JAMAICA

Monitoting and Evaluation of HIV/AIDS programs

Karen Lewis-Bell, Alfred R. Brathwaite, J. Peter Figueroa

Background

Jamaica, the third largest country in the Caribbean, has a population of approximately 2.5 million, half of whom reside in urban areas. The AIDS epidemic started among homosexual men and in seasonal male migrant farm workers who mainly worked in Florid a. The epidemic quickly spread into the female population and heterosexual contact became the predominant mode of transmission. According to the new classification of epidemic type, Jamaica is between a concentrated and a generalized epidemic. HIV preva lence among prostitutes, STD patients and men who have sex with men exceeds 5%, while HIV prevalence among antenatal women is 1% or less.

National response

In 1985, AIDS was made a notifiable disease and screening of blood donors was introduced. In the late 1980s HIV/AIDS control activities were incorporated into the STD control programme which had been in existence since 1930. In addition to the HIV/ST D control programme a national AIDS committee was established in 1988 as a private company with strong links and involvement of the government (including the HIV/STD control programme). The main components of the national programme are policy, planning an d programme management, STD case management, behaviour change communication, condom promotion, surveillance, research, laboratory strengthening, training and HIV/AIDS care, counseling and support. The UNAIDS theme group was launched in 1995 during the im plementation of the third medium-term plan. The theme group includes bilateral donors and works closely with the national HIV/AIDS/ STD programme and has undertaken several activities.

Monitoring and evaluation

M&E of the programme components and achievements have always been a priority of the national programme. M&E is incorporated in the surveillance activities and research is an integral component of the programme. Regular meetings are held to dis cuss progress and to plan for improvement. During the annual planning and evaluation workshop, research findings, HIV sentinel surveillance data, behavioural survey results and programme achievements are discussed. Donor representatives take part in thes e meetings, which also include strong representation from the field. A national database for HIV/AIDS cases and HIV/STD research has been established.

Among the weaknesses of the M&E component of the national programme are its dependence on donor funds for HIV testing and population-based surveys, and the lack of qualitative studies on obstacles to condom use by women. In addition, the number of HIV surveillance sites is small and limited to parts of the country. In 1993, the syndromic management of STDs was strengthened and STD surveillance was improved. Research is also conducted to monitor drug resistance of STDs. Five population-based surveys on knowledge, attitudes and sexual behaviour have been carried out since 1988, mostly at two-year intervals with average sample sizes of 1,200 respondents. The WHO/GPA protocol for such surveys has been used extensively.

Input, output and context

Resources of the programme include behaviour change communication interventions, condom promotion, training of hospital workers, school interventions and HIV/AIDS counseling, care and support. Condom distribution data are available and show an increas e from 2 million in 1985 to 10 million in 1995. Training of health workers and school programmes focusing on HIV/AIDS and STD is monitored and small-scale evaluation have guided the content and methods of the programmes.

The quality of STD services was evaluated in 1991 and again in 1996.

The national AIDS programme is a focal point and organizing entity for the over 60 member organizations and 5 subcommittees involved in all aspects of HIV/AIDS programme, technical issues, education, legal and ethical issues and social support. Donor o rganizations have been heavily involved in monitoring and evaluation activities.

Proximate determinants

The survey data suggest a recent decline in non-regular sex and an increase in condom use in non-regular partnerships (prevention indicators 4 and 5), although sample sizes are fairly small and not all data sources appear to be consistent. Reported con dom use was also high among commercial sex workers and bisexual men. Surveys have been conducted with short interval (two years in between), but the interpretation of the trends is not straightforward and perhaps longer intervals between the surveys would have been sufficient.

HIV and STD

HIV prevalence is monitored in a variety of populations, including commercial sex workers, prisoners, STD patients, antenatal clients, blood donors, life insurance and USA immigrant visa applicants and military recruits. There are only three urban ante natal clinics to monitor HIV and STD prevalence, but increasing the number of sites is considered costly.

In 1993 STD testing became decentralized (Behets et al., 1995), and preliminary data suggest a rapid decline in syphilis prevalence. Reporting of STD syndromes has improved leading to an increase in prevalence of genital discharge thought due to improv ed reporting.

AIDS impact mitigation

There are a number of facilities for counseling, care and support (hospices, social centers, mission clinics), although coverage is limited. Basic health care is provided by the government. There are AIDS policy guidelines, but these are now eight year s old and need to be revised.

The legal and ethical subcommittee of the national AIDS committee is working on legislative issues but progress has been slow so far. No assessment has been done of the quality of care in health facilities.

Data are available on trends in AIDS cases. Reporting by hospitals is thought to be good at 80-90% completeness. The HIV surveillance officer visits hospitals, hospices and social care centers on a regular basis to collect data and assess quality of th e reports.

All data are computerized and a follow-up and feedback system are in place. This M&E system pertains not only to AIDS patients but also to all HIV tested individuals.

Conclusion

The national HIV/AIDS/STD programme has incorporated monitoring and evaluation activities in its national programme and also ascertained a close link with policy making and planning through its annual evaluation and planning meetings with all partners in the programme, including donors. Continuity and strong leadership as well as a research capacity within the programme are important features that have guided the M&E component.

WHO/GPA sexual behaviour surveys have been used extensively, although in retrospect the frequency of population-based surveys (once every two years) was on the high side. HIV surveillance is based on multiple groups, although national coverage is incom plete and donor dependence is still high.