Programme Area 1: Prevention and Control of HIV Transmission

Programme Area 1: Prevention and Control of HIV Transmission

During the NSP period, prevention programming was undertaken by a broad range of stakeholders, including CSOs, partner Ministries, private sector organisations, the NHAC and MOH. Such programming largely focused on the provision of Information Education Communication (IEC) materials. Awareness and knowledge of STI/HIV transmission and prevention among the general population, although fairly high, appears to have dipped slightly over the course of the NSP period. Conflicting guidance on approaches and a definition of key populations to be targeted appears to have weakened the ability of the stakeholders to remain focused on high impact interventions with the best likelihood of impacting the epidemic and, thus, use resources efficiently.

1. 
   What has been done to raise awareness and knowledge of transmission and prevention of STI/HIV among key populations?
   

The NSP proposed a two-phased response to target 14 different populations. Under the first phase (2008-2010) young males and females (10-29 years); sex workers including ‘beach boys’; MSM and bisexual men; PLHIV; female single heads of households, especially low income earners and unemployed; females in long standing relationships and females seeking to get pregnant; and, OVC were targeted. In the second phase (2011-2013) the NSP identified workers in the tourism sector (hotel workers, visitors, support staff, transport sector, golf caddies, vendors, massage therapists, water sports personnel); prisoners; non-Barbadians (in light of the introduction of the Caribbean Single Market); persons with disabilities (PWD); people who are in constant contact with the rest of the population (Sanitation Service Authority, Port, Transport Board staff); Security Forces (Prisons, Royal Barbados Police Force and the Defence Force); workers in the Immigration and Customs Departments; as well as men and women 50 years and older for targeting. Thus, establishing a very broad base for programming.

While the Scarlett Communication Plan, which covered the period 2009-2013, identified the following at-risk groups: youth; CSWs; MSM; single, unemployed, dependent women; PLHIV; prisoners; and the sexual partners and clients of these populations, specified vulnerable populations were also identified in the Communication Plan, of which these were seasonal and long-term migrant workers such as construction workers; seamen or merchant marines; mobile populations such as deportees and undocumented persons; persons in uniform (police and military); persons with disabilities; and, intravenous drug users.

In recognition of the need to reduce the scope of the NSP and to provide a guide for a targeted prevention programme that focused on high-risk behaviours that place persons at greater risk of transmission, the 2010 Prevention Plan was developed. This plan identified the following four key populations: MSM; CSWs; prisoners; and PLHIV. Four additional special risk populations were also identified: children and youth; PWD; drug-using populations; and mobile populations (e.g. seasonal workers, merchant seamen). The Prevention Plan also stated that there was inadequate research on behavioural data for the specified risk groups to inform the design and implementation of targeted interventions.

The 2007 Behaviour Change Communication (BCC) Strategy provided a complementary guide for the development of targeted interventions for specified populations recognizing the impact of socio-economic determinants of health. The BCC Strategy however made no reference to key population groups such as MSM and SW.

2. 
   Were the activities effective in promoting awareness and knowledge of STIs/HIV transmission and prevention among key populations?
   

Prevention programming is currently being delivered to the community, group, and individual level by stakeholders. This programming features the following: the distribution IEC materials; free condom and lubricant distribution; provision of or referrals for HIV/STI testing; peer education, training and outreach; role-play and edutainment; life skills training; and, social welfare grants to reduce vulnerability. Notably, these activities were not standardized across the partners. Implementers reported focusing on stigma and discrimination against PLHIV and not on HIV sexual risk reduction or stigma and discrimination against key populations. Some CSOs appear to be particularly effective in undertaking HIV sexual risk-reduction interventions for key populations. These include Community Education Empowerment and Development (CEED), Jebez House, MOVADAC, and CHAA.

Through the World Bank Project, all Government Ministries and Agencies were mandated to include a line item in their budget to support the HIV response. This funding was primarily allocated to support the implementation of workplace programmes targeting staff of the Ministries, Departments and Agencies of that Ministry. There was, however, flexibility in targeting outside the Ministry and under three Ministries it was observed that funding was allocated to support CSO interventions targeting key populations, specifically CSW, MSM, PLHIV, and transgender. It was also noted that CSOs were given primary responsibility for reaching these key populations with risk reduction messages.

Key informants reported using the NSP to guide decision-making. However, the revised Prevention Plan was not used. As a result prevention programmes being funded by some of the Ministries were poorly targeted. The approval process for Ministry projects was also not under the jurisdiction of the NHAC, and technical guidance was not necessarily sought prior to implementation. Under the CSO Grants System, most grants targeted youth, rather than the key populations that are driving the epidemic. Thus, the number of agencies involved in the provision of services to key populations was limited. A revised method for allocating core HIV prevention resources to match the disease burden will be critical to the national programme’s success in the future.

During the NSP period, the NHAC undertook two mass media campaigns. Both campaigns focused on anti-stigma and discrimination and targeted the general public. It was noted by the evaluation team, however, that risk reduction messages were primarily undertaken at the community level and not through mass media. Informants also reported that the MOH had primary responsibility for conducting/disseminating risk reduction messages. This was undertaken by their community health aides, community health nurses, and health promotion staff. A robust BCC programme was developed by the Barbados Defence Force (BDF) to target the military with sexual risk reduction messages including the development of IEC materials (posters, brochures). Efforts should be made to replicate and adapt the BDF Prevention programme at the national level.

It was observed that IEC materials with risk reduction and anti-stigma and discrimination messages were a strong feature of the BCC programme. However, more emphasis had been placed on the anti-stigma and discrimination component. The development of targeted messages remains a concern as the messages were not developed using a strong communications approach including pre-testing of the messages prior to placement. In addition, a media recall survey had not been conducted for the mass media campaign to gauge impact.

Figure 3: Decrease in HIV prevention knowledge among youth

2011

The 2009 and 2011 Youth Knowledge, Attitudes, Beliefs and Practices (KABP) Survey Reports reflected that knowledge about HIV remained high with 98.7% of youth respondents in 2011 stating that they are aware of HIV, representing a 4.7% increase from 2009. This contrasted with declines observed in knowledge of how HIV can be prevented: correct, consistent condom use (76.8% in 2009, declined to 75% in 2011); one faithful uninfected partner (79.4% in 2009; decreased to 75% in 2011); and, abstinence (84.7% in 2009, down to 79.8% in 2011). Another area of concern was the decline in the rejection of the mosquito myth, where the percentage of respondents who reported that mosquito bites could not transmit HIV went from 80.4% in 2009 to 76% in 2011. KAPB data was not available for the other key population groups to measure improvements in knowledge and awareness.

3. 
   Was there efficient use of resources to respond to the knowledge and prevention needs of key populations?
   

1. 
   Develop BCC messages targeting sexual risk behaviours of key populations using both mass and new media technologies.
   
2. 
   Develop various targeted IEC materials (posters, brochures) with sexual risk reduction messages to target men and other key population groups based on epidemiological data adhering to BCC methodologies (i.e. focus group discussions to identify and develop message, pre-test of materials with target population, branding/distribution of materials at socializing sites and other venues, media recall of campaign after a minimum of one year of placement).
   
3. 
   Through collaboration with M&E Unit of the NHAC, maintain a strong focus on the use and analysis of available data to inform programming and design of interventions.
   
4. 
   Operationalize shift to key populations away from populations at low risk for HIV infection.
   
5. 
   Continue to promote collaboration with CSOs and training of HIV/AIDS Focal Points and Coordinators on addressing the needs of key populations to support the shift in focus.
   

During the NSP period, the national response appears to have continued to make progress in reducing the transmission of HIV. However, a lack of available data has limited the evaluation team’s ability to draw solid conclusions on the transmission of other STIs or any changes in the behaviours of key populations. Further to this, more effort is required to ensure the shift from IEC to BCC is fully embraced across the national response.

1. 
   Has there been a reduction in the transmission of HIV?
   

Figure 4: Men account for greater new HIV and AIDS cases in 2012

2. 
   Has there been a reduction in the transmission of other STIs?
   

3. 
   Has there been any positive change in behaviours as a result of activities implemented?
   

In order to plan an effective HIV prevention response, it is essential to know who is at higher risk of HIV as well as the behaviours that place persons at risk of transmission. The evaluation team observed that research on sexual risk behaviours and needs was not available to support the development of targeted interventions for key populations. In addition, some key informants from the government sector appeared to lack familiarity with existing research on populations that are currently being targeted and an understanding of public health approaches. There was a recurring request for additional research to be conducted and disseminated among implementers, as well as target populations.

As it relates to measuring achievement based on the indicators for CSW and MSM populations, data was not available to the evaluation team making it difficult to ascertain whether there has been any improved behaviour change among these key populations. It is to be noted, however, that the Evaluation Report for the Key Population Project ‘Creating Networks, Strengthening Communities stated that 71% of respondents reported that there is a need for more trained Peer Educators and Peer Counsellors in the community. This view was also reflected in the findings of the focus group discussions undertaken for this evaluation, where participants indicated that there were no outreach services for MSM, with the exception of those provided by CHAA and the Red Cross (who conduct outreach once per week) and CEED (that works with the transgender community). The implementation of BCC interventions with key populations will, for this reason, be greatly affected by the closure of CHAA, but such work is essential to achieving this objective.

The recognition by the NHAC and other stakeholders of the limited number of agencies providing services to the key population groups, has prompted action that has led to growth in the number of CSOs working with these groups, as beneficiaries of the response have moved on to form their organizations geared to delivering services. These CSOs include CEED, Helping Our Peers Effectively Now (HOPEN) and EQUALS. The CSO Grant System has been instrumental in facilitating the development of this sector, as many of the organizations have benefitted and built their capacity through their involvement, thus resulting in the expansion of the HIV response.

As previously mentioned, the prevention activities that have been implemented by government partners primarily focussed on anti-stigma and discrimination interventions and not on risk reduction, thereby missing an opportunity to improve prevention indicators. However, key informants reported partnering with MOH for the provision of HIV testing in outreach settings and to facilitate referrals. Collaboration between various ministries with CSOs was also evident in key population interventions targeting CSW, MSM, transgender and PLHIV populations. It was noted that CHAA was the only agency with the exception of the MOH that provides HIV testing in outreach settings.

4. 
   Has the programme shift from IEC to BCC been effective?
   

The BCC Strategy provides a guide to the development of BCC interventions targeting pre-adolescents; married persons in committed relationships; high school based intervention; newly diagnosed PLHIV; and young men 15-17 years. However, given the limited shift from IEC to BCC, it is imperative that additional guidance be provided to gain support for the need to de-emphasize interventions that serve populations at lower risk for HIV infection to high-impact prevention interventions with key populations.

1. 
   Build the capacity of HIV/AIDS Focal Points and Coordinators in public health approaches as well as BCC to strengthen collaboration and buy-in for the need to shift focus to key populations.
   
2. 
   Strengthen the BCC response through the following activities:
   

1. 
   Review and update interventions manual, BCC strategy, and Prevention Plan to mainstream focus on key population;
   
2. 
   Train and support stakeholders to implement high impact BCC intervention methodologies;
   
3. 
   Build the capacity of stakeholders (including focal points) to address the needs of key populations as identified in new NSP;
   
4. 
   Expand outreach testing and develop linkages to care protocol for key populations to increase access and uptake;
   
5. 
   Develop minimum package of prevention services for key populations; and,
   
6. 
   Strengthen oversight and approval process for BCC interventions (proposals, work plans, reports).