1998 Annual Report
SPECIAL PROGRAMME ON
SEXUALLY TRANSMITTED  DISEASES (SPSTD)

MISSION

To Reduce the spread and to minimise the impact of HIV/AIDS and other sexually transmissible diseases by behaviour modification and improved surveillance, diagnosis and treatment capabilities

Introduction

CAREC’s HIV/AIDS programme is currently supported by four funding and technical agencies, the Canadian International Development Agency (CIDA), the French Technical Cooperation (FTC), the Department for International Development (DFID-United Kingdom) and the German Technical Cooperation (GTZ). In order to address the various determinants of the HIV epidemic-biomedical, sexuality, sexual behaviour environment and socio-economic factors, CAREC, has, as a deliberate strategy, implemented a multi-disciplinary team approach. Thus, the work of the SPSTD can be compared to that of an orchestra, with its various components or disciplines working together to produce the desired melody or impact. Also, at the regional level, the goal is coordination and consultation through the continued support of and collaboration within PAHO/WHO and by including other UN-agencies or programmes and regional institutions in the SPSTD planning and implementation of regional activities. The SPSTD, therefore, strives to achieve synergy, where its various partners interact to develop an effective public health response to HIV/AIDS in the Caribbean.

Historically, the Programme has encouraged multi-sectorial involvement in the fight against AIDS. This perspective has served as the forerunner to an Expanded Response, which is the vision of UNAIDS and its partners. The Expanded Response concept is evolving and at the same time receiving increasing acceptance by country partners in recognition of the significant non-health implications and impacts of the epidemic. Thus, CAREC's inputs have contributed to increasing the countries’ and the region’s capacity to effectively manage their response to this significant public health problem in the following priority areas:

Key achievements/impacts

1. Advocacy, Policy, Planning and Capacity Building

ADVOCACY

All members of the SPSTD team advocate for various issues as an integral part of their work. However, the Programme has introduced a formal Advocacy Initiative at special sessions on the national and regional level. The resource teams at these sessions usually include representatives of People Living with HIV/AIDS (PLWHA) public health specialists, health economists, and national decision-makers. At these sessions experts share information on the determinants of the epidemic, and their impact on the country and region. The specialists present data on international, regional and national epidemiological data and projections of the epidemic in order to influence decision making and planning with respect to public health interventions. Adding significant value to sessions held under this initiative is the presentation of Modelling Projections on the economic impact of the epidemic, based on the epidemiological data and cost estimates developed which show the devastating magnitude in terms of its potential human, economic and social con sequences. The projections are the result of a study done in collaboration with the University of the West Indies, Health Economics Unit, Department of Economics, St Augustine. The importance of working with people living with HIV/AIDS in order to improve care and social support, as well as to underscore the crucial link between care and prevention, is also stressed. In addition, CAREC's work with media professionals and growing public concern have contributed to positive trends for improved prevention and control of the epidemic.

In 1998, there was evidence of a growing recognition among Caribbean leaders of HIV/AIDS as a national development issue whose origins and impacts go far beyond the realm of health. CAREC's political advocacy work contributed to this development. Growing public concern was reflected in a notable increase in letters to the editor and of media attention, and more than previously initiated by the media themselves, and usually of good quality.

Following a presentation by CAREC at the 1^st meeting of the CARICOM Ministerial Council on Human and Social Development (COHSOD), a resolution was adopted to give full backing to the promotion of an expanded response to HIV/AIDS. The COHSOD meeting was held in Jamaica in April.

In some CMCs, increased political commitment was translated into larger budget allocations to National AIDS Programmes, increased involvement of non-health sectors and policy decisions in support of HIV/AIDS issues, while elsewhere this has remained at the level of public pronouncements.

POLICY

Examples of growing government commitment include:

In St Kitts and Nevis, a new budget line was created in the national budget to fund the HIV/AIDS programme.

These developments have opened up opportunities for a broadened societal mobilisation because they bring about a better appreciation of the value of health in sustainable human and economic development, better collaboration between governmental and non-governmental sectors, as well as among regional institutions and ministries of health, and improved skills in collection and use of information for advocacy and decision making.

In order to promote an expanded response, at national and regional levels, CAREC in collaboration with UNAIDS Theme Groups exposed eleven countries to the strategic planning model which takes a three-pronged approach- situation analysis, response analysis, and plan formulation- and includes all key sectors. This process takes into consideration the cultural, social, political and economic factors which along with the bio-medical ones, determine the parameters of the epidemic. Of these eleven, the SPSTD has provided technical and/or financial assistance for five- Guyana, Trinidad and Tobago, St Kitts, Barbados, and St Lucia- to apply the process to development of their plans. These plans reflect a new role for NAPs -- as policy making and coordinating bodies rather than implementing agencies. To help prepare NAPs for this new role, the SPSTD trained five countries, including NGO representatives, at a Programme Management course using the WHO/GPA training modules (Trinidad, May 1998).

CAREC contributed to a Regional Consultation on AIDS held in Trinidad in June 1998 and together with CARICOM, UNAIDS and other regional institutions formed a Task Force on HIV/AIDS. The Task Force submitted a proposal for funding to the European Union in support of regional institutions to implement HIV/AIDS strategies. The role of the Task Force is to coordinate and broaden the regional response to the AIDS epidemic.

CAPACITY BUILDING

The capacity of NGOs and CBOs to play a more active role in the national efforts was strengthened, in terms of management skills building, skills to implement behavioural interventions and through technical assistance and grants to support care and prevention projects, project management, and proposal writing. Examples of support for NGOs in 1998 are:

Use of local and regional expertise, and collaboration with regional organisations such as UWI CARICOM and CRN+ was the strategy adopted to complement the cadre of qualified personnel attached to national partner institutions. For instance, the majority of short term consultants employed to assist with the strategic planning process behavioural interventions, guideline development, and counselling training were recruited from the Caribbean. In instances where consultants had to be recruited from outside the region, attempts were made to "pair" the Consultant with a local counterpart. In this respect the Canadian Public Health Association (CPHA) has played an invaluable role as CAREC’s Canadian partner in the implementation of the regional response to HIV/AIDS

Regional networking was supported not only to stimulate the inter-country exchange of personnel and experiences but also as an avenue to the empowerment of marganilised groups. As a result, organisations of PLWHA and MSM can act more freely and openly at regional level. The challenge is to help create a more supportive environment at country level one that is free of stigmatisation.

RESOURCE MOBILISATION

To help support the regional and national response to HIV/AIDS, four grant proposals were developed and submitted for funding during 1998, one in collaboration with CARICOM to the European Union, two to the United Kingdom Department for International Development (DFID) and one to the Inter American Development Bank (IADB). Positive responses have been obtained from the majority of these donors. A 1997 proposal to the European Union for strengthening medical laboratories through capacity building is awaiting final approval. 

2. Promotion of Behavioural Change

Building on earlier achievements towards healthy sexual behaviour and an environment supportive of this, the SPSTD continued to develop and disseminate its research and theory-driven health promotion strategy. Salient features of this concept are the focus on vulnerable groups, their particular environments, risks and needs, and a participatory approach which involves members of the target groups in all stages of an intervention. In addition to skills training, partners received technical assistance and advice in the design, implementation and evaluation of group-specific strategies, such as:

To inform the design of these interventions and to establish baseline indicators, operational research was conducted which involved target groups as far as possible. The HIV/AIDS Case Report Form which serves as a main surveillance instrument was modified to include socio-demographic and behavioural variables such as drug consumption ( instead of IV drug use alone) condom use, and number of sex partners . It is anticipated that this form which was disseminated for comment, will help to improve the monitoring of risk behaviours and intervention effects.

Important challenges remain: although youth has been widely recognised as a priority group, there was little progress in education ministries to integrate sexuality education into the curricula of schools and teacher training institutions. Discriminatory attitudes and practices of some health professionals dealing with HIV-infected clients continue to contribute to poor quality of care. This calls for renewed efforts towards behaviour change.

Implementing behavioural interventions

The capacity to implement behaviour skills interventions was enhanced for government and NGO representatives from 12 countries through their participation in a training workshop held in Trinidad in May. Participants drafted proposals for interventions to reach priority populations and technical assistance has since been provided to refine some of the projects. To plan content of the workshop, the SPSTD conducted a study of selected countries to assess the capacity of the government and NGO sector to plan, implement and evaluate behavioural interventions.

PEOPLE LIVING WITH HIV/AIDS (PLWHA)

Financial support was provided to staff of Mamio-Namen, a care and support organisation for PLWHA in Suriname, to attend a one-year training course in management and organisational skills for NGOs. As a result, the staff have improved their ability to process funds, use technology and manage the organisation’s business independently.

YOUTH

Technical and financial assistance has been provided for the past 3 years for a sexual Health Education Pilot Project in two secondary schools in Antigua, called "Project Smart Choice". The project increased the children's negotiation skills and improved knowledge and attitudes about sexuality issues and STDs/HIV/AIDS and provided peer support. In year three of the project, an additional component consisted of alternative activities such as music appreciation and drama. The students are now using these skills for edu-tainment around sexuality issues.

REACHING MEN WHO HAVE SEX WITH MEN (MSM)

The SPSTD published a technical report identifying interventions and policies to prevent and reduce the spread of HIV among MSM in the Eastern Caribbean.

This was based on the results of research among this population in Antigua and Barbuda, Commonwealth of Dominica, St. Kitts/Nevis, and St. Vincent and the Grenadines. IEC materials relating to the needs identified are being developed.

COMMERCIAL SEX WORKERS

Access to and quality of reproductive health services was improved through a prograrmme which included, sensitisation of brothel managers, condom promotion and distribution and evaluation of training activities conducted with CSWs and Genito-Urinary Medicine Clinic Staff.

In Barbados, research was conducted to map the characteristics of female sex work, including issues such as location of work, demographic characteristics of workers, their treatment–seeking behaviour, perceived needs and concerns.

A health promotion strategy including education and condom distribution enabled workers to adopt and maintain safer sexual practices and appreciate health-seeking behaviour.

HEALTH CARE WORKERS

The NAP in Guyana received assistance to introduce a decentralised voluntary Counselling and testing programme for HIV/AIDS. Counselors were trained and support provided for a counselling supervisor.

Plans were finalised for evaluation of the long-term outcomes of the Health Care Workers Sensitisation Training which took place in St Lucia in 1997. The evaluation will be carried out in January 1999 and will be among workshop participants, their supervisors, and clients (PLWHA).

VOLUNTARY COUNSELLING AND TESTING – GENERAL POPULATION

 Improved acce ss to voluntary HIV/AIDS counselling and testing services for the general population was achieved through technical and financial support for the establishment of services in two regions of Guyana.

NATIONAL AIDS HOTLINE–TRINIDAD AND TOBAGO

The SPSTD commissioned an evaluation study of the National AIDS Hotline of Trinidad and Tobago. This involved (1) analysing transcriptions of a series of telephone interviews between mystery callers and hotline listeners and (2) assessing the analyses against caller assessment of the interactions through their completion of post-conversation questionnaires.

A report was produced, addressing issues such as the competence with which listeners provided technical information about the disease and available services, their ability to communicate effectively and their levels of comfort and skill in dealing with delicate and emotional issues. The results will be used to up-date the training of current listeners and train new volunteers.

CATIN--CARIBBEAN AIDS TELECOMMUNICATION AND INFORMATION NETWORK

During 1998, the pilot phase of a Caribbean AIDS Telecommunication and Information Network (CATIN ) was completed in five countries. CMCs. This involved advocacy in countries, needs assessments, installation of computer equipment and software, training of staff to operate the computerised network and the development of guidelines and procedures to ensure sustainability.

As a result of this Antigua, Dominica, Grenada, St Kitts and Nevis and St Lucia, now have the capability to electronically download and systematically store information on HIV/AIDS from a variety of international sources and retrieve data for target groups requiring such information to enhance their capacity to inform, educate and communicate with the wider community on HIV/AIDS prevention and control.

INFORMATION DISSEMINATION

The Programme amplified its interaction with national and regional media for the dissemination of timely, accurate and relevant information on the HIV/AIDS epidemic and other public health issues in the Caribbean.

These efforts included presentations to and meetings with radio and television executives at the General Assembly of the Caribbean Broadcasting Union (CBU) in the Bahamas and senior executives of the Headquarters of the CBU and the Caribbean News Agency in Barbados.

This advocacy inspired partnerships with these regional media agencies for the production of a number of SPSTD inspired television and radio productions on HIV/AIDS issues for dissemination to the Caribbean.

Accordingly, audiences in all CMCs were able to view, listen and interact with a host of regional experts and young people to become better informed and to suggest ways of controlling the HIV/AIDS epidemic in the region. 

activities included

Consequently, there has been a noticeable shift by regional mass media in the treatment of HIV/AIDS issues from the generic, more global information to the programming of material that is more relevant and specific to the situation in the Caribbean. Examples of these included both print and electronic media treatment of such topics as the economic impact of HIV/AIDS on Caribbean economies, policies for the reduction of Mother-to- Child Transmission of HIV/AIDS in the region, and Caribbean youth as a force for change in HIV/AIDS prevention and control.

Additionally, there is new interest among regional media practitioners for sustained information of this type through production partnerships with CAREC. Both the Caribbean NEWS Agency and the Caribbean Broadcasting Union are on record as wanting technical assistance to develop these types of programmes for dissemination to Caribbean audiences.

MEDIA TRAINING

The programme continued its training efforts aimed at sensitising the regional media to the need for more responsible reporting on HIV/AIDS issues. Workshops to this end were held in St Lucia and Guyana.

As a result more than 40 journalists joined a cadre of their peers around the region who have been exposed to HIV/AIDS sensitisation training and who are now better informed about various dimensions of the epidemic. In turn, this has helped to produce a media community with a commitment to more responsible coverage of HIV/AIDS issues and a partnership with their respective National AIDS Programmes in efforts to bring about a more supportive environment to stem the tide of the epidemic.

The Guyana Workshop also facilitated recommendations from the media community to a National AIDS consultation on the role the country’s press, radio and television can play in the expanded response to HIV/AIDS prevention and control in that country. This paved the way for a relationship between the journalists and the National AIDS Secretariat for the generation and delivery of related messages.

A similar result was attained following the St Lucia Workshop with the local Media Workers Association agreeing to be part of a ministerial exercise to develop a national plan to battle HIV/AIDS. The media workers are also collaborating with the NAP to establish a National AIDS Foundation to provide a more supportive environment for PLWHA, especially children.

3. Clinical management – diagnosis, care and support

To facilitate improved management of clients at country level, guidelines are being finalised on : Home and community based care for people living with HIV/AIDS; Clinical management of HIV disease; Reducing mother to child transmission of HIV in the Caribbean; and Voluntary counselling and testing (VTC). These guidelines are being developed with involvement of the direct beneficiaries and stakeholders such as People living with HIV/AIDS, health care providers, epidemiologists, clinicians and community workers.

Grenada and St. Vincent and the Grenadines have introduced national policies for syndromic management of STDs. CAREC has been advocating for introduction of such policies in member countries to complement its training in this area.

To sustain the expected gains, evaluation tools for case management are being developed. During 1999, evaluations will be conducted to assess STD treatment at health care facilities. In 7 CMCs, training has been provided for the use of risk management and syndromic management of STDs.

Despite some resistance to adopting syndromic management of STDs, the SPSTD continued efforts to sensitise countries on the value of using this method to manage STD. Management and quality of care will be evaluated to determine what proportion of STD clinic patients accessing health care facilities receive correct management i.e, treatment, counselling condom use demonstration and partner referral.

Strengthening of case management and support for people living with HIV and AIDS (PLWHA) in CAREC Member Countries (cmcs).

Clinical management guidelines were reviewed during a CAREC workshop in December 1998, and will be completed in the first quarter of 1999. The medical management includes the anti-retroviral therapies to be introduced step by step (with the possible support of international and regional initiatives). A major emphasis was put on prevention of mother-to-child transmission (MTCT) of HIV with short course zidovudine (AZT) treatment protocols, associated with avoidance of breast-feeding. This is a major step towards improvement of care and support for people living with HIV and AIDS.

In order to improve the use of the case management guidelines by medical personnel, two main recommendations were made: 

In a continuing effort to support the provision of reliable HIV/STD diagnoses for clinical and blood transfusion services in CMCs, the SPSTD worked closely with the CAREC Laboratory to assist laboratory staff in CMCs to implement Quality Assurance (QA) programmes. QA monitoring and/or retraining visits were made to the Cayman Islands, Dominica, Guyana, Jamaica, Belize and the Turks and Caicos Islands. CMC staff continued to implement QA work-plans and to seek the support of key health, finance and planning decision makers in obtaining critically needed resources.

Laboratory Quality Assurance training, using a distance learning modus, was piloted in nine CMCs - Bahamas, Barbados, Belize, Cayman Islands, Jamaica, St Lucia, St Vincent and the Grenadines, Suriname and Trinidad & Tobago - in collaboration with the U.S. Centers for Disease Control and Prevention. Distance learning training was delivered through a combination of five videos, three audio-conferences and accompanying printed material. Preliminary evaluation suggests that distance learning approaches can effectively enhance CAREC's efforts to reach and train laboratory target audiences in the Caribbean. By the end of 1998, therefore, CAREC staff had initiated Quality Assurance training in sixteen CMCs. CAREC is actively assisting member countries to implement and monitor Laboratory Quality Assurance Programmes.

Work continued in 1998 on development of guidelines for implementation of a QA programme for distribution to all CMCs. This is being done in collaboration with the Laboratory Proficiency Testing Programme in Ontario, Canada. It is expected that this document will be completed in 1999 and will be relevant as well for laboratory quality building in other regions.

The Proceedings of the regional blood-banking meeting held in November 1997, were published and distributed in 1998. Blood Bank Directors identified the development of a draft blood banking guideline for the approval of regional governments and implementation by regional blood banks as a critical next step. In 1999 a regional committee will develop draft guidelines.

In 1998 CAREC held a retraining workshop for its staff which helped to ensure that its own reference and referral services continued to be reliable and relevant. The Laboratory Division provided HIV confirmatory testing services for eleven CMCs, testing a total of two thousand, two hundred and sixty-one samples. (A breakdown of samples submitted for testing is reflected in Table 1 SPSTD. Primary testing services were provided for St Kitts, whose HIV laboratory diagnostic service was disrupted by a hurricane in 1998. The Laboratory continued to support HIV surveillance studies in the region and to provide an HIV kit evaluation service to manufacturers. Two ELISA and two rapid HIV 1&2 assays were evaluated in 1998- the Chem-Index Akudex ELISA HIV 1&2; the Akucheck HIV 1&2 rapid assay; the Health Tech International Inc. HIV 1/2 Q Spot and the HIV 1/2 EIA. A collated report will be circulated to CMCs. In recognition of CAREC's responsibility to continue to provide a relevant HIV reference service to CMCs, the molecular biologist, supported by CIDA funding, pursued training related to the early detection of vertically transmitted HIV infection. CAREC expects to implement appropriate technology for the determination of HIV infection in babies in 1999. CAREC is currently evaluating an HIV PCR facility with a view to introduction in the near future.

Surveillance, research and evaluation

Generic guidelines on implementation of HIV/AIDS/STD surveillance , including new forms for reporting HIV/AIDS have been developed and will streamlined for introduction in 1999. 

HIV/AIDS/STD Surveillance Systems were evaluated in St Kitts and Nevis and Belize. The teams which carried out the evaluation collaborated with country partners to develop workplans to address the weaknesses identified. In 1999, priority will be placed on implementation of these workplans. HIV/AIDS data management training was successfully completed in Antigua and Barbuda, Barbados and Guyana.

For HIV vaccine trials and behaviour monitoring priority areas have been identified in terms of feasibility and implementation of programmes: Ethical issues, HIV Molecular Epidemiology, HIV Phenotyping and Genotyping (characterisation) resistance monitoring and availability of PCR techniques at regional level

Participants at the Mother- to- child transmission workshop

 Table 1

SPSTD : HIV ANTIBODY CONFIRMATORY TEST RESULTS¹

Caribbean Epidemiology Centre
16-18 Jamaica Boulevard, Federation Park
P.O. Box 164, Port of Spain
Republic of Trinidad and Tobago
Tel: (868) 622-4261, Fax: (868) 622-2792
E-mail: postmaster@carec.paho.org

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