INTERNATIONALBANK FOR WORLD BANK R E T C N O E N STRUCTION PM AND DEVELO July 2004 No. 49 A regular series of notes highlighting recent lessons emerging from the operational and analytical program of the World Bank`s Latin America and Caribbean Region DOMINICAN REPUBLIC HIV/AIDS PREVENTION AND CONTROL PROJECT INITIAL RESULTS Patricio V. Marquez and Luis Emilio Montalvo Background If the cost of treating patients remains constant, hospital costs will increase from US$4.8 million to US $7.4 million The Dominican Republic has 120,000 persons living with in 2005 (1998 US dollars). Adding anti-retroviral therapy AIDS (PLWAs), 9 times the total number of reported cases. could increase treatment costs to US$ 52.6 million in 2005, About 20,000 people have died from AIDS in the last 18.2 percent of the health care budget (assuming that prices decade. HIV/AIDS is the leading cause of death among remain around US$ 1,000 per patient per year). women of reproductive age. Prevalence is highest (5% of adults) among low-income groups that include many Haitian The Government's Approach immigrants living in rural communities and working in sugar cane plantations. Prevalence among female commercial sex The Government's response to workers is about 8%, reaching the HIV/AIDS epidemic 12% in some cities. incorporates the following Tuberculosis (TB) is the elements: largest opportunistic infection for PLWAs. PAHO estimates · Creating a political high-level that over 100 persons per institution by Presidential De- 100,000 are infected with TB, cree--the Presidential Commis- versus 2.6 per 100,000 in sion for HIV/AIDS Barbados and 4.9 per 100,000 (COPRESIDA) -- reporting di- in Jamaica. The 5,320 rectly to the President and re- reported cases in the sponsible for coordinating the Dominican Republic are fight against the epidemic. among the highest in the Latin COPRESIDA comprises public, America and Caribbean private, and community-based region. organizations. Heterosexual intercourse accounts for 81 percent of HIV · Dealing with HIV/AIDS from multiple perspectives-- cases in 15-44-year olds. The 4,000 women who had economic, social, and cultural, involving different sec- prenatal checkups and tested positive for HIV/AIDS are tors and actors through partnerships with government, likely to give birth to 1,300 infected children unless private, and civil society organizations, including transmission is prevented. Underlying problems include PLWAs. high rates of Sexually Transmitted Infections (STIs) and high birth rates among adolescent girls and young women, and active migration between cities and the countryside, · Innovating as the epidemic changes, strengthening and and from Haiti. Also, the Dominican Republic is a major expanding successful strategies, including HIV/AIDS tourist destination. voluntary counseling and testing, controlling STIs, re- 1 ducing mother to child transmission (MTCT), and pro- sector groups, and 4 military and police agencies. There are viding care and treatment for HIV infected persons who already tangible results from programs implemented with six require treatment according to established guidelines. ministries, as follows: · The Labor Ministry has begun an HIV/AIDS in the Work- Focusing on the most cost-effective interventions, typi- place Initiative (with the U.S. Labor Department) to reduce cally targeting the most vulnerable populations groups. stigma and discrimination and protect human rights of PLWAs and their families, by sensitizing and training busi- Before the project became effective, the Government had: nesses and providing legal assistance to PLWAs. · promulgated Law 5593 (1995) dealing with HIV/AIDS The Ministry of Youth Affairs provided information, more (the only country in the region to do so); than 20,000 condoms and instructions on their use to 7,000 young athletes, other national delegation members, and spec- · adopted a 2000-2004 National Strategic Plan for HIV/ tators at the 2003 Pan-American Games in Santo Domingo. AIDS; The Science and Technology Ministry completed "knowl- · launched HIV/AIDS and STI information, education edge, attitudes and practices" (KAP) surveys involving 75% and communication (IEC) campaigns targeted to vulner- of university students and 85% of teachers, and trained 90% able groups and the general population, which reduced of university teachers in HIV/AIDS prevention and control. frequency of causal sex and sex with multiple partners The Ministry of Women Affairs among young people and in- trained community leaders and creased condom use; women from Provincial Women Affairs Departments on HIV pre- · vention. increased coverage of screened blood from 80 to 95 The Tourism Ministry supported percent in 1999. establishment of a joint venture between COPRESIDA and the National Hotel and Restaurant The Project Association (ASONAHORES), following the experience with the Punta Cana Hotel Complex, To support and strengthen whose implementation is pro- implementation of the National gressing well. Plan, the Dominican Republic HIV/AIDS Prevention and Control The Sex Education Program Project (total cost US$30 million) (Programa Afectivo Sexual) in was launched in February 2002 the Education Ministry has intro- under the World Bank-financed duced important changes in pri- US$155 million Multi-Country mary and secondary school curricula and produced high HIV/AIDS Prevention and Control Program for the quality educational materials for teachers and students, in- Caribbean Region. Implementation partners include: the cluding a manual designed by a team of sexologists, psy- Global Fund for HIV/AIDS, Tuberculosis and Malaria, chologists and HIV/AIDS/STI experts. The program, an USAID, the Clinton Foundation, PAHO/WHO, UNDP, and example for other countries, is being implemented in 55 Partners for Health. percent of public secondary schools: 253,361 students attend twice weekly classes under the Program; 5,713 (54%) of public secondary school teachers have been trained on HIV/ Initial Results of activities financed in the three AIDS/STI prevention. project components Special Population Groups 1: Prevention/promotion activities to reduce HIV/AIDS Baseline KAP surveys of commercial sex workers (CSW), transmission including IEC activities and condom social men who have sex with men (MSM), Haitian immigrants marketing emphasizing vulnerable groups. living in bateyes (areas around sugar cane plantations), and prisoners will provide key information for designing A multi-sectoral approach is ensured by participation interventions to target these groups. agreements with 25 entities: 13 government ministries, 2 religious groups, 4 civil society organizations, 3 private 2 HIV/AIDS/STI prevention and care in the bateyes began with the Sugar State Council (CEA), responsible for most bateyes in the country. A civil society organization (CASCO) was hired to concentrate efforts in the bateyes. In March 2004 COPRESIDA and CASA VICCINI (the main private sector sugar industry whose territory includes 23 bateyes) signed an agreement. Prevention of HIV Mother to Child Transmission: This program began in 1999 as a pilot in only two maternity facilities, lacking funds and political will. Since 2002, project support has extended it country-wide in all public hospitals providing maternity services and 83 percent of health centers and municipal facilities, covering about 157,000 (78%) of the estimated 200,000 pregnant women in the country each year. In 2003, 78,118 women-- half of all pregnant women receiving care in Santiago and El Seybo, with a total population of over 2.4 public health facilities--were tested for HIV using rapid million; and piloting adapted TB/HIV coordinated screening, diagnostic tests; about 1,700 or 2 percent tested HIV+. prevention and care interventions for evaluation and Eighty four percent of the infected women and their children subsequent national scale up. received the antiretroviral Nevirapine at delivery (an important achievement compared to sharp falls in Nevirapine A pilot HIV/AIDS Prevention and Control Project in coverage in many other countries' programs). The other 16 Tourist Areas, the first initiative involving the private sector percent went untreated because they arrived at the facility at (the Punta Cana Group), aims to reduce the stigma of HIV/ the moment of delivery, drugs were unavailable, or they AIDS in the tourist industry, especially in the Bavaro and lacked proper registration. Punta Cana resort (whose 400 hotel rooms, luxury homes, golf course, and commercial airport attracted 1.2 million Condom Social Marketing: Most of 2 million condoms (mostly American and European) tourists in 2002). Some purchased in 2003 were distributed. A study on use and key prevention activities are: access to condoms in Santo Domingo motels/hotels shows increased use of condoms among clients, from 18% in 1990 · educational materials and IEC campaigns on HIV/AIDS to 36 percent in 2003. A mass media campaign distributed 100,000 flyers (with condoms), 5,000 posters, 50 billboards prevention and condom use for workers and their fami- (for urban passenger buses) and dozens of caps and t-shirts. lies, including activities in Creóle for illiterate and A TV campaign oriented to young people aims to convince migrant Haitian workers. them to use condoms even with a "pareja de confianza" (partner of trust). · Education and prevention workshops for school profes- sors, Parent/Teacher Associations, secondary students Strengthening tuberculosis (TB) prevention and control and Women Associations. is part of the national response to AIDS. TB is among the top killers of PLWA, and a public health threat. Approximately · With NGO support, a "100% Condon Use" program 12 percent of reported AIDS cases in the Dominican targeted to commercial sex workers. Republic have fallen ill with TB, and 5 percent of TB · Workshops on developing HIV/AIDS Policies for top patients have identified HIV infection. Co-morbidity is level managers and business professionals in the tourist probably higher because TB patients are not systematically sector. tested for HIV and TB screening is not routine among HIV- positive persons. USAID is supporting representative surveys of HIV among TB patients and of drug resistance. In 2: Diagnosis, basic care and support of individuals affected the mid-1990s, the Dominican Republic reported the highest by HIV/AIDS to reduce disability and death due to HIV/ rates of multi-drug resistant disease among countries in the AIDS, reduce the reservoir of HIV/AIDS, and mitigate Americas surveyed. suffering of children orphaned by AIDS. A 2004 work plan for TB control and TB/HIV linked The HAART Treatment Program is underway. Treatment interventions supports expansion of the DOTS strategy in sites have been selected; a private laboratory contracted for five provinces---La Altagracia, Barahona, Hato Mayor, CD4 and Viral Load Testing while waiting for equipment for 3 the National Public Health Laboratory; and personnel trained cofinancing arrangements to ensure long-term to administer antiretroviral treatment. With the Clinton sustainability of the national effort. Foundation's initial donation of ARV drugs, 300 patients are · Donor harmonization will require follow-up activities to receiving triple therapy and 500 are under follow up. It is further strengthen collaboration, avoid duplication, and expected that 1500 HIV-infected people will receive reduce unnecessary administrative burden on the local treatment in 2004. Establishing the Comprehensive Care teams. Central Unit (UCAI) at the Ministry of Health (SESPAS), · Strengthen collaboration among countries in the region jointly supported by the project, USAID and the Clinton to share their lessons learned regarding HIV/AIDS Foundation, was an important step toward scaling up ARV activities. therapy. Columbia University, Washington University, and Puerto Rico are training staff. By 2005, 8 UCAI will offer ************* complete care and treatment for HIV/AIDS patients country- wide, aiming to cover 20,000 patients over 5 years. Bank in Partnership to Provide Low-Cost Before 2002, HIV counseling services were available at AIDS Drugs only 14 sites in the Dominican Republic. In 2002-2003A, coordinated, collaborative efforts by Fundación Genesis (a local NGO), SESPAS/DIGECITSS and COPRESIDA, April 6, 2004--The Bank, in partnership with the supported by USAID and the project, established 100 Global Fund to Fight AIDS, Tuberculosis and Ma- Voluntary Counseling and Testing services in public and laria, UNICEF and the Clinton Foundation, today private sites throughout the country (63 in public hospitals, announced agreements that will make it possible for 17 in private centers and 20 in NGOs) and trained 361 developing countries to purchase high-quality AIDS counselors in basic pre- and post-test counseling. medicines at the lowest available prices. In many cases the medicines and diagnostics would cost fifty To standardize counseling services, "National Norms for percent less than their current prices. HIV/AIDS Counseling" and a "Counselor Training Guide" for counselors who will offer support services and follow-up The agreements will pave the way for countries to PLWA were developed. supported by the Global Fund, the Bank and UNICEF to gain access to drug and diagnostic prices negotiated by the Clinton Foundation. 3: Strengthening HIV/AIDS and STI Surveillance System, "We regard AIDS as being the single most important Project Coordination, Monitoring and Evaluation, and issue at the moment in Africa because of the Research. devastating effect that it has had throughout the Continent, and it is not something that is deferrable to Consultants have been contracted to implement HIV/AIDS discussions of economic or other issues," President surveillance using second-generation protocols including Jim Wolfensohn said of today's announcement. "The behavioral and biological surveys of high-risk groups. emerging epidemic in Asia, Europe and Central Asia Geographic mapping of vulnerable groups (youth, CSW, and the Caribbean is also a tremendous concern. This MSM) was done in Puerto Plata, and sentinel seroprevalence initiative will help to get treatment to those most in surveys are underway. need - the world's poorest people. The Bank is pleased to be a partner in the program and fully supports it." Monitoring and Impact Evaluation: Criteria, indicators and methods have been streamlined within a coherent framework. Harmonization among main donor agencies: The Global Fund, USAID, Clinton Foundation, PAHO/WHO, UNDP, About the Authors UNAIDS and World Bank have a strong commitment to join efforts, share information, accept a single evaluation report Patricio V. Marquez is a Lead Health Specialist in the World Bank's Latin America and Caribbean Region and Team instead of separate reports, and follow a Ten Year National Leader for the Multi-Country HIV/AIDS Prevention and Strategic Plan to be finalized in May 2004. A meeting in Control Program in the Caribbean. Luis Emilio Montalvo is February 2004 helped define coordination and cofinancing the Director, Dominican Republic Presidential Commission arrangements. for HIV/AIDS (COPRESIDA). Future Challenges About "en breve" · Further develop the relationship between the private and public sector on HIV/AIDS activities, including Subscribe to "en breve" by sending an email to en_breve@worldbank.org 4