from USAID/CONECTA, COPRESIDA, the HIV/AIDS Control and Prevention Project funded by the World Bank, the United Nations and other agencies. The HIV/AIDS care model relies on the Basic Care Units (BCUs), which act as specialized centers, adequately equipped and staffed with a multidisciplinary team of physicians, nurses, counselors and health educators who are trained on the treatment of HIV/AIDS patients. The model foresees the establishment of 27 BCUs at the national level. In addition to the BCUs, the system has Ambulatory Centres (AC), which provides care and ambulatory services for outpatients. These centers were equipped by the CONECTA project, which has also agreed to train and pay the staff during the first six months. These Centers are located in public and private facilities and some NGOs, and attempt to provide integral care using the same protocols and procedures as the BCUs. With the support of international cooperation, the implementation of the care model has been initiated, and it is expected to be fully operational at national level within the next five years. The spaces for the BCUs are already being renovated, refurbished and equipped in second and third care level hospitals. The following institutions are currently providing integral care services, although some are not totally restructured: • In Santo Domingo: the Dermatology Institute Dr. Bogaert, the Sanitary Center, the Central Hospital of the Armed Forces, the Children’s Hospital Dr. Robert Read Cabral, The Dominican Institute for Virological Research (IDEV), the Casa Rosada, the Luis E. Aybar Hospital, the Maternity Our Lady of La Altagracia and the Salvador B. Gautier Hospital (IDSS). • In Santiago: the Cabral y Baez Hospital • In Barahona: the Jaime Mota Hospital • In Puerto Plata: the CEPROSH (NGO) and the Ricardo Limardo Hospital. • In la Romana: Centro Micaeliano. A chart of all the Basic Care Units is attached. The BCUs have the capacity to provide integral care for people living with HIV/AIDS. Each Unit has a Registration and Information System (SIG‐REG) that includes the patient’s date of entry, dates of follow‐up visits and relevant information for the logistics and __________________________________________________________________________________________________ Caribbean Health Research Council
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epidemiological surveillance. In addition, they conduct clinical, nutritional and family assessments, tuberculosis testing and appraisals of the patients’ social and psychological behaviors. Likewise, they provide guidance in HIV prevention and stress on the need to have a CD4 count performed at least twice a year. The individuals on ARV treatment receive intensive and ongoing counseling for treatment adherence. They also provide community services with the support of partnering NGOs. The Care Program pretends to provide all care services and treatment free of charge. This will not be a problem as long as the current donations and loans are still in effect; however, once these funds are depleted, the continuity of the program is uncertain. The authorities should seek additional financial sources with sufficient time in order to ensure the future sustainability of the Program. 2.9.2 Voluntary Counseling and Testing (VTC) STI/HIV/AIDS counseling in the Dominican Republic began during the initial stage of the epidemic, as a useful tool in public health to help promote safe and healthy behaviors and to reduce risks among people who are not infected, and prevent those who are from infecting others. Since the early 1990s to date, different institutions, both governmental and non‐ governmental are joining efforts to establish HIV/AIDS counseling services in the DR. In 1988, PROCETS in collaboration with the Dominican Red Cross and CLETS of Puerto Rico, conducted the first STI seminars and established the AIDS Help Line, one of the first efforts to provide on‐line counseling. This is still operational. Another service that is working to this date is the Human Sexuality Institute, which in 1989 began giving test results and doing follow up of the STI/HIV/AIDS patients from the National Laboratory. In 1990, the AIDS prevention program in the social security institute, the PROPESID, developed a counseling component with a multidisciplinary group, and PROCETS inaugurated the integral care unit for people with AIDS at the Sanitary Center. This unit is still operational. The Padre Billini Hospital also provides counseling services. The first training workshops on emotional support and counseling services were conducted during the period 1991‐1995, coordinated by PLUS and the AIDS Foundation of Puerto Rico, and the technical assistance of FHI, AIDSCAP and USAID. These workshops provided the first instruction manuals which served as a start of a series of appropriate tecniques for HIV counseling. The NGOs involved in the response to AIDS have provided counseling services on a permanent basis. They have also developed intervention models and conducted research for their target audiences, as well as educational materials and training. __________________________________________________________________________________________________ Caribbean Health Research Council
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However, it was in 2002, with the development of the “National Regulations and Procedures on STI/HIV/AIDS Counseling” and the creation and implementation of the National Network for Voluntary Counseling and Testing (REDPAV) that the foundations were set to foster and establish standardized counseling procedures. The creation of this network (REDPAV) is the result of a joint effort between the DIGECITSS and COPRESIDA, with the technical and financial support from the project IMPACT/FHI (USAID), and the technical and administrative coordination of the Genesis Foundation. The Network was articulated in principle for the ENDESA 2002 survey to support the study on seroprevalence projections. This activity resulted in approximately 75 counseling sites throughout the national territory, which have now been increased to 100 sites. A total of 14 training workshops were conducted and 361 health professionals trained in pre and post test counseling. The BCUs and the ACs will provide medical treatment, testing, case management, nutritional information and counseling, including treatment adherence. These centers will have multidisciplinary teams including psychologists who will provide individual counseling, adherence, supervision and peer counselors to direct group sessions. STI/HIV/AIDS counseling still requires further strengthening to improve the quality of the services provided. This program plays a crucial role in increasing the rates of adherence to ARV treament, the prevention of OIs, and drug resistance. 2.9.3 Laboratory Testing The first institution in the country to conduct HIV testing was the National Laboratory Dr. Defilló of the MOH. At present, several other centers, both public and private, conduct HIV‐AIDS test. Within the MOH network, around 140 hospitals perform quick testing and about 30 of them also conduct Elisa tests. The most important private laboratories conduct also HIV‐AIDS tests, but they generally do not provide counseling. The National Laboratory Dr. Defilló performs Elisa, Western Blot and CD4 count, as well as aglutination (complementary), making close to 3,000 tests by trimester. As a national reference center, this laboratory should develop a quality control system, and COPRESIDA is currently in the process of negotiating the rental of the required equipment for molecular biology. A private non profit institution, the Dermatology Institute has also the capacity to perform tests at a lower cost than the private laboratories, including CD4/CD8 cell counts and viral load. Quality control is maintained in coordination with the Centers for Disease Control (CDC) in Atlanta. Testing for the recruitment of individuals into the ARV treatment __________________________________________________________________________________________________ Caribbean Health Research Council
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program is conducted in the Institute’s laboratory with funding from the CONECTA Project. To date, it has performed 956 tests in adults and 210 in children. The Dominican Red Cross performs voluntary HIV testing with pre test counseling. Private laboratories also conduct HIV testing, but in general, no pre or post counseling is provided. The Reference Laboratory is an exception. They provide Elisa, Western Blot , CD4 and viral load, with pre and post test counseling. More than 300 private laboratories at the national level refer to them the samples and also receive patients referred by public hospitals, who receive subsidized tariffs. They have external quality control from the American Pathology Association and the CDC, Atlanta. 2.9.4 Antiretrovrial Therapy (ARVT) In 2002 the network of PLHAs (REDOVIH) presented a suit before the Interamerican Court of Human Rights, demanding the Dominican government to begin implementation of a care program for HIV/AIDS patients. In response, the Court compelled the government to favor the petitioners with cautionary measures as a temporary solution. This event triggered the process of ARV provision in the country. ARV treatment began on March 2003. The same year, a Contingency Plan was developed to this effect, and presently more than 400 PLHAs are being treated with antiretrovirals. It is anticipated that this number will be increased to reach 800 by yearend. With this plan, all individuals requiring ARVT will be progressively enrolled in the program through a network of institutions that provide integral care services. In the near future, the country could have the capacity to provide an adequate response to the demand for ARV treatment, with two important support proposals: one from the Global Fund that will reach approximately 6,000 individuals; the other from the Clinton Foundation to cover the remaining group. In total, it is estimated that ten thousand people will require ARVT during the next few years. The integral care initiative will provide the government with institutional clinical support for ARV treatment. The MOH, the HIV/AIDS Prevention and Control Project, the CONECTA Project, Columbia University and the Clinton Foundation have developed a joint program for ARV treatment to be conducted in two initial stages. The criteria for the national ARV treatment include: a clinical evaluation, a CD4 cell count, and the patient’s consent to initiate treatment. A plan for treatment adherence should also be included, so the patient is committed to adhere to the therapy thus reducing drug resistance. Likewise, strict monitoring and follow‐up should be made by trained health personnel participating in the program.
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The therapy scheme was selected following the WHO guidelines for countries with lower incomes, and the participation of national technical personnel and the School of Public Health from Columbia University. First line drugs include the following: AZT+3TC+Nevirapime AZT+3TC+EFZ Second line drugs include: AZT+3TC+Lopinavir/ritonavir (Kaletra) In the private sector, there is an informal and uncontrolled use of ARV drugs by HIV individuals who purchase them in the local market or receive them from family members living abroad. The “National Commission on ARV Drugs” was created by COPRESIDA to provide information and to design strategies for the use of antiretroviral drugs. This Commission designed a Plan for the period 2003‐2008 to guarantee equal access to those individuals that comply with the criteria set forth in the National Protocol. This plan contemplates the establishment of guidelines concerning the scope, procurement, storage, logistics, administration and provision aspects of the ARV treatment. ARV treatment requires the proper support and care to ensure continued adherence. Those establishments providing the service must comply with the standard requirements. The provision of ARVT in the country is an ambitious and complex project that is still in its initial stage of development and it has already received numerous complaints from PLHAs, who feel that the number of recipients is still considerably low. Nonetheless, in order to extend coverage, it is paramount to ensure sustainable funds to finance the program and institutional capacity to provide the services, as once treatment is initiated, it has to continue during the whole life span of the patient. 2.9.5 Opportunistic Infections Primary and secondary prophylactic treatments are used to reduce morbidity and the risk of opportunist infections. Primary treatment refers to providing preventive medication to those patients who are asymptomatic. Secondary treatment refers to providing drugs to patients who have developed the disease and were asymptomatic, thus avoiding recurrence. This is considered as maintenance therapy. The most frequent opportunistic infections in the Dominican Republic are: tuberculosis, pneumonia (Pneumocistis Carini), recurrent diahrrea (Criptos Poridium), Kapossis Sarcoma and vaginal and skin diseases, but there is no regular pattern among AIDS patients. __________________________________________________________________________________________________ Caribbean Health Research Council
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The health system provides treatment and drugs for opportunistic infections, and these are available to all persons regardless of their status. Tuberculosis is endemic in the country, with the highest rates of resistance to antituberculosis drugs in the world. DOTS/TAES is the commonly used therapy, and the MOH assumes the cost of treatment and prophylaxis through the National Program for the Control of Tuberculosis (PNCT). 2.9.6 Home care and orphan support A bidding process is now in progress to conduct a pilot project for home care that will employ NGOs with previous experience in community work. In addition, a national Guide for Home Care has been developed and is currently being printed for its dissemination and use. This guide was elaborated originally in 1990, within a pilot project of two years, developed by PROCETS and the Institute of Human Sexuality, which implemented home care in a very structured way. Great benefits were obtained in terms of prolongation of the life of the patients, improvement of its quality, reduction of the hospitalizations, reduction of the financial impact of the disease and improvement of the family health in general, as a result of the education received. When the project was concluded, the home care intervention returned to become of informal and sporadic way. It was fundamentally under the charge of nurses of the Sanitary Center, some NGOs and members of REDOVIH. The new Home Care project will be implemented in the capital city, in low income sectors and under the scope of the Primary Care Units and the Basic Care Units of the MOH (SESPAS). The PCUs will be responsible for the health services and the NGOs will act as liaison with the community. The care provided is clinical as well as palliative. The project is also intended to provide support to AIDS orphans, whether they are infected or not. Some institutions in the DR foster orphans, but only the Casa Rosada takes in orphans with HIV/AIDS. There exist some other programs, as a study conducted by JSI/Promundo to estimate the existing number of orphans and vulnerable children in the country and some new interventions which are beginning through CONECTA.
2.10 Financing of the National Response to HIV/AIDS In 2000, the national spending in HIV/AIDS was estimated in US$40 million, of which households contributed approximately 42%, primarily as out‐of‐pocket expenditures.4 During recent years, with the consolidation of the National HIV/AIDS Program, the resources allotted both by the national government and the international financing agencies have increased considerably. In the beginning, the bulk of external resources were assigned to prevention Estimates are based on data provided by the National HIV/AIDS Accounts, 1998‐99 and the consultancy report prepared by Rolando Pérez Uribe, “Estimated spending of the national HIV/AIDS control program”, 2002. The household participation corresponds to 1999. 4
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efforts, and for 2004 with start of the National Program for Integral Care, a substantial increase of funds is foreseen, particularly for the provision of ARVT. Presently, the information on national health expenditure and its distribution of public‐private sources of financing and programmatic functions is not available. However, the Plenitude Foundation, under contract with COPRESIDA is collecting the data to prepare the National HIV/AIDS Accounts for the period 2001‐2003. Once completed, accurate and updated information will be available on the financing provided for the expanded response to HIV/AIDS in the country. This section presents some estimates, basically with respect to the commitment of resources with international funding. The following table shows the main financing contracted by the DR for the national response over a five‐year period. Although some of the projects began operations a few years ago, as in the case of the World Bank loan, their implementation is still as low as 20%. The Global Fund resources are in the initial phase of disbursement, and the funding from the Clinton Foundation has yet to be determined. Table 6 MAIN SOURCES OF EXTERNAL FUNDING FOR HIV/AIDS PROGRAMS IN THE DOMINICAN REPUBLIC FINANCIAL ORGANIZATION
RECIPIENT INSTITUTION
DESCRIPTION
US$ MILLIONS 30
TIME LIMIT 5
IMPLEMENTATIO N PERIOD* 2001/2006
World Bank
COPRESIDA
HIV/AIDS Prevention and promotion, basic care for PLHAs and STI surveillance
USAID/FHI
CONECTA
MTCT counselling centres, TV program, ENDESA
25
5
2002/2007
Global Fund
COPRESIDA
Access to HIV treatment, including ARV; support for PLHAs and family members
49
5
2004/2008
Clinton Foundation
COPRESIDA
Gap to be allocated basically for drugs and institutional strengthening of the national program for integral care, including training through the Columbia University.
Not determined
5
2004/2008
With respect to external funds that have been approved for the year 2005, the following table shows the contributions of the main international cooperation agencies, by program. As it can be observed, only from these sources, the country will receive US$ 22 million, disbursement subject to the implementing capacity of the national authorities. __________________________________________________________________________________________________ Caribbean Health Research Council
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In addition, other funds in a smaller scale and unquantified yet are available. The main characteristics are described in the Annex. .
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Table 7 ESTIMATED EXTERNAL FUNDING FROM MAIN SOURCES, BY PROGRAM – 2005 Program
World Bank
Components
Policies
0.8
Global Fund 0.8
USAID/ CONECTA 0.1
TOTAL
4.2
3.9
1.5
9.6
1.4
1.9
3
6.3
3.4
0.9
0
4.3
9.8
7.5
4,6
21,9
1.7
Legal Research Epidemiological Surveillance Social mobilization Prevention
Laboratories IEC Condoms STIs Mother to child transmission
Care
STI Training Counselling Integral care Networks
Cross cutting issues
TOTAL
Human Rights Gender Decentralization Equity Sustainability Institutional strengthening
Presently, a technical team from COPRESIDA, SESPAS and the cooperation agencies are in the costing process for the National Integral Care Program, which will require a larger volume of funds, both national and external for the next few years. To this effect, a projection has been made of the number of persons requiring ARVT, including those already in treatment, to reach 8,000 patients by the year 2008. A high percentage of this population will be reached, requiring a larger effort. A preliminary estimate places the cost of the program for the first five years in approximately US$95 million. Close to 70% consists of goods, products and drugs. After the assumptions in the model are completed – which include care packages to meet the needs of different types of patients, according to international protocols – available funds will be identified, both in the national budget and external resources already committed. The Clinton Foundation, which mobilizes donors worldwide and obtains substantial cost reductions in drug prices, will fill in the gaps.
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Based on the above, it may be assumed that most of the external resources to finance the expanded response to HIV/AIDS are available for immediate implementation. Developing the National HIV/AIDS Accounts at this time is an important milestone, because they would serve as the baseline for monitoring the financial response to the epidemic. It is important to highlight an important issue: how to guarantee the sustainability of the National Program in the long run. It is not realistic to assume that it is going to be financed always through international cooperation. It is required, consequently, that HIV‐AIDS is included in the discussions on the basic package for the new social security system. The present process of health care reform has the possibility of contributing substantially to the problem, as it intends to guarantee quality and efficient preventive and curative services. An integral response to the health problems of the Dominican population supports sustainability of the HIV‐AIDS program better than a vertical approach.
2.11 Stigma and discrimination Stigma is a negative and subjective factor which very often leads to the discrimination and self marginalization of people living with HIV/AIDS. Like the disease itself, stigma affects their standard of living, thwarting their possibilities of leading a normal life and diminishing their access to quality health care services. Also, the fear of social marginalization due to stigma increases the secrecy of the epidemic and contributes to its silent spread. No specific research has been conducted in the country specifically designed to determine the level of stigma, felt or perceived, associated with HIV/AIDS. However, there are other studies that deal with the issue. The 1998 Situation Analysis and the Response to HIV/AIDS in the Dominican Republic and other similar documents, highlight the importance of stigma and its consequences on the lives of PLHAs. There is no program or specific intervention to address the reduction of stigma and discrimination of PLHAs. However, this is a transversal objective present in most of the actions in response to the epidemic. All the actions in progress tend to promote greater acceptance and understanding of people living with HIV/AIDS by the general public. Some of the interventions that promote this change are HIV/AIDS information campaigns and the recognition of the human rights of PLHAs, and those that clarify the difference between a fatal and a chronic illness, since it is now clear that a positive HIV status is not a death sentence. These interventions have somewhat reduced the fear and rejection of the disease. The generalization of the epidemic has also influenced this conceptual change, since it now affects other population groups and not the initial outcast groups such as homosexuals, drug users and commercial sex workers.
2.12 Monitoring and Evaluation __________________________________________________________________________________________________ Caribbean Health Research Council
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The monitoring and evaluation component of the National HIV/AIDS Program is still at a very early stage. There is no actual system for its implementation, although there is increased awareness of its importance for improved management and a better use of the resources. The lack of a monitoring and evaluation system was clearly evident during the implementation and assessment of the National Strategic Plan 2000‐2003. In order to avoid repeating this deficiency, measurable indicators will be included in the NSP that is being formulated for the period 2004‐2008. The systematic tracking of core performance indicators has been scarce and inadequate in the country. As part of the requirements of all the international donors, it has been part of all plans and programs; but in general, at the national level it has been inefficient. A series of specific and baseline studies have been conducted since the beginning of the epidemic, but they have been implemented separately and not as part of a National Plan. Further details on the most relevant, are provided in the section on research. References of these studies are specifically stated in the bibliography. Two major assessments on the performance of the National HIV/AIDS Program were conducted in 2003. The first included a data collection exercise for the revision of the indicators approved during the United Nations General Assembly Special Session on HIV/AIDS on June 2001, (UNGASS) which became the Declaration of Commitment on HIV/AIDS. This exercise was in line with the guidelines established in the document Guidelines for the Construction of Core Indicators. The AIDS Programs Effort Index (API) is intended to measure the degree of effort put into national HIV/AIDS control programs by domestic organizations, individuals and international organizations. It measures the strength of the country’s effort for an effective National HIV/AIDS Program, and is based on the opinions and inputs provided by a group of experts, which are collected in a questionnaire comprised of 181 questions within 10 program components. The API was applied to 54 countries in early 2003. The results in the Dominican Republic are based on responses from the 19 most knowledgeable respondents from government organizations, NGOs, international donors, PLHAs and other representatives of the civil society. The level of program effort in the Dominican Republic varies considerably, from a low score of 25 in mitigation programs to a high score of 85 in the legal and regulatory environment. In comparison with the previous API conducted in 2001, the country has improved its total API score by 16 points from 47 to 63 in the last two years. The following chart shows the levels of effort made by national programs in each component. __________________________________________________________________________________________________ Caribbean Health Research Council
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AIDS Program Effort Index 100 90 80 70 60 50 40 30 20 10 0
2003
Total
Mitigation
Care Programs
Prevention Programs
Human rights
Legal and Regulatory
Eval. Mon., Research
Program Resources
Organizational Structure
Policy and planning
Political Support
2001
Source: Latin America and the Caribbean in 2003: AIDS Program Effort Index Results (API)
In comparison with the other Latin‐American and Caribbean countries surveyed, the country achieved effort ratings above average in all components, with the exception of Care and Treatment. The LAC average was 51 out of 100; 12 points lower than the Dominican Republic (63). Regional Comparation AIDS Program Effort Index of 2003 100 90 80 70 60 50 40 30 20 10 0 Political Support
Policy and planning
Organizational Structure
Program Resources
Eval. M on., Research
Legal and Regulatory
América Latina y el Caribe
Human right s
Prevention Programs
Care Programs
M itigation
Total
República Dominicana
Source: Latin America and the Caribbean in 2003: AIDS Program Effort Index Results (API)
As they increase their resources to the country, donors have also increased their requirements for assessing and measuring the impact of the various interventions. This has resulted in new information systems and different indicators to measure the results. The Country Response Information System (CRIS) is a Monitoring and Evaluation tool being promoted by UNAIDS. A workshop was carried out in June 2004 within the framework of the project Strengthening the Institutional Response to HIV/AIDS/STIs in the Caribbean (SIRHASC), to present this information system and analyze the alternatives for establishing an institution that could lead and be ultimately responsible for all M&E __________________________________________________________________________________________________ Caribbean Health Research Council
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activities in the national response. Several recommendations were made for possible implementation strategies of this M&E unit, as well as the implementation of CRIS. The most outstanding strengths identified included the general awareness among all stakeholders of the importance of M&E and the need to set up a unit within an institution like COPRESIDA that would formulate and report core indicators, including the UNGASS indicators and the Millennium Development Goals. This would facilitate proper channeling of resources and the reformulation of programs so as to benefit from the experiences of all sectors involved. At present, and with the increased coverage of ARVT, it is extremely important for the country to strengthen its control mechanisms. The health system must be very efficient in terms of logistics and storage of ARV drugs, and should create a computerized information system to register and keep and control of new patients and their requirements and use of ARV. The Integral Care Unit, in coordination with other departments, will be responsible for setting up an adequate system to monitor and control the new integral care system.
2.13 Epidemiologic Surveillance Serologic testing for HIV‐AIDS began in 1991 in the Dominican Republic and the epidemiological surveillance of this is responsibility of DIGECITSS. There are three different lines of surveillance: (1) notification of passive surveillance of infections and cases, done by doctors, laboratories and blood banks; (2) active surveillance in sentinel posts which capture information on pregnant women, sexual workers and STI patients, and national surveys like the DHS with serological testing; and (3) second generation surveillance, which refers to well defined territorial studies where beliefs, attitudes and practices are studied in risk populations in order to analyze changes in behavior which may support the need of special serological studies. The Dominican Republic initiated very early the HIV-AIDS epidemiological surveillance including the first sentinel posts in LAC. However, the institutional weakness of the health sector is responsible of the lack of precision and under reporting of the system.
2.14 Research Theoretical or applied, research is one of the aspects linked to the expanded national response. Research on sexuality issues began in the early 1980s. The first research study on HIV/AIDS was completed in 1985. There is no specialized documentation center for HIV/AIDS, but PROFAMILIA has a compilation of more than 160 studies on sexuality and HIV/AIDS. Most of these studies were made during the period 1986‐1992. An interviewed specialist attributes this fact to the impact, the alarm, fear and initial curiosity generated by __________________________________________________________________________________________________ Caribbean Health Research Council
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the emergence of the disease in the country. Most of the work available deals with HIV prevalence and psychological and social issues (beliefs, knowledge, attitudes and practices), followed by epidemiological data and anthropological factors. A large group of these studies have been made spontaneously, and close to 70% were financed by the researchers themselves. More than half are grade theses, postgraduate studies or masters degrees, and a variety of methodologies have been used. The most common research topics include: • Condom use among young people, female sex workers, men who have sex with men and adults in general. • HIV/AIDS and its incidence on premarital sex. • Knowledge, beliefs, attitudes and behavior patterns associated with HIV/AIDS among adolescents. • Social vulnerability to HIV/AIDS. During the last few years, a series of important research studies has been carried out, namely, a Situation Analysis and the Response to HIV/AIDS (1998), a Situation Analysis and HIV/AIDS Programs in the DR (2001), the ENDESA 2002 survey, which includes a module on HIV/AIDS, a study of the Socioeconomic Impact of HIV/AIDS in the Tourist Sector (2003), the AIDS Program Effort Index (API) (2003), Follow‐up and Monitoring of the UNGASS Declaration of Commitment (2003) and the Assessment of HIV/AIDS Care Services in the DR (2003). All these studies were consulted during the preparation of this report, and complete references are provided in the Bibliography. The Dominican Republic does not have a formal program for the study and research of HIV/AIDS, and there has been no regular and systematic management of the issues. The academic research studies have been made in response to the interest and personal curiosity of their authors, and most of the rest were made to comply with specific requirements of the projects and programs that financed them. However, according to the sources consulted for this report, there seems to be sufficient coherence in the approaches and a solid consistency in the results obtained.
It is relevant to point out that currently, the DR is taking part in a HIV vaccine trial. The negotiation process started in 2001 with a proposal once the country was included in the study by the HIV Trials Network (HVTN), which is financed by the United States National Institutes of Health (NIH). The project receives international financing for US$975,000 and a local contribution of US$300,000. The first project protocol, which consists of the recruitment of volunteers, was presented to and approved by the National Bioethics Commission on Health (CONABIOS)5. The next phase, which consists of the actual vaccine trial on a group of 20 people, requires the approval of a new protocol by the CONABIOS. The project, with the coordination of 5 The National Bioethics Commission, a división of the MOH, was created on August 2, 2000 to ensure that all research activites are carried out in compliance and with respect to the human rights, and that decisions are made based on correct information.
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UNAIDS, is a joint venture between the Dermatology Institute Huberto Bogaert, the DIGECITSS y and the Centro de Orientación e Investigación Integral (COIN), a national NGO that has worked for many years in the area of HIV/AIDS. The vaccine unit is located in the Dermatology Institute.
2.15 Core Caribbean Indicators The Caribbean Health Research Council (CHRC), as part of its objective to minimize the regional impact of HIV/AIDS, promotes joining efforts and increasing the existing organizational capacity to plan and coordinate an effective expanded response. The Caribbean Indicators and Measurement Tools (CIMT) for the assessment of national HIV/AIDS programs was developed as a common mechanism to guide nations in the collection of monitoring and evaluation data, that would contribute to a coordinated regional response for the development and implementation of effective and efficient programs. The main programmatic areas identified are: policies, prevention, care, support and treatment, human rights and socioeconomic impact. In the Dominican Republic, the Plenitud Foundation at the request of the CHRC, asked the institutions responsible for collecting these and similar indicators, to fill out a matrix in order to identify which of the Caribbean core indicators were available, the period covered, the source and time limit for submitting this information to the CHRC. This matrix is part of the Annex. As it can be observed, the institutions answered questions about the availability of the information, but they were not able to provide the data. The baseline for many of these indicators exists in the Demographic and Health Survey (DHS‐ENDESA), conducted in 2002. As previously mentioned, this survey included a module on HIV/AIDS, which represents the most complete research in terms of HIV/AIDS indicators with national scope, including insights, level of knowledge, prevention attitudes and prevalence. However, there is a need of further analysis of the database in order to obtain the quantitative indicators required, which makes them not available at present. The following paragraphs indicate some comments on the availability of the data in each programmatic area. 2.15.1 Prevention Communication for behavior change: The ENDESA contains the indicators for communication on behavior changes that have been identified by the CIMT. Some of these can be obtained directly, and others require data base processing. The CONECTA Project has been collecting indicators on commercial sex work through its behavior surveys (BSS) and it also applies to the indicators on adolescents and youth.
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Condom programs: The information on the access to condoms is included in the database of the ENDESA survey. Other indicators in the condom program are not available in the format defined by the CIMT. Intravenous Drug use: There is no data available in the Dominican Republic regarding the use of intravenous drugs. Most of the existing evidence and the reports prepared by those institutions working on the issue are not available. Voluntary Counseling and Testing (VCT): The collection of indicators on Voluntary Counseling and Testing is being initiated through the new care model in the Coordinating Unit for Integral Care (UCAI) of the MOH and the Genesis Foundation. The data is not yet available. Mother to Child Transmission: Some indicators are collected through the National Program for the Prevention of Mother to Child Transmission (NPMTCT) of the MOH. A further analysis work is required. Blood Security: These indicators are not available in the CIMT format. A variation of some indicators is collected by the Laboratory and Blood Bank of the MOH, but there is a need of some additional processing. 2.15.2 Care, Support and Treatment The indicators on care, support and treatment are going to be available soon through the Basic Care Unit of the MOH and CONECTA. 2.15.3 Training and Institutional Strengthening The indicator on the number of people trained over the last twelve months will be available soon through the CONECTA project. Other indicators, as defined by the CIMT, are not available. 2.15.4 Advocacy and policies The AIDS Program Effort Index (API) is performed by FHI for UNAIDS every two years and was referred to in the section on monitoring and evaluation of this report. Currently, the Plenitude Foundation is doing a study on HIV/AIDS Accounts for the COPRESIDA with WB funding. This study – which will be finished early in 2005 ‐‐ will provide data for the second indicator, which refers to the spending on HIV/AIDS prevention and care. 2.15.5 Human Rights, Stigma and Discrimination __________________________________________________________________________________________________ Caribbean Health Research Council
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Some of the pertinent indicators are included in the data base of the ENDESA, and can be constructed with some additional processing work. 2.15.6 Socioeconomic Impact Presently, the Plenitude Foundation is beginning a study for COPRESIDA with WB funding on the socioeconomic impact of HIV/AIDS and will be available at the beginning of 2005.
III. MAIN SUCCESSES AND CHALLENGES The initial response to HIV/AIDS in the DR was the provision of traditional health services for opportunistic infections when they emerged. As the epidemic began to spread and its consequences worsened, the social awareness of its magnitude increased. The impact of the disease had evolved from a clinical assistance issue, to a matter of public health, to finally assume a multisectorial dimension. As perception of the epidemic changed, so did the national response. At the present time, the expanded response to HIV/AIDS tends to be increasingly multidimensional and due to its basic nature, actions can be divided into the following areas: a) promotion and prevention; b) care and treatment; c) coordination and management of the sector; d) legal, recognition of rights and antidiscriminatory practices; e) organization of people living with HIV/AIDS; f) epidemiological surveillance; and g) theoretical and applied research. In its early years, the HIV/AIDS epidemic was concentrated in groups with specific sexual behaviors that were subsequently classified as high‐risk groups. However, the disease has spread among the general population, while sexual transmission is the most frequent mode of infection. In fact, most of the first cases registered were found in homosexual men, but since the late 1980s this situation has changed, and presently close to 75% of the cases are heterosexual. The same has occurred with preventive actions. Initially, prevention campaigns were focused on high risk groups and now they address the entire population, although in most cases the messages and the audiences are targeted. In an increasingly globalized world, it is only natural that AIDS and the response extend beyond national boundaries and become international in nature. Thus, the Dominican Republic has received support form the world community that works with HIV/AIDS, generating a strong and permanent exchange of methodologies, tools and experiences. In the international arena, the United Nations Joint Programme on HIV/AIDS (UNAIDS) has played a key role in the development, systematization and implementation of a wide array of management tools for the expanded response to HIV/AIDS worldwide. The standardization of best practices, tools and indicators has contributed to create an __________________________________________________________________________________________________ Caribbean Health Research Council
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international language and a culture on the issue, facilitating the exchange and comparison among nations. Any assessment of the national response to HIV/AIDS in the Dominican Republic would verify that, although many gaps and barriers need yet to be overcome, important successes have been achieved and the general outlook is hopeful. The following are some of the most significant achievements: • Political will and the incorporation of many social actors in the expanded national response to HIV/AIDS. The existence of COPRESIDA has been fundamental, as it has ensured national political commitment, although sometimes it appears to be only a formality because there has been insufficient budgetary support. On the other hand, it has served to increase the number of social actors involved in the national response to the epidemic, although the level of commitment is still low and great limitations persist. COPRESIDA has also played a key role in obtaining external funding, both in the form of donations and loans. • General planning to face the epidemic. Since the late 1980s, the nation has developed national plans to direct and conduct coherent actions in the response to HIV/AIDS. The greatest achievement to this end is the National Strategic Plan 2000‐ 2003, which is currently being revised for its reformulation towards the period 2004‐ 2008. • Launching of the program for antiretroviral treatment. The provision of ARV drugs for PLHAs has been recently initiated. This is a significant step that opens new perspectives of hope and better quality of life for PLHAs. There are still some serious technical and economic difficulties, but with the launching of the National Program of Integral Care and the arrival of funds from the Global Fund and the Clinton Foundation, greater improvement is foreseen. • Probable reduction of the national HIV/AIDS prevalence. According to the DIGECITSS, data from sentinel surveillance estimated that at the beginning of the year 2000 the national prevalence rate was 2.3%. As we have seen, recent data from the national survey ENDESA 2002 indicate a rate of 1% within the 15‐49 population group. Although the calculation methodologies are completely different, and the ENDESA findings represent only a moment in time thus they cannot be used in a dynamic assessment, it would seem possible to assume that there has been a slight reduction. • The formation of two organizations of PLHAs. The first national organization of people living with HIV/AIDS was formed in 1996. Since then, continuous work has been done to strengthen this space for exchange and support, where common interests are identified and joint actions are promoted. • Awareness among high‐risk groups of their vulnerability and the need to change their sexual behaviors to prevent the spread of HIV. The work that has been done with vulnerable groups has been successful in curbing the spread of the epidemic. • Sensitization regarding PLHAs. Despite the fact that stigma and discriminatory actions against people living with HIV/AIDS still take place in the country, the __________________________________________________________________________________________________ Caribbean Health Research Council
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•
•
disease has progressively lost its “demoniacal” facade from the early years, and people are now showing more respect to the rights of PLHAs. High level of information on HIV/AIDS among the population. The data from the ENDESA 2002 reflect that the DR has a good level of information about the disease, the ways of preventing the infection and the risk exposure, among others. Development of an epistemological community with human resources and managerial assets specialized in HIV/AIDS. The response to HIV/AIDS has produced a series of quality operational systems and tools and has formed a community of individuals that have been linked to the issue for years, creating a cultural environment of high technical and human conditions. This group is an example of commitment and devotion that enhances the nation’s social assets.
As indicated in the preceding paragraphs, the successes achieved in the response to HIV/AIDS are considerable. This, however, has not been an easy process. There are still many obstacles in the way, and a lot of conscientious efforts need to be made to overcome them. Some of these are the following: • Lack of integration of the National Program of HIV‐AIDS to the process of health sector reform. The Dominican Republic is immersed in a process of reform of the health sector and its social security system. Until the moment, the efforts in the fight against the epidemic have been made in a parallel way, without a true integration with the reform process. This situation attempts against the long term sustainability of the Program, particularly, of the integral care component, which will absorb the bulk of the financial resources in the years to come. • Low level of coordination in the sector. The decree that created the COPRESIDA grants it the tasks of coordination and the design of national policies on HIV/AIDS in the country. However, regardless of the advancements made, the sector is still disaggregated and requires more asserted actions in the general coordination and leadership of the process. • Overlapping of institutional functions, duplication of activities and leadership discrepancies. The country lacks a clear definition of the official roles, particularly in COPRESIDA, the MOH (SESPAS) and DIGECITSS, a situation that originates confusion, overlapping of actions, and conflict. Likewise, with a weak general coordination, the duplication of work among official institutions, NGOs, cooperation agencies and projects financed with international funding. Very often, assuming the leading role is placed before the national interest. • Insufficient resources allocated in the National Budget. The political commitment of the government should be consistent with the budgetary allocations to support the national response. There is no specialized budget for HIV/AIDS and even COPRESIDA has been faced with serious financial difficulties, having to support is operations costs with resources from the Work Bank project. Even the project activities have been thwarted by frequent setbacks and delays in the disbursement of the national counterpart funds. • Institutional weaknesses. Operational deficiencies in the national institutions have affected the quality of the national response. These weaknesses are common to the __________________________________________________________________________________________________ Caribbean Health Research Council
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•
•
•
•
entire organizational structure for the response, starting with the coordination and leadership of the sector, to the managerial, technical and administrative performance of public and private institutions, NGOs, and projects with external funding, and lastly with the management and provision of the medical services. Lack of monitoring and evaluation systems. For years, the country has had national plans to fight the HIV/AIDS epidemic. However, tackling the success stories has been difficult because adequate indicators were not identified in advance to allow follow‐up actions, and above all, the systems for monitoring and evaluation were never implemented, with the exception of some projects with international funding. Deficiencies in the legal system and lack of initiative on the part of PLHAs to demand their rights and the enforcement of the AIDS Law. The inherent weaknesses of the country’s legal system have been a limitation for the enforcement of the AIDS Law and to become a significant contribution to prevent the HIV infection and the respect for the rights of PLHAs. Notwithstanding, even more important is the lack of initiative among PLHAs to demand their legal rights and to stop illegal discriminatory practices. Poor access to organized information. Plenty of information is collected in the country, but most of it is not processed and is very disperse, which makes it very difficult to access. In addition, there is no documentation center where people can access studies, consultancies, reports and publications on HIV/AIDS. Very limited community participation in the search and implementation of solutions. The actual integration of community members throughout the country has not been achieved, which would add a social basis, popular knowledge and effectiveness to the activities.
IV. CONCLUSIONS AND RECOMMENDATIONS The balance of achievements and challenges described in the previous section, leads to the conclusion that the DR has made considerable advancements with respect to similar assessments made on previous periods6. At the institutional level, one major achievement has been the creation of COPRESIDA and DIGECITTS, although both still require greater budgetary support and institutional strengthening. These institutions have contributed to the mobilization of significant external resources that have made possible the startup of the National Integral Care Program. Important efforts have been made in the area of prevention, which possibly account for a decrease in the prevalence rates and the increased awareness of the problem in all levels of society. Important advancements have also been made in terms of strategic planning as well as research, although there is still some deficiency in monitoring and evaluation. The next paragraphs provide some recommendations to consolidate the National Response to HIV/AIDS in the Dominican Republic, and to overcome the barriers confronted. Cáceres, de Moya, et al, Análisis de la situación y la respuesta al VIH‐SIDA en República Dominicana, IEPD, Santo Domingo, 1998. 6
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These recommendations are based in most part on the consultations made to key informants from the National HIV/AIDS Program. • Integrate the National Program of HIV‐AIDS to the process of health sector reform. The long term sustainability of the National Program of HIV‐AIDS depends on its integration to the process of health sector reform and, particularly, of the social security system. Although it is certain that the National Program has a multisectorial character, that extends the health sector, it is not less certain that the bulk of the resources that the country will assign to it in the next years, will correspond to the program of care to patients. The inevitable transformations in the health sector as a consequence of the reform will have an important impact in the technical and financial viability of the HIV‐AIDS program, reason why it is not advisable that it stays like an isolated effort. Until now, the fight against HIV/AIDS has relied considerably on the international cooperation. To avoid a traumatic separation in the future, the country should begin to seek alternative operational modalities and resources to guarantee the sustainability of the activities once the international sources are depleted. • Reinforce COPRESIDA´s core functions. In coordination with other state institutions, COPRESIDA should have clearly defined roles, demand an increase in its budgetary resources, and build the organizational structure that is contained in its constitutional decree. This will encompass an important process of institutional strengthening, particularly with respect to its capacity to manage the bulk of international resources that have been committed. • Improve the coordination of projects, programs and donors. The State should assume with stronger authority its coordination and general leadership roles in the national response to HIV/AIDS. To this effect, it is essential that donor meetings are continued to be held, under the leadership of COPRESIDA. In fact, all projects with international funding should follow the guidelines that will be designed in the National Strategic Plan and COPRESIDA. • The formulation of the NSP 2004‐2008 should be concluded. The NSP 2004‐2008 will be a valuable tool that will incorporate the experiences and lessons learned in previous planning exercises; therefore, completion of the ongoing process is very important for future actions. • Set forth a monitoring and evaluation system for the national response to HIV/AIDS. In order to verify the appropriateness between planning and implementation, and to ascertain the level of the national response, the authorities must create a unit for M&E that includes external assessments of the national response to HIV/AIDS. The unit would be in charge of the selection and design of indicators and report the data to the CRIS, UNGASS and UNAIDS. In addition, it is indispensable to include the M&E component in all projects, programs and units in the sector. Likewise, M&E systems should be user friendly to facilitate its use. • Establish the production of National HIV/AIDS Accounts as a permanent activity. A systematic and permanent production of national HIV/AIDS accounts is required in order to monitor the spending and the financial resources available in the sector as __________________________________________________________________________________________________ Caribbean Health Research Council
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•
•
•
•
•
•
•
•
•
well as the shifts in resource allocation, and to ensure the funds are used to meet the local needs. Improve epidemiological surveillance. A revision of the HIV/AIDS epidemiological system would be convenient to improve the entire structure, from data collection to processing, as well as the presentation, dissemination and use of the information. Guarantee the access to integral care including ARV treatment and the efficiency of the national program. The Integral Care Program with the provision of antiretrovirals is a great achievement and a hopeful event for PLHAs. In terms of the TARV, a guarantee of continued and regular access is imperative. It is also essential to provide adequate information and to stress the importance of treatment adherence. Financial resources should be identified ahead to ensure program sustainability, as the cost of ARVs is high and the treatment is long and should not be interrupted once initiated. The Basic Care Units should be incorporated into the health system, and efforts made to avoid overlapping with other structures. Improve the management capacity of the STI program, the program for MTCT, laboratory and blood bank control, etc. Basic management of the various specialized programs must be improved in order to enhance an effective response to HIV/AIDS. Situation analyzes of each program should be conducted, and proposals for improvement should be designed and implemented. Promote changes in the sexual behavior among vulnerable populations. The main deterrent barriers against HIV infection are healthy sexual practices. Dominicans are provided with a lot of information on HIV/AIDS, but the real challenge is to shift over this information and education to actual behavior changes. Guarantee continuous access to condoms for the poorest population groups. Together with increased campaigns to promote condom use, effective distribution channels should be identified to ensure that free condoms are regularly provided to the population groups that are unable to purchase them. Efforts to promote regular condom use should be continued. Guarantee respect for the human rights and social integration of PLHAs. Stronger efforts must be made to reduce stigma and discrimination against people living with HIV/AIDS. Means should be sought to guarantee their right to work and the access to integral health care. Special emphasis should be made on the empowerment of PLHAs and their participation in the country’s social life. Ensure the approval in Congress of the modified AIDS Law. After a revision process of the Law 55‐93, which was carried out with the active participation of the main actors in the issue of HIV/AIDS, a draft bill is being submitted to the national congress. This process should successfully culminate in the approval of the reformed law, which includes amendments for its pertinent application. Increase community participation in decision‐making processes. Until now, communities have played a passive role in the response to HIV/AIDS. To improve the efficiency of the actions, community participation must be increased, both in decision‐making and implementation processes. Create an HIV/AIDS Documentation Center. The national authorities should create a documentation center specialized in HIV/AIDS related issues, to facilitate research and to document the historic memory of the process.
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BIBLIOGRAPHY Agreement of Collaboration Project Red‐PAV 2002, SESPAS‐DIGECITSS‐COPRESIDA. First draft of the Reformation to Law 55‐93 on AIDS, Version February 2004. Center on AIDS and Community Health (AED), SmartWork, Dominican Republic Country Brief, a critical need to government, business, and work tripartite response to HIV/ADIS AT the workplace, July 16, 2003. CESDEM, Demographic health survey (ENDESA), Santo Domingo, 2002, Caribbean Health Research Council (CHRC), Indicators and Tools of Measurement of the Caribbean (CIMT), to evaluate the National Programs against the AIDS, Port of Spain, Trinidad and Tobago, 2003. COPRESIDA, Prevention and Control of VIH/SIDA Project, Report of Progress BM, June 2003. COPRESIDA, Detailed plan of Antirretroviral Therapy (ARV) 2003‐2008, Santo Domingo, 2003. COPRESIDA, COPRESIDA’s role in the integral attention in VIH/SIDA, Power Point Presentation. Santo Domingo, 2004. COPRESIDA, Monitory and Evaluation: Follow up of UNGASS Declaration, Santo Domingo, 2003. COPRESIDA, National Strategic Plan of ITS/VIH/SIDA, 2000‐2003, Santo Domingo, 2002.. COPRESIDA/Clinton Foundation, SESPAS/ DIGECITSS /UCAI, National initiative to the strengthening of the National Program for People Living with HIV‐AIDS in the Dominican Republic, 2004‐2009, Santo Domingo, 2004. COPRESIDA, Integral Care Net for HIV‐AIDS,, Santo Domingo, 2004. De la Rosa, Jaime, Ventura, Gisela, de Moya, Antonio and Wise, Maria, National strategy of information, education and Communication for the Prevention of HIV‐AIDS in the Dominican Republic, SESPAS, Santo Domingo, 2003. Del Conte, Adriana, A reform to be in health: keys for professionals of the sanitary sector, SESPAS / ONFED, EUROPEAN UNION, PROSISA, Santo Domingo, 2004. __________________________________________________________________________________________________ Caribbean Health Research Council
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Francisco I. Caceres Ureña, Isis Duarte, E. Antonio de Moya, Eddy Perez‐Then, Julia Hasbun, M. and Margot Tapia, Situation analysis and the Response to HIV‐AIDS in the Dominican Republic, 1998. Santo Domingo, 1998. Guerrero, Fátima and Elizabeth Tapia, Situation of Programs and Institutions related to HIV‐ AIDS in the Dominican Republic, Prevention and Control of HIV‐AIDS Project, COPRESIDA, Santo Domingo, 2001. ONUSIDA, Action SIDA/USAID, UNESCO, Results of the Index of Effort of the Program against AIDS (API) In the Republic Dominican, Evaluation 2003. Ortiz Bosch, Milagros, Angel Hernandez, Leandra Tapia and Irma Levasseur, Program of Sexual Affective Education, Secretariat of State of Education, Santo Domingo, 2003. Perez Then, Eddy, Monitoring of the Strategies of Reduction of Vertical Transmission of HIV‐ AIDS in the Dominican Republic , National Center of Mother and Child Research (CENISMI), Santo Domingo, 2002. Perez, Eric, Considerations on Values, Stigma and Discrimination for a New Reading of the Normative Answers to the Problematic of HIV‐AIDS in the region. International Seminary “The United Caribbean, Several Languages and Many Cultures to fight HIV‐AIDS”, Santo Domingo, March, 2004. Quezada, Tirsis, Update of the Context, Analysis of Situation and the Response, National Strategic Plan of ITS‐SIDA 2004‐2008, First report of consultancy. PNUD, Dominican Institute for Social Development, (IDESARROLLO), Santo Domingo, 2004 Rathe, M., Lora, D., Social security basic package in the Dominican Republica: An analysis of the interventions on sexual and reproductive health, INSALUD / Plenitude Foundation, Santo Domingo, 2002. Rathe, M., Lora, D., Rathe, L., Socio economic impact of HIV‐AIDS in the tourist sector of the Dominican Republic: a case study in the East coast, COPRESIDA/PNUD/Plenitude Foundation, Santo Domingo, 2003. REDOVIH, Program of Reduction of the Vertical Transmission and Importance of an Organization Integrated by People Living with HIV, Santo Domingo, 2003.
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ABBREVIATIONS
ARV
Antiretroviral
CAL
Center of Logistical support
CA
Centers of Attention to Ambulatory Patients with HIV‐AIDS
CDC
US Centers for Disease Control and Prevention
CRD
The Dominican Red Cross
CEPROSH
Center of Promotion and Human Solidarity (NGO)
CHAI
HIV‐AIDS Initiative of the Clinton Foundation
CPV
Counseling and Voluntary Test, also PAV
CNUS
Advice National Unit
COPARDOM
Confederation of Dominican Employerʹs association
COPRESIDA
Presidential Council for AIDS
TRSX
Sexual workers
DIGECITSS
General Direction for Infections of Sexual Transmission and AIDS
DOTS
Therapy of Direct Observation
FNUAP
Population Fund of the United Nations
GFATM
Global Fund against AIDS, Tuberculosis and Malaria
GDRD
Government of the Dominican Republic
GAMET
World‐wide Team Support Group on Monitory and Evaluation
HSH
Men who have Sex with Men
IDSS
Dominican Institute of Social Insurances
IEC
Information, Education and Communication
ONG
Nongovernmental Organization
IO
Opportunistic Infections
PEN
Strategic Plan
PVVS
People who live with HIV‐AIDS
PMTCT
Prevention of the Transmission Mother to Child
PNCT
National Program for the Control of Tuberculosis
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PNS
National Program for AIDS
PNRTV
National Program of Reduction of Vertical Transmission
SESPAS
Secretariat of State of Public Health and Social Assistance
AIDS
Syndrome of Acquired Immunodeficiency
ITS
Sexually Transmitted Infections
TB
Tuberculosis
UAB
Basic Unit of Attention
UCAI
Coordinator Unit of Integral Attention
UNDP
United Nations Program for the Development
USAID
Agency of the United States for the International Development
UNAP
National Unit of Primary Attention
ONUSIDA
Joint program of the Nations United for HIV‐AIDS
VIH
Human virus of Immunodeficiency
BM
World Bank
TAR
Antirretroviral Therapy
M&E
Monitoring and Evaluation
CHRC
Caribbean Health Research Council
CONASIDA
National Council on AIDS
PROCETS
Program for the Control of Sexually transmitted Diseases
ENIEC
National Strategy of Information, Education and Communication
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ANNEX
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ANNEX I LIST OF KEY INFORMANTS´ INTERVIEWS CONDUCTED KEY INFORMANT 1. José García Ramírez 2. Jaime De la Rosa 3. Fátima Guerrero 4. Antonio de Moya 5. Mayra Toribio 6. Nery Estévez 7. Adys Peralta 8. Tirsis Quezada 9. Elizabeth Gómez 10. Sofía Khouri 11. Adela Ramírez 12. Tessie Caballero 13. Rosa Julia Flores 14. Ydelsi Hernández S. 15. Ysidora Zabala 16. Clara Morillo 17. Juliana Martínez 18. Romario Castillo 19. Mayra García 20. María Isabel Tavárez 21. Ramón Acevedo 22. Dulce Almonte 23. Ramón Portes 24. Irene López 25. Ernesto Guerrero 26. Martha Butler 27. William Duke 28. Dulce Chaín 29. Jorge H. Blanco 30. Yudy Chong 31. Juan Lladó 32. Eddy Pérez Then 33. Irma Levvassier 34. Rafael Montero 35. Ivelisse Garris
POSITION COPRESIDA, Executive Director COPRESIDA, Technical Coordinator COPRESIDA, Promotion and Prevention COPRESIDA, Research COPRESIDA, Care and Treatment COPRESIDA, Policy COPRESIDA, Financial Unit COPRESIDA, Consultant, Strategic Planning COPRESIDA, Consultant, Epidemiology DIGECITSS, DIGECITSS, Epidemiologic Surveillance DIGECITSS, Epidemic Surveillance DIGECITSS, ITS‐HIV‐AIDS Component DIGECITSS, ITS Epidemic Surveillance DIGECITSS, Mother child transmission DIGECITSS, Administrator DIGECITSS, Laboratory and blood DIGECITSS DIGECITSS DIGECITSS, Integral Care Coordinator Unit REDOVIH, President REDOVIH, Executive Director Coalición ONGSIDA, President Coalición ONGSIDA, Executive Director UNAIDS, Country Program Advisor CONECTA‐USAID, Executive Director CONECTA‐USAID, HIV‐AIDS Program Man. CONECTA‐USAID, M&E Officer CONECTA‐USAID, Policy Officer CONECTA‐USAID, Technical Assistant Living work, Executive Director CENISMI, Deputy Director Education Ministry, Orientation Department Global Fund, Consultant Sanitary Center, Minister of Health
DATE OF INTERVIEW June 3rd June 16th June 17th June 21st June 15th June 21st June 15th June 8th June 18th June 14th June 14th June 14th June 14th June 14th June 14th June 14th June 14th June 14th June 14th June 4th June 21st June 21st June 17th June 17th June 18th June 4th June 4th June 4th June 4th June 4th June 21th May 19th June 21st June 2nd June 15th
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ANNEX II BASIC CARE UNITS AND DAY CARE CENTERS (In process of refurbishing or installation by financing project) Year 1 2 2
Number of UAB & CA 2 8 9
2
3
3
2
4
3
Total
27
Center and place
Project
Hosp. Arturo Grullón, Stgo. Hosp. San Vicente de Paul, SFM *Hosp. Cabral y Báez. Stgo. *Hosp. Luis E. Aybar, Sto. Dgo. Hosp. Antonio Musa, S.P.M. **Hosp. Jaime Mota, Barahona **Hosp. Ricardo Limardo, P. P. *Centro Sanitario, Sto. Dgo. *Hosp. Central F.F.A.A. Sto.Dgo. *Hosp. Infantil Dr. Robert Reid Cabral, Sto. Dgo *Centro Micaeliano, La Romana *CEPROSH, Puerto Plata y Dajabón Centro Activo 20‐30, Santo Domingo, SESPAS Lotes y Servicios, Santo Domingo *Instituto Dermatológico Dr. Bogaert, Santo Domingo y Santiago *Instituto Dominicano de Estudios Virológicos, Santo Domingo. Hospital Santo Socorro, SESPAS, Santo Domingo Hospital Francisco Gonzalvo, La Romana Hosp.Padre Fantino, Monte Cristi Hosp. Alejandro Cabral, San Juan de la Maguana Hosp.Juan Pablo Pina, San Cristobal Hosp. Luis L. Bogaert, Mao Valverde Hosp. San Bartolomé, Bahoruco Hosp. General Menenciano, Dajabon **Hosp.Maternidad Nuestra Señora de la Altagracia, Santo Domingo Hosp.Antonio Yapour, Nagua
CHAI World Bank USAID (CONECTA)
CHAI
CHAI CHAI
Source: Based on the National Initiative of CHAI * Offering integral care
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ANNEX III MAIN PROJECTS WITH EXTERNAL FINANCING __________________________________________________________________________________________________ Caribbean Health Research Council
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HIV‐AIDS PREVENTION AND CONTROL PROJECT Name of the Project HIV‐AIDS Prevention and Control Project Financing Agency World Bank World Bank ID PE‐P‐071505. Global Financing US$30 million. US$25 million in a loan from the World Bank and US$5 million DR Government Effectiveness date October 2001. Project implementation period 5 years Expected closing date December 2006 Implementing agency Consejo Presidencial del SIDA (COPRESIDA)
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PROJECT DESCRIPTION Component #1: Promotion/Prevention to Reduce HIV Transmission—US$14.35 million. Under this component, the project would support the development of five cost‐effective priority interventions: • • •
Information, education, and communication (IEC) activities to reduce HIV/AIDS transmission, with emphasis on high‐risk groups; Condom social marketing programs, with emphasis on high‐risk groups • Improved management and treatment of STIs; Interventions to prevent mother‐to child transmission of HIV; • Quality control of HIV testing in blood bank and laboratories.
Component #2: Diagnosis, Basic Care and Support of Individuals Affected by HIV/AIDS—US$7.65 million. Under this component, the project would support the implementation of the following diagnostic and basic care interventions aiming at reducing disability and death due to HIV/AIDS, reducing the reservoir of HIV/AIDS, and mitigating the suffering of children orphaned by HIV/AIDS: • • • • •
Organization of voluntary HIV testing with pre‐ and post‐test counseling services; Support of home care for HIV/AIDS patients; Establishment of basic AIDS Health Care Units; Implementation of directly observed treatment (DOT) regimens for tuberculosis (TB) patients; and, Support to children orphaned by AIDS.
Component #3: Strengthening HIV/AIDS and STI Surveillance; and Project Coordination, Monitoring, Evaluation and Research—US$3 million. Under this component, the project would support: •
•
Improvements in the HIV/AIDS and STI disease surveillance system; and,
Project coordination, monitoring, evaluation and research.
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NATIONAL RESPONSE TO HIV‐AIDS IN THE DOMINICAN REPUBLIC Name of the Project: National Response to HIV‐AIDS in the Dominican Republic Financial Agency: Global Fund Financing: US$44.8 Ms (Total 5 Years) US$14, 698,774 for the first two years. Disbursed: US$227,000 (6/2004) Effectiveness date 14 of June 2004 Period of Execution: 2 years approved, with an extension of three years more. Expected closing date 30 of May 2006. Main Beneficiary: The UCP of the Presidential Council of SIDA (COPRESIDA) Goal To reduce and to control the expansion of the HIV‐AIDS and to mitigate its impact in the Human Development of the Dominican Republic. Strategies: Advocacy. The project will contribute in the creation of a favorable a political environment and human rights for the prevention and treatment of the sexual transmitted infections, including the HIV. Prevention. It will contribute to increase the access to prevention services and strengthen the institutional capacity to fight against the sexual transmitted infections ITS). Treatment. It will contribute to increase the access for the treatment of ITS and AIDS to a significant number of people living with AIDS. Expected Results: ‐ All sexually active people who wish it, know their condition of HIV and can carry out an evaluation on their own risks of contracting the disease in order to be able to assume a change of positive behavior. ‐ Risk of transmission mother to child, reduced. ‐ Adoption of safer sexual practices. ‐ Better access to you condoms. ‐ Access to ARV for cases that need it (6.000 PVVS). ‐ Better support to the PVVS and relatives.
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NATIONAL INITIATIVE FOR THE STRENGTHENING OF THE PROGRAM FOR PLWHA Name of the Project National Initiative the Strengthening of the Program for PLWHA Financing Agency Clinton HIV/AIDS Initiative (CHAI). Financing: ARV and inputs, technical assistance, qualification of human resources. Effectiveness date 2004 Period of Execution: 5 years Expected closing date 2009 Executing Agency Consejo Presidential of SIDA (COPRESIDA) Final Goal To increase the longevity and to improve the quality of life of the people living with HIV‐AIDS in the Dominican Republic. Strategies: Goal 1: To implement and to expand efforts by means of the integration of treatment and prevention: To fortify the expansion of VCT networks, integrating prevention and treatment. Goal 2: To provide well‐taken care of and effective treatment for all patients that requires it. To develop a continuous care for HIV+ adults and children integrated to the SESPAS health system. Complete follow up from VCT at the UAB up to management of advanced therapies, including ARV. Expansion of VCT at the same time a chain of necessary services for the care of the PLWHA is constructed. Goal 3: To fortify infrastructures of health of the Dominican Republic through the improvement of the logistics system, structural administration, the capacity of the laboratories and the training programs. Expansion of the number of sites that would offer VCT. Cooperation with programs of TB and PNTV. HIV‐AIDS training at all levels of the health system, including SESPAS administrators, NGOs.
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CONECTA Name of the Project: CONECTA Financing United States Agency for the International Development (USAID) Contract 517‐C‐00‐02‐00116‐00. Global Financing: US$25 million. Approx. 70 % for HIV‐AIDS Effectiveness Date: October 2002 Execution period: 5 years. Expected closing date: September 2007 Executing Agencies: Family Health International (FHI), Abt Inc. Associates.(Abt) and Latin American Agency of Experts in Planning H (ALEPH) Operational Areas of the Project: HIV‐AIDS, obstetric care, family planning, integral health of the adolescents, immunizations and communitarian systems of access to potable water. Transverse axes like communitarian mobilization, institutional development and communication for change of behavior. There have been identified seven sub‐projects, according to thematic, geographic and programmatic components. 1. Program of Integral Attention in HIV/AIDS. 2. Improvement of the quality in the attention in reproductive health in selected public hospitals 3. Support to the Extended Program of Immunizations (PAI). 4. Program of Donations to NGOs. 5. Essential Logistics and Supplies. 6. Strengthening of HIV‐AIDS services and reproductive health in the border region with Haiti. 7. Strengthening of the role of SESPAS in the programmatic areas of CONECTA. Sub‐Project 1: Program of Integral Care in HIV‐AIDS General Objective: To improve the technical and operative capacity of the centers involved within the National Plan of HIV‐AIDS Care, so that they provide services of quality of PAV, prevention of mother to child transmission and attention to HIV +. Specific Objectives: Coordinator Unit • To establish and to support a central office in SESPAS, to allow the administration, monitoring and supervision of the activities of the national program for PVVS. • To advice in the design of an information system in support of the sustainability of the program. __________________________________________________________________________________________________ Caribbean Health Research Council
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• To provide technical assistance and support to the administrative, financial and logistic systems of the National Program. Centers of Ambulatory Care of HIV‐AIDS and Units of Basic Attention. • To increase the conscience and the level of knowledge of the personnel of National Program in the work with PVVS. • To build technical and clinical capacity in the providers of services that work in the diurnal centers of care. • Reimburse to the NGO providers a basic package of services for PLWHA. Program of Prevention of the Transmission Mother to Child: • To advice in the design and implementation of a plan to increase the coverage of the program. • To support the system of formation of the program. • To improve the technical capacity of the clinical personnel. • To support the DIGECITSS in the design and execution of a strategy of communitarian mobilization for the program. Program of Communitarian Connection (Project ENLACE) • To develop the capacity of the local NGOs to incorporate a communitarian approach of the attention. • To include the even advisers to the services in order to improve the participation of the community. Strengthen of the Voluntary Testing and Counseling for HIV AIDS at the local level. • To evaluate the quality of the services of laboratories for HIV tests and to develop a program of pursuit of the quality that covers all the country. • To improve the flow of information and the supervision of the PAV centers. • To extend the qualifications to advisors in all the national system. • To extend the referrals from the counseling services to support groups of PLWHA and other services available.
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OTHER EXTERNAL FUNDS FOR HIV‐AIDS PROGRAMS IN THE DR FINANCING ORGANISM
EXECUTING INSTITUCION
ONUSIDA
COPRESIDA
USAID
REDSALUD
GERMAN COOPERATION AGENCY (GTZ)
COPRESIDA
SPANISH COOPERATION AGENCY
COPRESIDA
AXILOS
DIGECITSS
BRASIL
DESCRIPTION
US$ MILLIONS
YEARS
Human rights support, institutional strengthening, condom policy, bilateral agenda DR/Haiti
0.25
1
EXECUTIO N PERIOD* 2002
Decentralization of DIGECITSS within the context of health sector reform Training Institutional strengthening Technical assistance to CORESIDA and three NGOs, epidemiological surveillance, institutional strengthening, human rights, juvenile organizations and sexual workers. Support to continous education
0.45
4
2000‐2004
4 Technical persons
2
2003
ND
permane nt
ARV for the mother to child program
ND
2
2003
DIGECITSS
ARV for 100 women in the mother to child program, during two years.
0.02
1
2004
La Rioja Española
DIGECITSS
Drugs for the mother to child program.
ND
8
2000
Government of Canada
CARECATSS
Technical support for epidemiologic surveillance and strengthening of institutional capacity.
2.5
4
2003
ACCION Internacional
DIGECITSS
ARV for the mother to child program (500 in year 1, 500 year 2, 800 in year 3)
ND
3
2003
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DIGECITSS
Support to the mother to child program in 9 provinces, tests, supervision, control and evaluation.
ND
2
* Some of these funds are still in execution.
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Assessment of the HIV-AIDS Program of the DR ____________________________________________________________________________________________________ _
ANNEX IV NON GOVERNAMENTAL ORGANIZATIONS WHICH WORK IN HIV‐AIDS
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NGOs MEMBERS OF THE HIV‐AIDS COALITION NAME OF THE ORGANIZATION Coalition of nongovernmental organizations of the area of HIV‐AIDS of the Dominican Republic (COALITION ONG AIDS) Woman and Health Collective
RESPONSIBLE PERSON Ramon Portes Carrasco Irene Lopez S.
TARGET POPULATION HIV‐AIDS decision makers
Sergia Galván Ortega
Young women
Centro de Promoción de la Atención Integral a la Infancia (PROINFANCIA)
Tanya Medrano
Vulnerable children by HIV‐AIDS
Center of Planning and Ecumenical Action (CEPAE)
Zoila Mercedez
Dominican association of Family Planning (ADOPLAFAM)
Ramon Portes Carrasco
Friends Always Friends
Leonardo Sanchez
Adolescents Women in reproductive age. Men in risk Adolescents M And F Men at risk “Batey” population Men that have sex with other men
Dominican Institute of Integral Development (IDDI)
David Luther
Young people and batey population
Foundation Health and Well‐ being INC., (FUSABI)
César Jesurum Cruz Felix Batiste
700 Families 16 Bateyes
PROGRAMS Political Advocacy and management Management of technical and Financial Resources
Services of Sexual and Reproductive Health Natural medicine and Emotional Support Sexual and Reproductive program of political Action for the defense of the women, rights. Youth and reproductive rights Training in gender equity Education Integral Health Psycho‐social support Communitarian mobilization Program “Ask for a wish” Integral health and prevention of HIV‐AIDS and STI.
Prevention of the ITS‐VIH‐SIDA for adolescents Pre and post test counseling Care and support of PLWHA Condom distribution Stop to AIDS project Emotional support and counseling Sugar refineries as opposed to AIDS Project of reproduction of HIV‐ AIDS in the sugar sugar refineries Program of prevention of HIV‐ AIDS Healthy bateyes of Monteplata
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Dominican Foundation for the Promotion and Social Action (PROPAS) Coordinadora de Animación Socio‐Cultural (CASCO)
Silvani Gomez H.
Elizardo Puello
Institute of Development and Nelson Moreno Integral Health Ceballos (INDESUI) Commission of Dominican Amarylis Reyes Ecumenical Work (COTEDO)
Dominican Institute of Virologic Studies (IDEV)
Dominican Institute of Support to Youth (INDAJOVEN) Movement of Dominican‐ Haitians Women (MUDHA)
United Educators of Cibao (EDUDELC)
Ellen Koening
Women in reproductive age, children and adolescents Young people Community leaders Local authorities Parents, mothers of the beneficiaries Population in general Population in general
Integral health Education Production Young people in bateyes Young people in districts Young people in the border Eradication of the infantile work Educative programs with adolescents, children, mothers, parents and teachers
HIV‐AIDS Three projects on communitarian health and environmental cleaning
Ambulatory care Home care Clinical investigation and tests Training for medicine students and doctors Education for patients Source of reference for HAART handling Prevention of the Program of education and HIV in communities support to young people for the action against the HIV‐AIDS Dominican Communitarian education Population of Encounters with religious Haitian ancestry and leaders, healers and parents immigrants who live in bateyes Adolescents of Prevention of the VIH/SIDA Santiago Health community organizations Preventive and Fixed evaluation programs curative health Consultations and clinics programs Popular pharmacy Emotional support Support to PLWHA Program of nutrition to orphans and families with HIV‐AIDS Assistance to PLWHA. To provide training and information to health professionals and the community in general
Rafael Felix
Sonia Pierre
Rafael Cruz
Communitarian Action for Progress (ACOPRO)
Juan Popoter
Research Center and Cultural Support (CIAC)
Josefina Padilla
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Network of People Who Live With HIV‐AIDS (REDOVIH)
Ramon Acevedo IEC directed to Dulce Almonte PLWHA Pregnant women Emotional support
Dominican Association for the Family Wellness (PROFAMILIA)
Magaly Caram
Center of Orientation and Integral Investigation (COIN)
Santos Rosario
Center of Education for the Communitarian Development (CEPAC)
Luis Ellis
Group of Investigation for the Cultural Action (GRIPAC)
Elvis Soto
Clara Group
Inma Mendoza
Center of Health Active 20‐30 Foundation
Institute of Communitarian Action (IDAC)
Prevention of HIV‐ AIDS in adolescents and young people Work with decision makers Sensitization directed to health personnel Actions of IEC and human rights addressed to migrant population and sexual workers. ITS Services Training to health personnel in ITS Pre and post test counseling Batey population
Support groups Human rights Access to ARV Sexual and reproductive health with adolescents and young people Prevention in HIV‐AIDS Education for risk prevention addressed to youngsters and adolescents Prevention migrant women Prevention AIDS and place of work Human rights Services of health Investigation
Prevention Program of voluntary multipliers Prevention ITS/VIH/SIDA
Actions of IEC directed to young women and children
Communitarian network for the prevention in marginalized districts Prevention of HIV‐AIDS‐TSI in the municipal scope Emotional support to Basic workshops in HIV‐AIDS people living with Meetings of support to positive HIV‐AIDS people
Rosa Sanchez de HIV‐AIDS care Carreras Emotional support to PLWHA Laboratory tests for public in general Medical operatives Antonia Florián Mobilization and prevention of women, young people of both sexes Training in ITS in bateyes
Prevention and counseling in HIV‐AIDS Pre and post test counseling Detection of HIV‐AIDS Center by day communitarian work Bateyes against AIDS Project of sexual and reproductive Health in 7 bateyes of San Pedro de Macorís Project in San José de los Llanos
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Women in Development (MUDE)
Rosa Rita Alvarez
IEC with adolescents, fathers and mothers
Movement of United Women (MODEMU)
Yeri Arias
Prevention of the HIV‐AIDS in Sexual Workers
World‐Wide Vision
Claudia Doñé
Southwest of the Country Guaricano Sabana Perdida Villa Altagracia HIV AIDS Patients and With STI
Rafael Isa Isa
Dermatological Institute and Surgery of the Skin Movement Cultural Partner of Haitian Workers (MOSCTHA)
Center of Promotion and Human Solidarity
Joseph Cheribin
Bayardo Gomez
Bateyes Haitian population and immigrants and border vulnerable population, Barahona, Elías Piña Sexual workers, young and adolescent, young vulnerable and pregnant mothers
Access of the rural population to services of sexual and reproductive health Integral development project for women in the border zone and their families Credit fund for health Work with adolescents to reduce the incidence of the HIV‐AIDS and STI. Prevention HIV‐AIDS‐STI Emotional Support To Women With HIV Training for another work Human rights and law of protection of women Legal support Programs of Education on Health and HIV‐AIDS Economic development Emergency Treatment ITS Treatment HIV‐AIDS Laboratory Health HIV‐AIDS Training for promoters
Project let us advance Young and adolescent youthful networks Integral action for young infected and pregnant mothers Clara Group
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ANNEX V
CORE CARIBBEAN INDICATORS’ MATRIX
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Definition
Available/collected by Country (Yes/No)
*Knowledge of HIV prevention methods ‐ Composite of 3 components (prompted)
The percent of respondents who, in response to a prompted question, say that people can protect themselves from contracting HIV by having no penetrative sex, using condoms or having sex only with one faithful, uninfected partner.
Knowledge of prevention of mother to child transmission of HIV
The percent of respondents who report that maternal to child transmission of HIV can be prevented through anti‐retroviral therapy during pregnancy and avoiding breastfeeding.
Comprehensive correct knowledge about AIDS (2 ways to prevent AIDS and reject 3 misconceptions)
The percent of respondents who correctly identify the two major ways of preventing the sexual transmission of HIV (using condoms and limiting sex to one faithful, uninfected partner), who reject the two most common local misconceptions about HIV transmission, and who know that a healthy‐looking person can transmit HIV.
Available for which time periods?
85
Estimate of time needed to compile and send data to CHRC?
yes
Each 5 years
USAID/
To analyze Data Base DHS‐ 2002
CESDEM / DHS
yes
Each 5 years
USAID/
To analyze Data Base DHS‐ 2002
CESDEM/ DHS
yes
Each 5 years
USAID/
To analyze Data Base DHS‐ 2002
CESDEM / DHS
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Available from whom? (i.e., agency and person)?
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*Risky sex in the last year
Condom use at last higher risk sex
Commercial sex in last year
Condom use at last commercial sex, reported by client
Condom use at last commercial sex, reported by sex worker
The percent of respondents who have had unprotected sex with a non‐marital, non‐cohabiting partner in the last 12 months of all respondents reporting sexual activity in the last 12 months The percent of respondents who say they used a condom the last time they had sex with a non‐marital, non‐cohabiting partner, of those who have had sex with such a partner in the last 12 months. The percent of men respondents reporting sex with a sex worker in the last 12 months. The percent of men respondents reporting condom use the last time they had sex with a sex worker, of those who report having had sex with a sex worker in the last 12 months. The percent of sex workers who report using a condom with their most recent client, of sex workers who report having sex with any clients in the last 12 months.
yes
Each 5 years
USAID/
Available
CESDEM / DHS
yes
Each 5 years
USAID/ CESDEM/ DHS
yes
The age by which one half of young people aged 15‐24 have had penetrative sex (median age).
2002‐2003, Probably 2007
yes
2002‐2003, Probably 2007
86
Available
CONECTA BSS in Adolescent and young people
Available
CONECTA BSS in Adolescent and young people
Available
CONECTA BSS in Adolescent and young people
Available
yes
2002‐2003, Probably 2007 2002‐2003,
Probably 2007
__________________________________________________________________________________________________ Caribbean Health Research Council
CONECTA BSS in Adolescent and young people
Yes *Median age at first sex among young men and women
Available
Fundación Plenitud
Assessment of the HIV-AIDS Program of the DR _____________________________________________________________________________________________________
Yes
Each 2 years
Behavioral Survey DIGECITSS
Condom use at first sex
Age‐mixing in sexual relationships
Injecting drug users sharing equipment at last injection
Injecting drug users never sharing equipment in the last month
The percent of young people (aged 15‐24) who used a condom the first time they ever had sex, of those who have ever had sex. The percent of respondents aged 15‐ 19 who have had non‐marital sex with a partner 10 years or more older than themselves in the last 12 months, of all those who have had non‐marital sex in the last 12 months disaggregated by sex of respondents. The percent of active injecting drug users who report sharing needles, syringes or other injecting equipment the last time they injected drugs. The percent of active injecting drug users surveyed who report never sharing injecting equipment during the last month.
yes
2002‐2003,
87
CONECTA BSS in Adolescent and young people
Available
CONECTA BSS in Adolescent and young people
Available
_
‐
‐
‐
_
‐
Probably 2007
?
2002‐2003, Probably 2007
No
No
__________________________________________________________________________________________________ Caribbean Health Research Council
Available
Fundación Plenitud
Assessment of the HIV-AIDS Program of the DR _____________________________________________________________________________________________________
PROGRAM AREA: CONDOM PROGRAMMING
Indicator
*Condoms available for distribution nationwide
*Retail outlets and services with condoms in stock
Condom accessibility Condoms that meet quality control measures
Definition
Available/collected by Country (Yes/No)
Total number of condoms available for distribution nationwide during the preceding 12 months, divided by the total population aged 15‐49. This indicator was formerly the WHO/GPA Prevention Indicator 2. The proportion of randomly selected retail outlets and service delivery points that have condoms in stock at the time of a survey, of all retail outlets and service delivery points selected for survey. The percent of target populations surveyed reporting that they can acquire a condom if they need one within a specific time period. The percent of condoms in central stock and in retail outlets that meet
Available for which time periods?
88
Estimate of time needed to compile and send data to CHRC?
No
‐
‐
‐
No
‐
‐
‐
Yes
Each 5 years
USAID/CESDEM DHS
Available
No
‐
‐
‐
__________________________________________________________________________________________________ Caribbean Health Research Council
Available from whom? (i.e., agency and person)?
Fundación Plenitud
Assessment of the HIV-AIDS Program of the DR _____________________________________________________________________________________________________ WHO quality specifications PROGRAM AREA: VOLUNTARY COUNSELING AND TESTING (VCT) Indicator
Definition
The percent of respondents who Population requesting an HIV have ever voluntarily requested an test, receiving a test and receiving HIV test, received the test, and test results received their results. Number of clients seen at VCT centers
*Districts with VCT services
Quality post HIV test counseling
*VCT centers with minimum conditions to provide quality services
The number of individuals who request counseling on HIV testing at a VCT center. The percent of districts that have at least one centre staffed by trained counselors providing specialized HIV counseling and testing services free or at affordable rates. The percent of post HIV test counseling sessions at voluntary counseling and testing facilities that meet international standards for quality counseling. The percent of clients served by VCT services that meet minimum conditions necessary to provide quality counseling and HIV testing
Available/collected by Country (Yes/No)
Available for which time periods?
89
Estimate of time needed to compile and send data to CHRC?
Yes
Monthly
UCAI/SESPAS Fundación Genesis
Available
Yes
Monthly
UCAI/SESPAS Fundacion Genesis
Available
Yes
Monthly
UCAI/SESPAS Fundacion Genesis
Available
No
‐
‐
‐
Yes
Annually
UCAI/SESPAS Fundacion Genesis
Available
__________________________________________________________________________________________________ Caribbean Health Research Council
Available from whom? (i.e., agency and person)?
Fundación Plenitud
Assessment of the HIV-AIDS Program of the DR _____________________________________________________________________________________________________
VCT laboratories that follow quality testing protocols
*Pregnant women counseled and tested for HIV
Antenatal clinics offering or referring for VCT
Quality HIV counseling for pregnant women
*HIV‐positive women provided
services. The percent of HIV tests requested by voluntary counseling and testing No ‐ centers over a one‐month period that follow recommended testing algorithms. PROGRAM AREA: PMTCT The percent of women who were counseled and offered voluntary HIV testing during antenatal care for their most recent pregnancy, accepted an offer of testing and received their test results, of all women who were pregnant at any time in the two years preceding the survey. The percent of clients at public antenatal clinics that attend clinics offering counseling and voluntary testing for HIV by trained staff, or referring to VCT services. The percent of post‐HIV test counseling sessions for women attending antenatal clinics offering counseling and voluntary HIV testing that meet international standards for quality counseling, including referral for care where necessary.
90
‐
‐
No
‐
‐
‐
yes
Annually
PNRTV/
Available
SESPAS
No
‐
‐
‐
Annually
__________________________________________________________________________________________________ Caribbean Health Research Council
Fundación Plenitud
Assessment of the HIV-AIDS Program of the DR _____________________________________________________________________________________________________ with anti‐retroviral therapy in pregnancy
yes The percent of women testing positive at selected antenatal clinics in the last year who are provided with a complete course of anti‐ retroviral therapy to prevent mother to child transmission according to national/ international guidelines. PROGRAM AREA: BLOOD SAFETY
Indicator
*Screening of blood units for transfusion
Reduction of blood transfusions
Districts/regions with donor recruitment and blood transfusion services
Health care settings with guidelines and practices for prevention of accidental HIV transmission
Definition
The percent of blood units transfused in the last 12 months that have been adequately screened for HIV according to national or WHO guidelines. The number of blood units transfused in the previous 12 months, per 1000 population. The percent of districts or regions with access to blood transfusion services which do not pay blood donors, and do not recruit donors from among relatives of the patient. The percent of health care facilities in a facility survey that have guidelines to prevent nosocomial transmission of HIV, adequate sterilization procedures, and surgical gloves in stock.
Available/collected by Country (Yes/No) yes
Available for which time periods? Annually
91
Available
SESPAS
Available from whom? (i.e., agency and person)? SESPAS/DIGECITSS
Estimate of time needed to compile and send data to CHRC? Available
yes
Annually
Blood laboratory SESPAS
Available
No
‐
‐
‐
No
‐
‐
‐
__________________________________________________________________________________________________ Caribbean Health Research Council
PNRTV/
Fundación Plenitud
Assessment of the HIV-AIDS Program of the DR _____________________________________________________________________________________________________ PROGRAM AREA: CARE, SUPPORT AND TREATMENT Indicator
Definition
*Number of individuals (adults and orphans/vulnerable children) reached by community and home based care and support in the past 12 months
The number of individuals who received any community or home based care and support services in the past 12 months, disaggregated by age (adult and orphan/vulnerable children) and by type and location of service.
*Number of individuals (adults and orphans/vulnerable children) receiving ARV and care for opportunistic infections in the past 12 months.
The number of individuals receiving ARV and care for opportunistic infections in the past 12 months, disaggregated by age (adult and orphan/vulnerable children) and by type of care received.
*Health facilities with the
The percent of health care facilities at different levels of the health care system that have the
Available/collected by Country (Yes/No)
Yes
Available for which time periods?
92
Estimate of time needed to compile and send data to CHRC?
Quarterly
CONECTA
Available
Quarterly
UCAI/SESPAS
Available
Quarterly
UCAI/SESPAS
Available
Yes Number of PVVS (adults or children) receiving ARV and care for opportunistic in the past 12 months Yes
__________________________________________________________________________________________________ Caribbean Health Research Council
Available from whom? (i.e., agency and person)?
Fundación Plenitud
Assessment of the HIV-AIDS Program of the DR _____________________________________________________________________________________________________ capacity to deliver appropriate care to HIV‐infected patients
Households receiving help in caring for chronically ill adults
Households receiving help with care of orphans
capacity to deliver appropriate palliative care, treatment for opportunistic infections and referral for HIV‐infected patients, according to national guidelines. The percent of households with an adult aged 15‐49 who has been ill for at least three consecutive months during the last 12 months that received external unpaid help in caring for the patient or replacing lost income.
In households caring for orphans, the percent receiving free help with care from outside the household within the last 12 months.
No
‐
‐
‐
Yes
Quarterly
CONECTA
Available
In households caring for orphans, the number receiving free help with care from outside the household within the last 12 months
PROGRAM AREA: TRAINING AND CAPACITY BUILDING
Number of people trained in the past 12 months Strengthened management and technical systems of organizations
The number of individuals trained in the past 12 months, disaggregated by topic of training and audience (e.g., nurses, female sex workers, youth peer educators, etc.). The score on a scale measuring the individual and organizational resources, skills, and systems in six areas including technical,
yes
Quarterly
CONECTA
Available
No
‐
‐
‐
__________________________________________________________________________________________________ Caribbean Health Research Council
93
Fundación Plenitud
Assessment of the HIV-AIDS Program of the DR _____________________________________________________________________________________________________
*Number of organizations/ institutions actively engaged in responding to the HIV/AIDS crisis
*Number of organizations/ institutions participating in strategic planning activities and contributing to national strategic plans
management and networking. The number of organizations/institutions No ‐ actively engaged (e.g., providing services or information, training, funding, advocacy, etc.) in responding to the HIV/AIDS crisis, in the past 12 months. The number of organizations/institutions No ‐ participating in strategic planning activities (such as national meetings of NGOs, PLWHA, conferences, etc.) and the number of organizations contributing to national strategic plan design, review and evaluation in the past 12 months. PROGRAM AREA: ADVOCACY AND POLICY
‐
‐
‐
‐
Yes
Each 2 years
UNAIDS/Future Groups
Available
*AIDS Program Effort Index (API)
The average score given to a national program by a defined group of knowledgeable individuals asked about progress in over 90 individual areas of programming, grouped into 10 major components.
Spending on HIV prevention programs
The amount of money allocated in national accounts for spending on HIV prevention and care programs, per adult aged 15‐49
In process preventive and
2001‐2003
COPRESIDA/World Bank/
2004
curative
__________________________________________________________________________________________________ Caribbean Health Research Council
94
Fundación Plenitud
Fundacion Plenitud
Assessment of the HIV-AIDS Program of the DR _____________________________________________________________________________________________________ expenditure total and per capita PROGRAM AREA: HUMAN RIGHTS, STIGMA AND DISCRIMINATION Indicator
*Accepting attitudes towards those living with HIV ‐ Composite of 4 components
Accepting attitudes ‐ person allowed to keep HIV+ status private * Percent of non‐health care organizations/institutions (e.g., workplaces, schools, etc.) with policies/guidelines to protect
Definition
The percent of respondents expressing accepting attitudes towards people with HIV: • The percent of respondents saying that they would be willing to care for a family member who became sick with the AIDS virus. • The percent of respondents who say they would buy fresh vegetables from a vendor whom they knew was HIV+ • The percent of respondents who say that a female teacher who is HIV+ but not sick should be allowed to continue teaching in school • The percent of respondents who say that they would not want to keep the HIV+ status of a family member a secret. The percent of respondents who say that, if a person became infected with HIV, they should be allowed to keep it private. The proportion of institutions and (formal‐sector) employers sampled with non‐discriminatory policies and non‐discriminatory practices in
Available/collected by Country (Yes/No)
Available for which time periods?
95
Estimate of time needed to compile and send data to CHRC? Available
The percent of respondents saying that they would be willing to care for a family member who became sick with the AIDS virus
Each 5 years
USAID/CESDEM/ DHS
Yes
Each 5 years
USAID/CESDEM/DHS
Available
No
‐
‐
‐
__________________________________________________________________________________________________ Caribbean Health Research Council
Available from whom? (i.e., agency and person)?
Fundación Plenitud
Assessment of the HIV-AIDS Program of the DR _____________________________________________________________________________________________________ against discrimination
Percent of health care facilities that protect against discrimination (e.g., HIV tests with informed consent, persons living with HIV/AIDS not segregated, etc.).
‐ Cost drivers of the epidemic ‐ Impact of HIV/AIDS on individuals and household units :‐ income, expenditure, quality of life ‐ Impact of HIVAIDS/STI on key macroeconomic indicators ‐ Estimated cost of operationalising the strategic plan
recruitment, advancements and benefits for employees with HIV. The proportion of health care facilities at all levels sampled with non‐ No ‐ discriminatory policies and non‐ discriminatory practices (HIV tests with informed consent, persons living with HIV/AIDS not segregated). PROGRAM AREA: SOCIO‐ECONOMIC IMPACT
In process Impact in key economic sectors, health sector and house holds
2004
‐
‐
2005
COPRESIDA/World Bank/ Fundación Plenitud
__________________________________________________________________________________________________ Caribbean Health Research Council
96
Fundación Plenitud