Abstract
Final evaluation of a project (8/88-12/00) to prevent and control HIV/AIDS and sexually transmitted infections (STIs) in Jamaica. The project continues to record successes, as demonstrated by positive changes in risky sexual behavior; greater public awareness of, and response to, the dangers posed by HIV and STIs; and the strengthened technical and administrative capacity of the Ministry of Health (MOH) at the central and regional levels. Increased condom use, reduction in sexual partners, continued declines in STI rates, a possible leveling off in HIV prevalence, and greater involvement of regional, parish, and community organizations have contributed significantly to stabilizing HIV/AIDS in Jamaica. Specific components are rated below. The project has implemented a strong behavior change and communications (BCC) program, which emphasizes face-to-face, interactive, culturally appropriate HIV/AIDS education (as distinct from an earlier approach that emphasized mass media). There has been positive behavior change in recent years: high condom user rates (especially with non-regular partners); a significant decrease in Jamaicans reporting multiple partners; and a slight rise in the median age of sexual debut. However, there has been slippage in condom user levels among females age 20 and older and some older males, and a slight rise in the proportion of women reporting multiple partners. The National HIV/Sexually Transmitted Disease (STD) Control Program (NHCP) has implemented a strong STD control component that includes syndromic management, plus an unusually effective program of contact tracing and HIV counseling and testing. As a result, prevalence and incidence (when data for the latter are available) of most STDs has declined markedly for several years. The contact tracing program has worked well and has much to teach other countries. Sentinel surveillance has been in place since 1990 and now covers 10 parishes. Surveillance is also carried out in several high-risk groups and in 10 low-risk groups, some of which can serve as proxies for the general population. Quality control is maintained through links with the U.S. Centers for Disease Control and Prevention (CDC). Condom promotion programs, including condom social marketing (CSM), and a BCC emphasis on condom promotion, have been successful. CSM was included in the recent project from 1997 to 1999. An island-wide network of at least 2,000 non- traditional retail outlets was established in collaboration with the National Family Planning Board. The MOH feels that a national-level CSM program is no longer needed, but the former national CSM manager feels that problems of condom availability persist in rural areas, and that mass media promotion is still needed. The integrated management and services approach in the Epidemiology Unit has built on its successes under the original project agreement, supporting policy decisions and providing technical guidance for BCC, CSM, and STI prevention. It has evolved into the NHCP's administrative and technical center and has the ability to assume greater responsibility for implementing the NHCP, including the USAID-funded components. With decentralization, the unit has steadily disengaged itself from day-to-day regional and parish operations and has been absorbed into the MOH's Health Promotion and Protection Division. The project's weakest intervention has been strengthening the management capacity of the National AIDS Committee (NAC), which suffers from problems of public perception, executive leadership, and a lack of resources to build a strong infrastructure and mobilize a multisectoral response. Failure to consolidate infrastructure can be attributed to a lack of political commitment, a poor mix or balance in active volunteers, and lack of independence from the MOH. Key problems that continue to hinder HIV/AIDS control efforts include: the absence of a monitoring and evaluation plan and trained personnel to keep policymakers and program managers abreast of trends and outcomes; inattention to capacity building outside of the Epidemiology Unit, especially at the regional level; an underutilization of NGOs in planning and implementing project activities; and the absence of a training infrastructure for both the public and private sectors.