PSI Feasibility Study of Condom Social Marketing in the Eastern Caribbean Region

Publication date: 2002

POPULATION SERVICES INTERNATIONAL Social Marketing Assessment to Examine the Feasibility of Condom Social Marketing In the Eastern Caribbean Region Submitted to: UNAIDS and PAHO Elizabeth Beachy, MHS August 2002 Social Marketing Assessment for HIV/AIDS Prevention in the Eastern Caribbean Region August 2002 EXECUTIVE SUMMARY The social marketing assessment for HIV/AIDS prevention in the Eastern Caribbean began in September of 2001 and concluded in May of 2002. PSI’s Regional Technical Advisor, Elizabeth Beachy, made several trips to the region throughout the project period to gather information and meet with host government institutions, National AIDS Programmes, NGOs, international donors and multilateral agencies, advertising agencies, market research firms, and consumer product distributors and retailers. In April 2002 a condom distribution survey was conducted in 5 countries by Carmen Chan, PSI Consultant, and quantitative and qualitative research was conducted by the Earle and Phillips Consulting Group over a 5-month period in 4 different countries. The report that follows is a synthesis of these findings, including recommendations for the design and implementation of a social marketing project. Key Findings: The level and quality for HIV/AIDS prevention activities varies greatly from island to island, and while coordinating bodies exist, there are very few regional interventions; Few programs exist to address prevention issues specific to high-risk groups (notably CSWs and MSM) however there are many initiatives to reach youth; Condoms are widely available and considered affordable by youth, there is an abundance of condom brands on the market, yet barriers to purchase remain; While knowledge of HIV/AIDS among youth is high, knowledge of other STIs is low, knowledge of correct condom use is low and several myths about HIV/AIDS still abound; Social support for condom use is weak, perception of local severity of the epidemic is low, and personal risk assessment is often inaccurate; Approximately 60% of youth report condom use in their last sexual act with a steady partner and 80% report use with a casual partner, however use is not always consistent; Local public and private institutions have expressed strong interest in behavior change communication interventions and capacity building, as the most important contributions of a regional social marketing project in the region. ACRONYMS and ABBREVIATIONS AIDS Acquired Immunodeficiency Syndrome BCC Behavior Change Communications CAREC Caribbean Epidemiology Centre CARICOM Caribbean Community CBD Caribbean Development Bank CBO Community Based Organization CHRC Caribbean Health Research Council CRN+ Caribbean Regional Network of People Living with HIV/AIDS CSM Condom Social Marketing CSW Commercial Sex Worker ECLAC Economic Commission for Latin America and the Caribbean FPATT Family Planning Association of Trinidad and Tobago HIV Human Immunodeficiency Virus IPPF International Planned Parenthood Federation KAP Survey Knowledge, Attitudes, Practices survey MSM Men who have Sex with Men MTCT Mother To Child Transmission (of HIV/AIDS) NAP National Aids Programme OECS Organization of Eastern Caribbean States PAHO CPC Pan American Health Organization office of Caribbean Program Coordination PanCAP Pan Caribbean Partnership for HIV/AIDS PLWHA People Living with HIV/AIDS PSI Population Services International STI Sexually Transmitted Infection UNAIDS Joint United Nations Program on HIV/AIDS UNGASS United Nations General Assembly Special Session on AIDS USAID United States Agency for International Development UWI University of the West Indies VCT Voluntary Counseling and Testing (of HIV/AIDS) WHO World Health Organization List of Tables Table 1 Demographic Overview of the Eastern Caribbean Table 2 Priority Areas and Lead Institutions Responding to HIV/AIDS in the Eastern Caribbean Table 3 Most Common Methods of Contraceptive Use Among Youth Table 4 Why Youth Use Condoms Table 5 Support Requested of PSI Table 6 Priorities for Potential Interventions Table 7 Private Sector Sales Outlets Table 8 Brands and Pricing Table 9 PSI Behavior Change Framework Table 10 Condom Attributes Table 11 Reactions to Youth being seen with a condom Table 12 Correct Responses to Knowledge Based Questions Table 13 Spontaneous Recall of STIs Table 14 Youth Perceptions of How to Protect Oneself from HIV/AIDS infection TABLE OF CONTENTS Introduction Eastern Caribbean Background Demographic Overview HIV Prevalence in the Caribbean Economic, Political and Social Climate Regional Myths and Barriers National and Regional Responses to the Epidemic Regional Donors Private Sector Interests HIV/AIDS Among High-Risk Groups Youth Men Having Sex with Men Commercial Sex Workers Other Risk Groups Country Findings Trinidad and Tobago Barbados OECS The Netherlands Antilles Other islands Regional Condom Accessibility Sales Outlets Brands and Pricing Sales Volume Visibility and Accessibility Regional Barriers to Condom Use Condom Affordability, Availability, and Accessibility Condom Appeal Social Support for Condom Use Personal Risk Assessment Self-Efficacy and Solution Efficacy Barriers to Condom Use Summary VII. Recommendations Branded Regional Condom Use Campaign Targeting Youth Local Capacity Building in Behavior Change Communication Targeted Interventions for High-Risk Groups Private Sector Partnerships Sentinel Surveillance, Monitoring and Evaluation VIII. Appendices List of Persons Contacted Caribbean Organizations References INTRODUCTION In September of 2001, UNAIDS invited Population Services International (PSI) to prepare an assessment and proposal for the condom social marketing component of the Regional Strategic Plan of the Pan Caribbean Partnership. The Eastern Caribbean Social Marketing Assessment and Strategic Implementation Plan were supported by UNAIDS through the Programme Accelerated Funds mechanism. The assessment was implemented by PSI with WHO/PAHO CPC acting as the Executing Agency. The project objectives and outputs were defined as follows: Main Objective: To provide the basis for the formulation of a Strategic Implementation Plan for HIV/AIDS Prevention Social Marketing in the Eastern Caribbean. Specific Objectives: To attain a comprehensive understanding of: Condom availability and affordability for populations at greatest risk of contracting HIV/AIDS; Current sexual practices including condom usage and cultural barriers to usage within the identified countries; Current activities being conducted by NGOs and public, private and corporate sectors in the realm of HIV/AIDS behavior change communication (BCC) and social marketing. Project Outputs: Assessment of the current HIV/AIDS prevention context and potential for social marketing and BCC activities; Strategic Implementation Plan for HIV/AIDS Prevention Social Marketing in the Eastern Caribbean; Proposal for resource mobilization from regional donors for the social marketing program. Methodology: PSI made several trips to the Eastern Caribbean region during the period September 2001 through April 2002 in order to meet with National AIDS Programmes (NAP), UNAIDS, PAHO, CAREC, CARICOM, NGOs, Ministers of Health, regional donors, advertising agencies, market research agencies, regional distributors, and other public and private sector institutions. Countries visited during the assessment period included Trinidad, Barbados, St. Lucia, St. Kitts, St. Vincent, St. Maarten. Several representatives from other countries in the Eastern Caribbean attended meetings organized in the countries listed above. PSI collected a broad scope of documents and research related to HIV/AIDS prevention efforts in the region, supplemented by personal testimonies and interviews with those working directly with high risk groups and existing programs to address the epidemic. To supplement the information collected during the initial assessment, a PSI consultant conducted a condom distribution survey in Trinidad, Barbados, St. Lucia, St. Vincent and St. Maarten. The survey examined sales volume, brand availability and pricing in traditional and non-traditional sales outlets, condom and price displays, barriers to purchase, consumer trends (gender and quantity of condoms per purchase), and distributors and suppliers. Findings are presented in Section V, Regional Condom Accessibility, of this document. The complete condom distribution survey report is provided as a separate document. The Earle and Phillips Consulting Group conducted a quantitative KAP survey (sample size 1176) for PSI with youth ages 13 to 19 in Trinidad, Barbados, St. Kitts and St. Vincent. Similarly, qualitative research was conducted with men having sex with men (MSM), commercial sex workers (CSWs), and “beach boys” in most of these countries. This research examined levels of knowledge, attitudes, and practices related to HIV/AIDS, personal risk perception, and stigmatization of people living with HIV/AIDS. Findings are presented throughout the body of this document, and the final research report is provided as a separate document. Given the broad scope of the assessment, and budgetary and time constraints, it was not possible for PSI to visit every country in the Eastern Caribbean to collect information. While the results of this assessment emphasize certain countries more than others, this assessment presents a comprehensive picture of the HIV/AIDS situation in the region with findings and recommendations that should be relevant to each country in the Eastern Caribbean. EASTERN CARIBBEAN BACKGROUND Demographic Overview For the purposes of this project the “Eastern Caribbean” refers to Trinidad and Tobago, Barbados, OECS member states (St. Kitts and Nevis, St. Lucia, St. Vincent and the Grenadines, Antigua and Barbuda, Grenada, Dominica, Montserrat), and the Northern Netherlands Antilles (St. Maarten, St. Eustatious, Saba) . The following table summarizes relevant demographic and health indicators for the region. Table 1. Demographic Overview of the Eastern Caribbean Country Surface Area (sq km) Population Pop. Growth Rate Total Fertility Rate Life Expectancy M/F GDP Per Capita Reported HIV Prevelance Trinidad and Tobago 5,128 1.17 mill -0.51% 1.81 66/71 $9,500 1.2% Barbados 430 275,000 0.46% 1.64 70/75 $14,500 1.5% Anguilla 91 12,000 2.68% 1.79 73/80 $8,200 0.8% Turks & Caicos 430 18,100 3.41% 3.22 71/76 $7,300 5.0% Netherlands Antilles 960 212,226 n/a 2.07 73/77 $11,400 0.5% Antigua & Barbuda 442 67,000 0.74% 2.31 68/73 $8,200 1.6% Dominica 754 70,800 13.39% 2.03 71/77 $4,000 0.2% Grenada 340 89,200 -.06% 2.54 63/66 $4,400 1.3% Montserrat 100 7,574 -0.98% 1.82 76/80 $5,000 0.4% St. Kitts & Nevis 261 38,750 -0.11% 2.4 69/74 $7,000 0.9% St. Lucia 620 158,000 1.2% 2.38 69/76 $4,500 0.6% St. Vincent & Grenadines 389 115,942 0.4% 2.06 71/74 $2,800 0.9% The selected countries represent a total population of 2.2 million people, with widely varying rates of population growth and GDP per capita. Estimates of HIV prevalence are conservative due to underreporting and lack of systematic sentinel surveillance data collection. HIV Prevalence in the Caribbean [image: image1.wmf]Nine out of the 12 countries with the highest HIV prevalence in the Americas are in the Caribbean basin. In Haiti, Bahamas, Barbados, Guyana and the Dominican Republic the HIV/AIDS epidemic has spread to the general population affecting 2-8% of the adult population. Overall prevalence in the Caribbean is estimated at 2.2% among adults, making the Caribbean the region with the highest prevalence rates outside of Sub-Saharan Africa. The countries selected for this exercise experience lower prevalence rates but are considered to be at high risk due to widespread regional migration and tourism. AIDS is currently the leading cause of death in the 15-44 year age group. Public health specialists estimate that close to 700,000 people in the region are living with HIV/AIDS. However, widespread underreporting and poor surveillance suggest that these figures are actually much higher. Many of the islands do not possess the necessary staff and financial resources to ensure comprehensive and reliable data collection. Given the social stigmas associated with HIV/AIDS, persons who are infected often seek private treatment overseas, thereby reducing the likelihood of inclusion in official statistics. In addition, systematic data collection is impeded by a lack of national policies on testing and reporting of HIV in many countries in the region. [image: image2.wmf]Heterosexual transmission accounts for an estimated 64% of AIDS cases among CAREC member countries and mother-to-child transmission of the virus accounts for approximately 6% of all cases. In 1996, the male to female infection ratio was 2:1 in the English-speaking Caribbean. However, in 2001 the male to female ratio in the 10-19 age group was as high as 1:7 in some countries . Despite the increasing infection rate among women, male-to-male sexual contact continues to be a major route of transmission. CAREC estimates that as many as 50% of reported cases among men could be due to homosexual practices. With widespread homophobia, bisexual transmission is highly underreported. Many MSM lead outwardly “heterosexual” lives, thus putting their female partners in danger as well. Factors unique to the Caribbean contribute to the complexity of the epidemic. More than 20 million tourists visit the region each year, primarily from North America and Europe. Dependency on tourism is attributed to an increase in commercial sex. Since commercial sex is illegal in most countries, it is also unregulated, leaving sex workers vulnerable to exploitation. Homosexuality and bisexuality are highly stigmatized and make the dissemination of information to these groups difficult. In addition, many Caribbean people have multiple sex partners, condoned by social and cultural norms. Women’s emotional and economic dependence on men limits their ability to negotiate safer sexual behaviors, there are high levels of sexual violence and sexual activity begins at young ages. Furthermore, widespread mobility among Caribbean people increases risk because sexually active people are often separated from stable partners. Economic, Political and Social Climate Economic Impact of the Epidemic AIDS is the leading cause of death in the Caribbean among the 15-44 age group and it is predicted that this will have a severe negative effect on the economy. A study by the University of the West Indies (UWI) conducted in 2002 predicts: The total cost (direct and indirect) of the Caribbean epidemic will reach $80 million by 2020; GNP will fall between 4% - 6% in Trinidad & Tobago and Jamaica; Savings will decline by 10% in Trinidad and Tobago, and by 24% in Jamaica. Political Climate At the conclusion of the 22nd Meeting of the Conference of Heads of Government of CARICOM member countries in 2001, the chairman, Rt. Hon. Owen Arthur, Prime Minister of Barbados, emphasized HIV/AIDs in an address which urged members to meet the challenges facing the region. Following this, Heads of Government pledged their support for the Pan Caribbean Partnership on HIV/AIDS, and resolved to support national capacity building programs and pursue joint efforts to negotiate affordable prices for anti-retroviral drugs and education programs. On July 6, 2001, CARICOM member countries issued the Nassau declaration of Health : “The Health of the Region is the Wealth of the Region.” This declaration stresses the need for access to services for vulnerable groups, behavior change in youth and empowerment of women. These actions represent significant progress in the commitment of the region’s political leaders to address the HIV/AIDS epidemic in the Caribbean. However, many challenges remain. The National AIDS Programmes are often housed within the respective Ministry of Health and are linked directly to the government. As a result, pressure from groups that oppose condom use, and regard work with MSM, CSWs and other stigmatized populations as controversial, has limited the scope of NAP activities and messages. Several Ministries of Health expressed strong support for an outside entity who can address the more controversial topics and work with the vulnerable groups that Ministries are prevented from working with for political reasons. To date, few countries have developed national policies on human rights, and the legal and ethical framework for HIV/AIDS. Homosexuality is still against the law in Trinidad and Tobago, and recent efforts to include homosexuals in the Equal Opportunities Act have met with strong resistance. The increase in the number of HIV/AIDS specific NGOs and CBOs in the region may lead to an increase in advocacy on these issues, however the initiative has rarely come from the government itself. Tourism and Mobility The Caribbean is one of the most popular tourist destinations in the world. More than 20 million travelers, primarily from Europe, Canada and the United States, visit the region each year. On an average day, 20 different cruise ships transport more than 20,000 passengers and 7,000 crew-members to different points in the Caribbean. Risky sexual behaviors among tourists and people working in industries that respond to the needs of tourists expose visitors and residents of the region to many serious health threats. Broad HIV/AIDS Policy Guidelines for the Tourism Sector were developed by CAREC/WHO/PAHO and distributed to members of the Caribbean Hotel Association in June 2001. Recommendations included posting brief messages on HIV prevention in bathrooms, guest information packages and other conspicuous places. It also was recommended that condoms be made available to guests and staff on the hotel premises 24 hours a day. Although the recommendations are a positive step, much more work remains to be done to ensure that tourism industries comply with these recommendations. Caribbean people are very mobile, often traveling between islands for work, study, personal, political and economic reasons. Women increasingly dominate migration streams and the predominance of one sex in a migration stream indicates that immigrants are not moving with spouses, thus increasing the likelihood of commercial sex and multiple sexual partners. Tourism and mobility both contribute to the increased activity of a commercial sex industry. Sex workers in the Caribbean include short-term and fixed brothel workers, mobile sex workers, and “beach boys”. Sex work is illegal and unregulated in most Eastern Caribbean countries. As a result, social and health services are rarely responsive to the needs of sex workers, and it is exceedingly difficult for women to seek protection from abusive clients, bar owners, or pimps. The police are often regarded as part of the exploiting forces and rarely provide help in the case of abuse. Religious Groups [image: image3.wmf]Religious groups, primarily conservative Christian groups, staunchly oppose the discussion and promotion of condoms. The majority of the islands visited warned PSI consultants that strong opposition to a condom social marketing campaign would undoubtedly come from the religious communities. In 2001, a study on the responses of the religious community to HIV/AIDS was conducted in Trinidad and Tobago with Christian, Hindu, Muslim and other religious groups; it is likely that similar views are held on the other islands. Many respondents suggested that AIDS was a direct result of immorality or not adopting a religious lifestyle. Very few of the respondents acknowledged that abstinence before marriage may be difficult for young people. Overall, those interviewed felt that there were only a few conditions for which condom use was acceptable, mainly as a last resort or in marriage. In Tobago, 30% of youth agreed that teenagers should not be encouraged to use condoms because it encourages immoral behavior. Strong social and religious taboos have prevented the incorporation of sex education into school curricula and few high-profile messages have promoted consistent condom use. Some campaigns have focused on raising awareness of AIDS through messages such as “AIDS kills”. However, these campaigns neither recommend a specific call to action, nor do they identify appropriate changes in behavior, perhaps due to strong social stigmas against condom use. Regional Myths and Barriers Myths [image: image4.wmf]There are an abundance of myths among various religious and social groups in the region related to transmission and treatment of HIV/AIDS. The FPATT study in Tobago revealed that 19% of the sample cited “praying to God” as an effective way to prevent transmission while only 50% cited condom use. 4% cited bush medicine and 7% referred to anal sex as a way to prevent transmission of HIV/AIDS/STIs. Similar ideas existed related to contraception. While abstinence, condoms and the pill were cited as the top methods known to prevent pregnancy, high levels of confidence were reported in other methods such as “Hot Guiness” (16%), “Blue soap” (7%) and anal sex or “bulling” (17%). A 1998 KAP study conducted in Barbados revealed a number of other different myths. 40% of those surveyed believed that kissing was a transmission source, while 11% believed that oral sex could prevent AIDS. Astonishingly, 40% believed that AIDS could not be contracted through vaginal sex. 71% believed that donating blood was risky and 33% believed that AIDS could be transmitted through insect bites. Similarly, 33% believed a vaccine for AIDS already existed, and 33% believed AIDS could be cured if diagnosed and treated early. The 2002 PSI/Earle and Phillips KAP survey with youth ages 13-19 revealed that 21% of those surveyed thought that AIDS could be contracted from a mosquito bite and 18% believed that a person could be infected by sharing a meal with someone who has the virus. Additionally, 4% of the sample thought that AIDS could be transmitted through Obeah or witchcraft, and 5% thought there was a cure for AIDS. Moravian and Orisa (primarily African roots) representatives mentioned the predominant belief in their communities that if you have sex with a young virgin it will cure AIDS. As a result some fathers have sexual relations with their daughters as preventive and curative measures. Discrimination and Stigmatization Discrimination and stigmatization are major issues throughout the region. Families often disassociate themselves from people living with HIV/AIDS out of fear of the disease, fear of being associated with the stigmas related to the disease and unwillingness to provide care. Typically disclosure of HIV+ status is associated with separation of partners, and isolation from families and friends. [image: image5.wmf]Over the years many people have reported losing their jobs because of their HIV+ status and there have been several instances reported where a physician contacted a patient’s employer and disclosed his/her status, resulting in a HIV+ person being fired. As a result, the majority of PLWHA refuse to disclose their status to family, friends and employers. People living with HIV/AIDS have also reported being turned away from hospital rooms, and not being touched or examined if hospitalized. The mental and physical impact of stigmatization on those with the disease has resulted in many PLWHA not seeking health care or employment, retreating from all social interaction, and believing that death would be the best solution. All of the sex workers interviewed by Earle and Phillips had personal experiences with HIV/AIDS and few believed that they would receive support from close family or friends if they contracted the virus. CSWs also expressed little or no confidence in government health services. Given these extremely high rates of stigmatization and dissatisfaction, it is not surprising that the case fatality rate for HIV is extremely high in the region. Addressing the fear and stigmatization surrounding HIV/AIDS should be among the top priorities of HIV/AIDS campaigns. Decreasing stigmatization of people living with HIV/AIDS will help them to receive the care they need, participate more fully in HIV/AIDS prevention activities, reduce barriers to HIV testing, increase accuracy of surveillance figures, and enable more open and meaningful discussions about risk and prevention. Privacy and Confidentiality The ability to discuss sensitive issues such as sex and HIV/AIDS is further inhibited by a perceived lack of confidentiality and privacy. In focus groups, youth expressed concern about community gossip and rumors in their small island communities. For example, 94% of all youth surveyed did not believe that it was easy to keep a secret on Tobago (FPATT study in Tobago). Dating is often conducted in secret because gossip and labeling of boys as “bad” and girls as “sluts” can destroy relationships. As a result, it is difficult for youth to receive advice and support. Similarly, MSM and CSW populations reported reluctance to seek health care and the preference to commit suicide if found to be HIV positive, due to strong social stigmas. Young people feel that health care workers make it difficult for them to receive the services they need, as many prefer to lecture rather than to provide the services. It was also suggested that the management of patients in the clinic space might unintentionally facilitate the spread of confidential information. For example, nurses may give instructions, drugs and treatments to patients in the waiting room and other public spaces. Sensitization of health workers to issues of confidentiality and privacy is a necessary component of any intervention. Generation Gap While many parents, teachers and religious leaders are preaching abstinence and shying away from discussions of sex and condom use, it is clear that the realities of the older and the younger generations do not coincide. Members of the older generation seek to ban frank discussions about sexuality and shield youth from “harmful” messages in an effort to prevent sex before marriage. However, the PSI/Earle and Phillips youth KAP survey revealed that 46% of the youth interviewed had already had sex. Among sexually active youth, 16% had sex for the first time between the ages of 10 and 12, 47% had sex for the first time between the ages of 13 and 15, and 31% had sex for the first time between the ages of 16 and 19. Despite efforts to discourage sexual relations and discussions of condoms, many youth are already sexually active. National and Regional Responses to the Epidemic National AIDS Programmes have taken the lead role in the fight against HIV/AIDS, and are the key players at the national level for HIV/AIDS prevention efforts. Faced with budgetary and political constraints, they have had varying levels of impact throughout the region. There are few NGOs in the region dedicated solely to HIV/AIDS prevention (notable exceptions include the AIDS Action Foundation in St. Lucia, the Saint Maarten AIDS Foundation, CRN+ and small local groups supporting people living with HIV/AIDS). Some NGOs, such at the Family Planning Association affiliates of the IPPF have been broadening the scope of their activities to include HIV/AIDS prevention. After the 26th UNGASS meeting, a Declaration of Commitment on HIV/AIDS, “Global Crisis-Global Action”, was passed emphasizing the need for development of national strategies and financing for the effective integration of leadership, prevention, care, treatment and support. The CARICOM Caucus, recognizing the need to increase information and communication flow, called upon countries to develop a national multi-sectoral strategic plan to include government, private sector and local communities. Throughout the Caribbean many governments have drawn up strategic action plans. However, the status of completion of these plans and the identification of tangible implementation mechanisms varies from country to country. Some countries have just begun preparation, while others have finalized their plans and begun implementation. In order to facilitate exchanges between NAP Coordinators in the region, a Technical Cooperation Group of NAP Coordinators was formed and meets at least once a year to discuss progress and share lessons learned. Regional Responses to the Epidemic The Caribbean Task Force on HIV/AIDS, under the leadership of CARICOM, initiated a process that led to the emergence of the Pan Caribbean Partnership against HIV/AIDS in February 2001. This partnership has developed a Regional Strategic Framework to provide a plan for reducing the spread and impact of HIV/AIDS in the Caribbean. The framework identifies areas for priority action at the regional level with a focus on promoting a strengthened, effective and coordinated regional response to the epidemic. The identified lead institutions follow: Table 2. Priority Areas and Lead Institutions responding to HIV/AIDS in the Eastern Caribbean Priority Area Lead Institution Advocacy, policy development and legislation CARICOM/UNAIDS Care, treatment and support for PLWHA CRN+ Prevention of HIV transmission among youth Red Cross/ UNICEF/Caribbean HIV/AIDS Youth Network Prevention of HIV transmission among vulnerable groups: MSM CSWs Prisoners or incarcerated populations Mobile populations People in the Workplace UNAIDS/CAREC/IOM CAREC/UNAIDS Secretariat CAREC UNDCP IOM ILO Prevention of mother to child transmission of HIV CAREC/PAHO Strengthening national and regional response capability UWI Resource Mobilization CARICOM Many of these initiatives are still in the planning stages only. Refer to Appendix B for a comprehensive list of regional players, initiatives and the role of institutions in the fight against HIV/AIDS. Regional Donors In recent years there has been a trend of increased donor interest in HIV/AIDS prevention in the Caribbean coinciding with the recognition that it is the region with the highest HIV prevalence outside of Sub-Saharan Africa. Bilateral donors seeking to support regional HIV/AIDS prevention activities in the region have traditionally focused their support on CAREC. A summary of regional donors and their stated commitment to HIV/AIDS prevention in the Caribbean (as of Nov 2001) follows: USAID (United States Agency for International Development) USAID has pledged US $20 million in HIV/AIDS funding for 2002 to the Caribbean as part of the United State’s Third Border Initiative. $10 million will go to CAREC and $10 million will go to other institutions as yet to be determined. CDC (US Centers for Disease Control) The CDC will be setting up operations in Trinidad with CAREC. Initial efforts will focus on ramping up epidemiological surveillance in the region. CIDA (Canada International Development Agency) CIDA is providing CDN $8.5 million in support of CAREC’s Strategic Plan for the Prevention and Control of the HIV/AIDS Epidemic in the Caribbean (2001-2005). CIDA has also approved CDN $20 million for a new five-year regional initiative with CAREC, CARICOM and other regional organizations for work in Pan-Caribbean countries. The Netherlands Government The Netherlands government committed $2.5 million per year for a three-year period to UNAIDS in support of regional HIV/AIDS efforts. DFID (United Kingdom Department for International Development) DFID has indicated its intention to continue its support of the HIV/AIDS response in the Caribbean, and has currently made almost $2 million available to CAREC GTZ (Germany) Through CAREC, the German Technical Cooperation (GTZ) provides DM 4 million in support of the regional response to HIV/AIDS through current funds for the period 2000-2004 . FTC (French Technical Cooperation) The French Technical Cooperation (FTC) provides support to National AIDS Programmes in prevention, care, surveillance and program management through CAREC. FTC is also seeking to support HIV/AIDS programs in French departments. CEU (European Union) The CEU is providing 7 million Euros over 3 years for institutional strengthening to CARICOM, CAREC, UNAIDS, CRN+, UWI, and CHRC. World Bank The World Bank has earmarked a $5 million IDA grant for a Caribbean regional initiative through the Pan Caribbean Partnership. $150 million has been approved for the Caribbean Multi-Country HIV/AIDS Prevention and Control Adaptable Program Lending which is available for country-specific loans for actions to prevent and control HIV/AIDS. The Caribbean Development Bank (CDB) The CDB has offered $1 million in grants and $5 million in loans to the Caribbean countries. Private Foundations UNAIDS is in the process of negotiating direct funding opportunities for projects/programmes in the Caribbean with various private foundations, including the United Nations Foundation and the World AIDS Foundation. Other donors present and active in the region include JICA (Japanese), Spain, and the Nordic Countries. Private Sector Interests The corporate sector has far-reaching interests in the Caribbean. These include oil companies, car companies, textiles, high-tech industry, clothing stores, beverage companies, along with many commercial condom companies and distributors. Various opportunities exist for corporate sponsorship of activities and events, and public health organizations are beginning to take advantage of this prospect. Some of the larger companies are turning to cause-related marketing as support of highly visible “good causes” bolsters their corporate identity. In addition, several of the condom distributors are interested in contributing to marketing campaigns that could increase the overall market for condoms in the region. A number of highly professional advertising agencies with region-wide coverage of the Caribbean are based in Trinidad. Some advertising agencies conduct their own market research, however market research agencies with experience working with health-related institutions also exist, such as the Earle and Phillips Consulting Group. HIV/AIDS AMONG HIGH-RISK GROUPS Youth Limited information is available regarding actual HIV/AIDS rates among youth in the Eastern Caribbean, however it is widely acknowledged that the vast majority of HIV cases are contracted during adolescence or in the early 20’s. While sentinel surveillance among youth is extremely limited in the region, there is plentiful data regarding knowledge and behaviors which are predictors of HIV transmission risk. Knowledge of HIV/AIDS [image: image6.wmf]Knowledge of HIV/AIDS transmission routes and risks is generally quite high among Eastern Caribbean youth. Almost 100% of the PSI/Earle and Phillips sample (2002) of youth affirmed that they had heard of HIV/AIDS, and 88% had heard or seen information about it in the past month. Almost 97% knew that someone who looks healthy may still be a carrier of HIV/AIDS. A majority of the respondents was aware of primary transmission routes, however there was still uncertainty about transmission through mosquito bites and witchcraft. Among the islands where youth were surveyed, the highest levels of accurate knowledge were found in Barbados and the lowest levels were found in Trinidad. Despite these high levels of awareness about transmission and risks, youth still consider HIV/AIDS to be something that affects “other” people. Age of Sexual Onset Three studies in the Eastern Caribbean region by PAHO (2000), FPATT (2000) and the PSI/Earle and Phillips KAP (2002) reveal that the age of sexual onset is very young among both girls and boys. The PAHO study with in-school youth found that 22% of females were sexually active. Of the respondents 42% stated that they first had sex before the age of 10 and 20% reported having their first sexual encounter by the age of 11 or 12. Many of these cases are due to coercive sex, rape, incest, and predatory “sugar daddies” that increasingly seek young girls for sex because they are believed to be HIV-free or capable of curing HIV/AIDS. The FPATT survey in Tobago found that the average age at first sexual encounter was 14 with over 6% of youth having had their first sexual encounter before age 10, and 75% by the age of 16. Anal sex was reported as most common among the 10-14 age group. The PSI/Earle and Phillips KAP survey also revealed high levels of sexual activity among youth. 46% of youth between 13-19 were already sexually active and more than 20% of the males and almost 10% of females in the sample stated that they had sex for the first time between the ages of 10 and 12. While the statistics vary somewhat from study to study, all three studies demonstrate that average age of sexual onset in the Eastern Caribbean is between 13-15 years of age. Those youth who report sexual activity at a much earlier age are primarily victims of sexual abuse or coercive sex. The PSI/Earle and Phillips survey revealed that a total of 48% of girls and 32% of boys stated that their first intercourse was forced or somewhat forced. In Tobago, one in 15 youth had their first sexual experience with a relative. In the PAHO survey 10% of youth reported sexual abuse. Monogamy The PSI/Earle and Phillips KAP survey found that high rates of casual partners were reported among youth, some youth reported having more than one regular partner simultaneously. The survey also found that 25% of youth felt it was normal for a man to have multiple sex partners; male respondents were twice as likely as female respondents to answer that it is natural for a man to have multiple sex partners. Contraceptive Use [image: image7.wmf]According to the PAHO survey, only a quarter of the youth always use some form of birth control, and only slightly more worry about getting pregnant or causing a pregnancy. The PSI/Earle and Phillips KAP survey (2002) found that during the last sex act with a regular partner, 74% of the youth sampled stated that they had done something to avoid pregnancy. The response rate was lowest in Trinidad, where 40% of those surveyed stated that they did nothing to avoid pregnancy. These figures show that some youth are taking responsibility for the consequences of their sexual activity. However, there is still much to be done to encourage those who are not yet using contraception to do so, and to ensure that safe methods are being used consistently. In addition, more must be done to sensitize youth who are not using barrier methods to the dangers of STIs and HIV/AIDS. [image: image8.wmf]Condom Use Among Youth The PSI/Earle and Phillips KAP survey revealed that 60% of youth who are sexually active used condoms in the last encounter with their regular partner. 78% of the youth surveyed report using a condom in their last encounter with a casual partner. Condom use seems to be reinforced by peers, with over 50% of youth reporting that their friends would approve if they saw them with a condom and more than ⅔ of the sample stated that they would feel comfortable asking a partner to use a condom. In contrast, many youth feel that their parents would strongly disapprove if they saw them with a condom, and many (particularly girls) would feel embarrassed purchasing a condom at a local store. Reported condom use is already quite high, however efforts must be intensified to ensure that condoms are being used correctly and consistently, and to promote societal norms conducive to condom use. These issues are discussed in greater depth in Section VI, Regional Barriers to Condom Use, of this report. Youth Interventions There are already many interventions targeting youth throughout the region, and youth are the highest priority target group for many National AIDS Programmes and NGOs. Programs range from youth centers and peer education programs to outreach activities and materials developed specifically for youth. However, a focus group with youth in Barbados suggested that “boring one-dimensional safe sex and abstinence material is no competition for the glamorous portrayal of sex in all kinds of interesting and entertaining mediums.” A new, creative approach using innovative and interactive methods would significantly improve the impact of youth interventions in the Eastern Caribbean. Men Having Sex with Men Data related to HIV prevalence among men who have sex with men (MSM) in the Caribbean is scarce. Trends in transmission have tended to follow global trends, shifting away from high male to female ratios of infection to ratios of 1:1. It was estimated that the male to female radio was 2:1 in the English-speaking Caribbean in 1996. In 1987, one sample of MSM in Trinidad found prevalence rates as high as 40%. While these ratios are decreasing, MSM remain a high-risk group for a variety of cultural and behavioral reasons. [image: image9.wmf]Homosexuality and bisexuality are highly stigmatized in the Caribbean. As a result, many gay men adopt a bisexual lifestyle where underground homosexuality co-exists with a socially accepted, heterosexual lifestyle. This makes it particularly difficult to reach MSM with messages they relate to. Many MSM feel that they must hide their sexual orientation rather than risk social sanctions if discovered. This negatively impacts the general population through risky behaviors such as more relaxed condom use with regular, female partners. In addition, vaseline, creams and other substances are often used as lubricants, possibly jeopardizing the effectiveness of condoms when they are used. MSM self-identify based on different criteria. According to one man who was interviewed by PSI/Earle and Phillips, identification with homosexuality appears strongly linked to the active versus passive role in homosexual sex; a man who is “taking” is more likely to perceive himself as gay than a man who “gives”. The PSI/Earle and Phillips research revealed that most MSM are conscious of the risks of HIV/AIDS and usually engage in protected sex. Many of the MSM interviewed admitted to having multiple sex partners of both genders. Condom use appeared to be non-negotiable with male partners but was more relaxed for sexual activity with stable female partners. Homosexuality is a taboo subject in most of the Caribbean, however it appears to be quite common, especially among the younger generation. In addition, sexual tourism may draw young men into same sex relationships for economic reasons rather than because of sexual orientation. There are few programs targeting MSM in the Caribbean. Most National AIDS Programmes have not yet worked with MSM and have not listed this among their priorities. The only regional effort to specifically address MSM issues is the CAREC Leadership and Facilitation Project which aims to build social networks among MSM in order to reduce the damaging effects of a hostile, homophobic social environment. It seeks to provide community-building skills to people willing to play a leadership role to promote sexual health among MSM. While this program provides skills for MSM to address sexual health issues within their communities, it provides few specific guidelines and strategies to reach homosexual and bisexual communities with targeted HIV/AIDS prevention messages. Commercial Sex Workers Commercial sex workers (CSWs) have received little attention in the Eastern Caribbean and there is little data available on HIV/AIDS prevalence rates among CSWs. While prostitution is illegal and hidden in almost every island of the Eastern Caribbean, a booming tourist industry contributes to the presence of CSWs on every island. [image: image10.wmf]Few National AIDS Programmes are prioritizing work with CSWs. However, the PSI/Earle and Phillips qualitative research found that sex workers were anxious for a group to provide them with information and support in protecting themselves against STIs in general and HIV/AIDS in particular. Many CSWs who participated in the PSI/Earle and Phillips KAP research reported that they are in “stable” relationships in which they do not practice safe sex and that some relax the condom condition when they form emotional attachments with regular clients. Client insistence on anal sex appears to be an issue for many CSWs who fear that this puts them at additional risk. Most women interviewed were firm in their stance on condom use, though they conceded that many other CSW will accept a client’s offer to pay more for sex without a condom. A significant problem among CSWs is mistrust of existing government services. Several CSWs perceived employees of public-sector health facilities as lacking discretion and overly judgmental. All of the CSWs interviewed had personal experience with HIV/AIDS and few believed that they would receive support from close relatives in the event they contracted the virus, preferring to commit suicide or move to another island and live in isolation. HIV/AIDS is a significant issue among CSWs, cited as the top concern among women of their profession. They need additional support and understanding, and empathetic interventions to help them to manage their risk. This should be one of the priorities of the HIV/AIDS social marketing program. Other Risk Groups Other risk groups identified in the region include uniformed men, migrant populations, incarcerated populations, and people in the workplace. Little information exists on these groups, however various organizations are either already working with these populations or proposing to begin work. While differences exist among these populations, interpersonal communication and mass media interventions can be effective at reaching members of most of these groups. General Population The Barbados 1998 KAP survey with the general population revealed high levels of risky behavior, low levels of risk perception and inaccurate information about transmission. For example, 33% of those surveyed stated they did not use a condom at their partner’s request. Loss of pleasure, rather than cost, was the main factor in not using condoms. While 85% of the respondents were afraid of catching AIDS, only 33% stated that they were at risk. 80% of all respondents believed that 17-24 year olds were the main group at risk. However, within this same age group only 38% believed they were at risk. Approximately 50% of the sample stated that they would not be willing to get tested for HIV. 13% believed AIDS was linked to divine intervention and 23% felt that persons with HIV/AIDS had themselves to blame for contracting the virus. Beach Boys: “Beach boys” are young men who hang out on the beaches and alongside cruise ship stops to greet female tourists and “show them a good time.” According to the beach boys interviewed by PSI/Earle and Phillips, the visitors they have sexual relationships with are usually women from Britain, Canada or the USA in their thirties or older. Many beach boys will even move from island to island to be there waiting for a woman when she gets off the cruise ship. The beach boys appear to be well-informed with respect to HIV/AIDS transmission through messages they have heard in both the electronic and print media. They are aware that a person’s HIV status can not be evaluated based on appearance, however they still reported looking for physical clues when determining the risk of a client. The beach boys interviewed stated that their tourist sexual partners more often than not suggested condom use during sexual encounters, however they reported decreased condom use subsequent to substance misuse (alcohol and/or drugs). It should also be noted that most beach boys rarely use condoms in their stable relationships. Any interventions focusing on the beach boy populations should emphasize the risk of HIV/AIDS transmission from sexual encounters with stable, local and casual, tourist partners. It is also important to work with the tourist industry so condoms are more readily available and to sensitize tourists to the risks of HIV/AIDS in the region. People Living with HIV/AIDS: A recent assessment of services for people living with HIV/AIDS in Barbados revealed that PLWHA are marginalized by society and that the fear of being ostracized, exposed, and losing a job are significant barriers to seeking treatment. [image: image11.wmf] Several organizations exist throughout the region to provide support for PLWHA and their families, however they are often lacking in the necessary financial resources. CRN+ is the most visible of these organizations, with local membership in most Eastern Caribbean countries. The most important stated needs of PLWHA are access to standard care, treatment and support. This includes protection of basic human rights, psychosocial care of persons infected with and affected by HIV/AIDS, palliative care for HIV-related symptoms, prevention and treatment of common opportunistic infections, social welfare programs for economic support for PLWHA, their families, and particularly their children. It is recommended that the regional HIV/AIDS prevention project involve PLWHA as much as possible, hiring them for education outreach efforts (regardless of whether they decide to disclose their HIV status to the public) as they are most aware of the risks and needs related to people living with the virus. COUNTRY FINDINGS While each island in the Eastern Caribbean exhibits its own particularities, there are several common trends throughout the region: The primary player in HIV/AIDS prevention has been the National AIDS Programmes; Interventions to date have largely focused on youth, and due to financial constraints have been primarily confined to interpersonal communication activities; Some countries have run short mass media campaigns or targeted groups for interventions—most notably people in the workplace; The high-risk groups identified regionally (MSM, CSW, beach boys, men in uniform, prisoners, migrant populations, PLWHA) have generally not been addressed. PSI distributed a general survey to all countries in the Eastern Caribbean to inventory existing mass media programs and solicit information about what types of educational materials are most needed. Anguilla, St. Eustatius, Saba, Barbados, St. Maarten, Antigua/Barbuda, Trinidad and Tobago, Dominica, and St. Lucia responded. With the exception of St. Maarten, St. Eustatius and Saba, who do not currently report mass media messages, all of the islands reported that some type of radio and television campaigns were currently airing. Of those islands that currently air pubic service announcements related to HIV/AIDS, all reported that the quality of messages was either ineffective or “somewhat” effective in reaching their intended audience. All of the islands with the exception of Saba reported occasional condom shortages. However, this may be biased to shortages among the National AIDS Programmes, who were the primary respondents on the surveys. All countries, with the exception of Antigua and Barbuda, reported that strong stigmas exist against condom use. [image: image12.wmf]The countries requested the support of PSI in the areas listed in Table 3. Highest priority was given to printed youth materials, youth training materials and materials for MSM. Without exception, the countries responding also requested support from PSI in developing BCC strategies, increasing access to condoms, providing training for service providers and increasing visibility via mass media. Of all the potential interventions with the different target groups, youth and the general population were prioritized. The next most important populations were uniformed populations and PLWHA, followed by MSM and the tourist industry. In addition, ⅓ of the countries responding to the survey felt it would be important for PSI to intervene with CSWs and migrant populations: These recommendations for PSI provide valuable insight into National AIDS Programme priorities and identifying populations that may have received little attention to date. This insight will help PSI to define its priorities for the regional social marketing project. What follows is a brief overview of different HIV/AIDS prevention activities currently underway in several countries of the Eastern Caribbean. While not all countries are mentioned, the overview provides a useful framework of efforts in the region to date. TRINIDAD AND TOBAGO Of Trinidad and Tobago’s population of 1.7 million, it is estimated that there are 39,000 PLWHA. In 1985 the male to female ratio of HIV infected persons was 9:1. It is currently estimated at 1.3:1. Trinidad and Tobago National AIDS Programme. When the first cases of AIDS were identified in 1983, the Ministry of Health set up the existing National Surveillance Unit to monitor HIV/AIDS cases. In 1987 the National AIDS Programme was established. An assessment of the NAP in 1998 led to a new division of the NAP, the National AIDS Technical Coordinating Unit (NATCU). The role of the NATCU was to coordinate the national response to the epidemic, and guide and empower others to join in the response. A 1999-2001 initiative focused on building partnerships with the public and private sector, NGOs and PLWHA. The Documentation Center of the NAP also provides information to the public on HIV/AIDS. Within the NAP strategic initiative there are 4 major strategies: Strengthen capacity of government sectors in multi-sectoral partnerships; Strengthen capacity of NGO sectors to serve in multi-sectoral partnerships; Conduct activities that provide capacity building for Trinidad and Tobago HIV/AIDS alliance of HIV/AIDS service organizations; Conduct advocacy, networking and communication training for NGOs. Family Planning Association Trinidad and Tobago. The FPATT, an affiliate of the International Planned Parenthood Federation, is the primary organization responsible for family planning counseling and contraceptive use in Trinidad and Tobago. The FPATT has been running a condom social marketing project of Panther condoms since the late 1980’s. However, demand has decreased as donor funding (and condom subsidization) has diminished. Panther condoms are now distributed through 120 pharmacies; mainly in the same outlets as commercial condom brands. Panther is not generally available in non-traditional outlets such as bars, rum shops, hotels or other small points of sales. FPATT is increasingly concentrating its efforts on HIV/AIDS prevention with mobile clinics, a full IEC team, a family life radio program, youth center and other activities. FPATT is beginning to conduct voluntary counseling and testing for HIV with support from CAREC and GTZ. FPATT is well-respected in the country, has significant experience in BCC and HIV/AIDS, and represents a strong potential partner for PSI in the social marketing project. The Rap Port, Trinidad. The Rap Port is a youth information and community outreach project of the NAP focusing on youth between 13-24 years of age. Launched in 1995, the staff provides information and training to young people. Within Rap Port there is a resource center and a call-in counseling center. It is estimated that in-house activities reach 300 youth per month and outreach activities, at schools, churches and community events, reach 900-1000 people per month. The Rap Port model is interesting and should be studied for possible replication on other islands. Other HIV/AIDS NGOs. CARe is a voluntary non-profit charitable organization with the mandate of empowering and improving the lives of PLWHA. CARe has strong leadership but lacks resources. CRN+ other small grassroots organizations are active in Trinidad and Tobago to provide support to PLWHA. TOBAGO: There has been no official government HIV/AIDS intervention specific to Tobago. The National AIDS Programme based in Trinidad has guided the Tobago response by developing and disseminating information. Despite campaigns of the Church, multiple sexual partners and extra-marital relationships are common in Tobago The FPATT has conducted extensive research among youth in Tobago and is currently developing a youth sexual health promotion project to be implemented jointly by the FPATT and Tobago Aids Society in collaboration with CAREC-GTZ. This project will support BCC interventions that target youth ages 10 to 24. Interventions will combine IEC to individuals and small groups, parent education and monitoring, community outreach, policy recommendations and media campaigns. BARBADOS Barbados is the second largest country in the Eastern Caribbean, though its population of 275,000 is significantly smaller than that of Trinidad and Tobago. Much like Trinidad and Tobago, the response to the HIV/AIDS epidemic has largely been driven by the government’s National AIDS Programme (NAP). Barbados HIV/AIDS Findings. A KAP survey was conducted in Barbados in 1998 reaching across all age groups and genders, with a sample size of 961. Over 50% of the people surveyed had spoken about AIDS with someone in their social network in the previous month; discussions about HIV/AIDS were much more common among those with secondary education and above. 90% of respondents stated that television was a significant source of information about the virus, while 80% mentioned radio. 41% cited the Church as a source of information, however more respondents with primary school education cited this source. 40% recalled seeing a brochure on AIDS distributed through the national press, and 89% of the population was aware of the AIDS Hotline, however only 7% had ever called. These figures provide some indication of the level of coverage of issues related to HIV/AIDS in Barbados. National AIDS Programme. Since 1985, the Ministry of Health has been responsible for all HIV/AIDS programs including prevention, care, treatment and support, epidemiology and surveillance. From 1995-1998, the NAP adopted a multi-sectoral approach to programs which included Government Ministries, PLWHA, civil society and the private business sector. In September of 2000, the Prime Minister announced that the National HIV/AIDS Programme would move into the Office of the Prime Minister and indicated that Barbados $100 million (approximately US$50 million) would be made available for the HIV/AIDS program. The National Program currently falls under a Minister of State in the Prime Minister’s Office where an inter-ministerial sub-committee was appointed. The 2001-2006 HIV/AIDS Strategic Plan, integrates several ministries into HIV/AIDS prevention (Health, Tourism and International Transport, Government Information Services, Labour, Sports & Public Sector Reform, Education & Social Transformation, and the Civil Service). New strategies in the strategic plan include walk-in clinics and the inclusion of PLWHA in core groups of each Ministry and the NAP agency, and easier access to social services and skills training. An HIV/AIDS Prevention and Control Project ($15.5 million over 5 years) in collaboration with the World Bank was recently approved. The project objectives are to reduce the incidence of HIV, increase life expectancy of PLWHA and build sustainable institutional arrangements for managing HIV/AIDS. The goals of this new program are to achieve a 50% reduction in the HIV/AIDS mortality rates within the next 3 years, and a 50% reduction in HIV incidence over the next 5 years. The AIDS Information Centre, located within the Ministry of Health provides printed materials, condoms and runs a volunteer-run hotline to the general population. Unfortunately, the low volume of calls makes it difficult to recruit and retain volunteers. However, this is a valuable resource to exploit in mass media efforts in Barbados. NGO and other sectors An AIDS foundation and the Barbados AIDS network are being developed. Special care is provided to PLWHA in Barbados at the Queen Elizabeth Hospital Respiratory Unit. Family Care provides support to families of PLWHA and assists in dealing with issues imposed on them by the surrounding community. Among other activities they hold a camp for children infected with or affected by HIV/AIDS. CARe also has a self-support network in Barbados for PLWHA with the goal of exchanging information and skills, developing mutual support, and empowering PLWHA and those who work on behalf of HIV/AIDS infected and affected persons. The Elroy Phillips Centre in Barbados is a hostel for PLWHA who are homeless. This facility is supported by the Ministry of Health, and is supervised and managed by the AIDS Information Centre. The Family Planning Association of Barbados is increasingly active in the fight against HIV/AIDS. Although there are several NGOs active in HIV/AIDS prevention and care in Barbados, many are in need of capacity building measures. OECS MEMBER STATES ST. KITTS and NEVIS The St. Kitts and Nevis Situation Analysis (2001) identified some of the underlying psychosocial and economic factors influencing the epidemic: early initiation of sexual activity among boys and girls, sex between young girls and older men, inconsistent and rare use of condoms, incest and domestic violence, underground homosexuality, stigmatization and discrimination of PLWHA, migration among Caribbean countries, high rates of tourism and absence of targeted behavior change interventions for high-risk populations. National AIDS Programme. St. Kitts and Nevis have developed a strategic plan with 5 priority areas: prevention; treatment, care and support; advocacy and surveillance; epidemiology and research; program coordination and management. The target groups identified are youth, general population, MSM, CSW, disabled and special education groups, the Rastafarian movement, and married men. The strategies to be used are an effective and culturally sensitive IEC strategy, improved clinical STD management, and increased condom promotion and access for prevention of STIs and HIV/AIDS. The organizational structure includes an inter-ministerial committee under the office of the Prime Minister, and working with a National AIDS Advisory Committee and a Nevis AIDS Implementation Committee. The National AIDS Advisory Committee is comprised of one representative from each ministry, as well as representatives of religious groups, media, business and the commercial sector, unions, NGOs and PLWHA. NGOs. FACTTS (Facilitating Access to Confidential Testing, Treatment & Support) is the self-support group of St. Kitts. However, recruitment of PLWHA for participation is challenging as many PLWHA prefer to keep their status secret out of fear of being ostracized by the community. GRENADA National AIDS Programme. For the first time since HIV cases were first reported in Grenada, the government specifically targeted HIV/AIDS in the 2001 country budget. The program focuses on multi-sectoral collaborations, strengthening of health information and surveillance systems, policy, and counseling for PLWHA. NGOs. The Grenada AIDS Foundation assists patients with HIV/AIDS in implementing health care measures and promoting behaviors that prevent further spread of HIV. The group is involved in educational activities throughout Grenada. HOPALS (Hope, Help & Empowerment) provides support to families of infected persons, educates the general public on HIV/AIDS and conducts advocacy activities with the government. ST. VINCENT & THE GRENADINES In 1998, the Kingstown General Hospital of St. Vincent and the Grenadines estimated that 38% of hospital admissions were related to HIV/AIDS. A total of 535 cases of HIV have been positively identified thus far. Sex workers are a hidden population on the island, and no programs are directed specifically toward CSWs. Mass media efforts include interviews broadcast over local radio stations. Popular local shows have also addressed issues related to HIV/AIDS. National AIDS Programme. The National AIDS Programme, housed within the Ministry of Health, plays a very active role in HIV/AIDS activities in the country. The NAP distributes condoms through 39 health centers, and provides condoms to police stations, restaurants, bars, hotels and nightclubs. Similar to other countries, it specifically requested that PSI provide support for BCC strategies and activities, prioritizing men and youth. The NAP also expressed a need for increased resources for PLWHA in terms of treatment and accommodations, addressing stigmas, and integration into HIV/AIDS prevention activities. NGOs. The St. Vincent Planned Parenthood Association has been a leader in providing sexual and reproductive health services and has now recognized the urgent need to intervene in the context of HIV/AIDS education awareness and support. The US Peace Corps is providing educational sessions on HIV/AIDS, which have been well received. However, printed materials are lacking. The House of Hope and the PLWHA self-support group provide services to PLWHA. Other NGOs working on HIV/AIDS prevention include service clubs, in particular the Anglican movement. However, many of these groups are not specifically dedicated to HIV/AIDS. THE NETHERLANDS ANTILLES The Windward Islands of the Netherlands Antilles are situated near Puerto Rico. The Netherlands Antilles are territories of the Kingdom of the Netherlands and as such are subject to the government in The Hague. ST MAARTEN There are people of over 70 different nationalities living in St. Maarten, and the majority of the inhabitants of the island were born on other islands or in other countries and have migrated for economic reasons . The tourist industry is very important, and St. Maarten is host to both cruise ships and many stay-over tourists. HIV Prevalence. St. Maarten has the highest HIV/AIDS prevalence rate in the Netherlands Antilles. Within the Netherlands Antilles and on St. Maarten, AIDS is the primary cause of death among the 25-44 age group. As of September 2001, 800-900 persons had been confirmed as HIV+ in St. Maarten. It was estimated that heterosexual transmission accounts for almost 80% of these cases, perinatal transmission for 6%, and IV drug-use for 5%; it is unknown how many cases of bisexual transmission are also occurring. There is unregulated male and female sex work on the island in dance clubs, bars and among beach boys. In addition, high levels of promiscuity are culturally acceptable. The seroprevalence among pregnant women in St. Maarten is 2.5%, which may indicate that overall prevalence on the island is between 2.5-3.5%. National AIDS Programme: The St. Maarten AIDS Committee was founded in September 1991 as a subcommittee of the Foundation for Health Promotion. Its objectives are to promote awareness of HIV/AIDS among the general population and STIs, prevent transmission, and reduce possible negative social and/or personal consequences of the AIDS epidemic. Educational activities continue on a small scale and most efforts are currently focused on support for PLWHA. The strategic plan includes provisions for the formation of a community-based platform to monitor, evaluate, advocate, and encourage realization of the different aspects of the strategic plan. Current actors in HIV/AIDS prevention include the Ministry of Health, St. Maarten AIDS Foundation, Red Cross Youth & AIDS program, Rotary HIV/AIDS awareness program, a local HIV/AIDS support group called HOPE (Helping Ourselves in a Positive Environment), the Health Information Center and an AIDS helpline. Aside from the establishment of the Health Information Center and AIDS helpline, activities to date include: sensitization of government officials; printing and distribution of locally adapted folders, posters, bumper-stickers and newspaper articles; radio and TV appearances; call-in programs and four programs including a person living with HIV/AIDS; and broadcasting of videos and films on HIV/AIDS. A KAP survey was conducted in 1993 and World AIDS Day activities have been implemented on an annual basis. All funds for these activities were locally raised, as no funding had been received from international organizations (2001). This trend is beginning to change as additional funding is being invested in local NGOs (notably the St. Maarten AIDS Foundation is receiving support from UNAIDS and the Dutch AIDS Foundation) and soon in the government as well. SABA Saba has been marketed as the “gay island” for tourism, capitalizing on the high expenditures typically associated with gay men. There are a total of 8 hotels on the island, and a reported “surface tolerance” of PLWHA—an improvement over the environment in many Eastern Caribbean countries. Even Churches have been opening their doors to PLWHA. Most of the PLWHA are MSM who work in the private sector and generally support each other in care and treatment. Condoms are available at the hospital for a small fee. There have been relatively few interventions for HIV/AIDS prevention on the island, however the preparation of the national strategic plan has sparked renewed interest and action. The AIDS Foundation, inactive for the last 5 years, is now restarting its efforts. Among other activities, the foundation has created a “life jacket” program aimed at youth that includes educational videos and discussion sessions to sensitize them to HIV/AIDS issues. SAINT EUSTATIUS Like other islands in the Windward Netherlands Antilles, St. Eustatius has a large population of immigrants from neighboring islands. Many of the CSWs are Spanish-speakers from the Dominican Republic who require HIV/AIDS materials in Spanish. In order to respond to the call for National HIV/AIDS Strategic Plans, the island has brought together a core planning committee consisting of 7 people representing different health and non-health sectors. The island currently has one social worker that gives out condoms. OTHER ISLANDS ANGUILLA Anguilla, a territory of the United Kingdom, is a small island in the Northeastern Caribbean with an estimated population of 12,000. The island regularly hosts more than 100,000 visitors from overseas and tourism is an important source of revenue for the country. The first case of HIV/AIDS in Anguilla was diagnosed in 1988. Since this time, 21 cases have been identified by the National Health Service and confirmed by CAREC. 57% of people infected are Anguillan and the rest are from other Caribbean countries. HIV+ people generally head travel to St. Maarten or the USA for testing and clinical management. Throughout the 1990s the National AIDS Programme was managed by a committee primarily comprised of health professionals. Efforts focused on preventing HIV transmission through sexual activity and blood transfusions. Strategies implemented were health education and promotion, including outreach to the community and school populations. Lack of funding severely affected the implementation of other strategies. The NAP currently has 3 broad strategic areas of action: health promotion for behavior change; treatment, care and support; advocacy and partnerships . The health promotion component involves sensitization of the community through TV, radio programming, and print media, coordination with community groups, conducting HIV/AIDS sensitization session in the workplace and with religious groups, interventions for vulnerable groups, treatment, care and support, and advocacy and policy changes. There is no indigenous media in Anguilla; media content is imported and word of mouth is deemed the most effective communication mechanism on the island. Anguilla has specifically requested support from PSI in the areas of BCC, developing youth to youth projects and materials. TURKS AND CAICOS The estimated number of cumulative cases of HIV per 100,000 people in Turks and Caicos is the highest in the English-speaking Caribbean after the Bahamas (CAREC). PSI did not originally plan to include Turks and Caicos in its project. However, given the need for supporting materials in English, Spanish and Haitian Creole, and the high levels of migration to and from neighboring islands, PSI now proposes to include Turks and Caicos in the initiative as well. V. REGIONAL CONDOM ACCESSIBILITIY PSI conducted a condom distribution survey in April 2002 in Trinidad, Barbados, St. Lucia, St. Maarten and St. Vincent in order to help determine the feasibility of a condom social marketing project in the Eastern Caribbean region. The findings were pivotal to the feasibility study, revealing the existence of a multitude of brands already on the market that are perceived as affordable by the target population. These findings make it difficult to justify launching a condom social marketing project with yet another brand, which would have difficulty competing with current brands and may undercut current private sector sales. While it became clear that the traditional condom social marketing approach is not appropriate, the survey revealed many barriers to condom purchase and availability that must be addressed. For instance, condoms are generally stored behind the counter or in other non-visible places, and prices are rarely displayed. Consumers must ask for the condoms by name and inquire about prices, often while standing in line with other people. This situation constitutes a significant barrier for adolescents who are highly conscious of their surroundings and are afraid of being observed by adults who could report the purchase to their parents. Approximately 50% of potential condom sales outlets in the region do not currently carry condoms, many for reasons as simple as lack of visits by a condom sales agent. There are no promotional materials at the majority of sales points, contributing to a lack of awareness of whether or not condoms are available. Many non-traditional sales points (bars, clubs, hotels, barber shops) expressed interest in condom vending machines, and some countries already have plans for their installation. A local vending machine company in Barbados has begun to import condom vending machines with plans to sell condom vending services to establishments in the food, nightlife and hospitality industries. A bar owner in Barbados expressed his desire for a condom vending machine, with no preference for which brand would be sold in the machine. While a multitude of condom brands exist, efforts must be intensified to increase the number of sales points in both traditional and non-traditional outlets, to increase visibility through point-of-sale materials and to begin displaying the condoms in a way that will reduce barriers for potential consumers. The condom distribution survey, conducted from April 8-17, 2002, sought to evaluate the following points: General Market Characteristics (size of market, range of brands, brand visibility and recognition, major condom importers and distributors, retail mark-up rates); Buying Patterns (number of packs per purchase, frequency of female customers); Accessibility (types of sales outlets and availability, business hours, product range available in outlets, retail prices, visibility of condoms and prices at outlets, promo materials). The results of the survey are presented in the following sections. A. Sales Outlets The condom distribution survey covered eight different private sector outlet types across Trinidad, Barbados, St. Lucia, St. Maarten and St. Vincent At least one outlet of each of the following categories was visited per island: Pharmacies; Supermarkets; Mini-marts/convenience stores; Gas stations; Hotels; Bars; Rum and Barber shops. Private Sector Sales Outlets. A total of 18 outlets were visited in St. Lucia, 24 in Trinidad, 18 in Barbados, 12 in St. Vincent and 17 in St. Maarten. Condoms are available in all pharmacies, many supermarkets, and all of the new gas station convenience stores such as Shell Select, Esso Tiger Mart, Quick Shoppe and Texaco Star Mart. Gas station chain stores are open late or 24 hours, and are a dependable source of condoms for late-night customers. Approximately 50% of all private sector sales outlets visited had condoms available at the time of visit. Reasons for not stocking condoms among those outlets varied, however the reason most often cited was that a sales agent had not visited the outlet. Some outlets stated that they usually had condoms for sale but were temporarily out of stock and waiting to be revisited by a sales agent. One supermarket intentionally decided to stop selling condoms as it was located near a high school and the number of youth buying condoms was increasing rapidly (the owner was morally opposed to providing condoms to youth). The sample size of the outlets surveyed is too small to say with any certainty that the findings are representative at the national or regional level. With that in mind the survey found the following proportions of the various outlets selling condoms: Table 7. Private Sector Sales Outlets Type of Sales Outlet % Carrying Condoms Actual # of Outlets Pharmacy 100% 15 out of 15 Supermarket 63% 10 out of 16 Mini-Mart 70% 7 out of 10 Gas Station 62% 8 out of 13 Hotel* 33% 3 out of 9 Bar 19% 3 out of 16 Rum Shop** 66% 2 out of 3 Barber Shop 20% 1 out of 5 *Hotels often have mini-mart type convenience stores on-site or nearby, thus decreasing their perceived need to keep condoms on hand. The highest mark-ups throughout the islands (100% or more) were found at those hotels that did sell condoms. ** Customers usually only purchase one condom at a time, and weeks may go by without the outlet making a sale. By contrast one rum shop in Barbados had the third highest reported condom sales volume among all the outlets participating in the questionnaire for the island. These findings correspond to the findings from the PSI/Earle and Phillips KAP survey with youth. 91% of the youth surveyed know of a place where condoms could be obtained, and those who did not were often 13 or 14 years old. When asked where the nearest place to their home was where they were sure to find condoms, 41% responded that it was a pharmacy, 28% responded that it was a convenience store, 20% cited a health center, 12% mentioned a food store (or supermarket) and 9% cited a rum shop. Interestingly, only 1.7% mentioned a gas station despite the widespread availability in gas stations found in the condom distribution survey. When asked how much time it would take to get to the nearest place they could buy condoms from home on foot, 50% of the youth responded that it would take 5 minutes or less, and 25% stated that it would take between 6 and 10 minutes. Clearly, geographic accessibility does not seem to be an issue among youth. Non-Traditional Outlets. In St. Lucia and St. Vincent, social marketing programs are extending condom distribution to small or non-traditional outlets. The AIDS Action Foundation in St. Lucia runs a social marketing program which covers 130 outlets throughout the island, including restaurants, small shops and barber shops. In St. Vincent, the Planned Parenthood Association runs a small social marketing program covering 26 outlets, including small shops, barber shops and prominent families. The FPATT also runs condom social marketing projects in Trinidad and Barbados (Panther condoms). However, the pricing is similar to market prices of the other brands and they are primarily distributed through the more traditional outlets. Public Sector Distribution. The public sector distributes free condoms in every country. However, the extent of use of free condoms is low compared to use of private-sector branded condoms. The youth KAP survey conducted by PSI/Earle and Phillips found that only 12% of sexually active youth stated that they had ever used public sector condoms. The rates of use were much higher in St. Vincent (19%) and St. Kitts (21%) than in Barbados (8%) and Trinidad (9%). Distributors. In St. Lucia, Trinidad and Barbados there are several distributors of food and beverages, pharmaceuticals and health & beauty products that have island-wide coverage. In St. Maarten, there is at least one pharmaceuticals importer/distributor that covers the entire territory. These distributors provide island-wide or territory-wide coverage of pharmacies and supermarkets for condom distribution. Brands and Pricing A total of 12 condom brands were identified in St. Lucia, 23 brands in Trinidad, 10 in Barbados, 8 in St. Vincent, and 14 in St. Maarten. According to the sales outlets and distributors, the top selling brand in each of these markets is Rough Rider (ranging from 25% of the market in St. Lucia to 50% in Trinidad). The next most popular brand varies from island to island, and includes Durex, Long Love and Panther. These findings are again confirmed by the PSI/Earle and Phillips KAP survey, where 83% of all youth spontaneously mentioned Rough Rider as the condom brand they had heard of. This was followed by Durex (30%), Trojan (26%), Panther (24%), Slam (19%), Bare Back (16%) and Long Love (9%). When asked if they had every actually purchased a condom, only 30.3% of the youth stated that they had. Figures were highest in Barbados and St. Kitts, and in every case more than twice as high for boys than for girls. Overall, of youth who had purchased condoms, 42% had purchased Rough Rider, 10% purchased Durex, 10% purchased Long Love, and 8% had purchased Slam. In Trinidad, 62% had purchased Rough Rider. Table 8. Brands and Pricing US$/pack Rough Rider (three-pack) Long Love (two-pack) Lowest-Priced commercial brand Social marketed brand St. Lucia $1.37 $1.53 $0.98 $0.78 Trinidad $0.99 $0.93 $0.77 -- Barbados $1.02 $0.89 $0.89 -- St. Vincent $1.06 $1.07 $0.98 $0.59 St. Maarten $1.95 -- $1.50 -- Condom Affordability. According to the PSI/Earle and Phillips KAP survey with youth, condoms were largely perceived as affordable. 60% of all respondents stated that condoms are not expensive, while 30% stated that they did not know and only 9% answered that they did feel condoms were expensive. When asked what they considered to be an affordable price for a condom of good quality, 44% responded that they would pay US$1-$1.50 for a package of 3 condoms. More than 40% of the youth felt that above $1.50 for a three-pack was reasonable. When asked why they decided to purchase a particular brand, an overwhelming 52% of the youth stated that they did so because it was “high quality”. The second most frequent reason cited was that “it was available” (28%) while only 10% stated they selected that brand because “it was affordable.” Price is not a key factor in the decision to purchase a condom, but perceived high quality is. Outlet managers responded overwhelmingly that customer demand is the most important factor in deciding which condom brand to carry. Many also mentioned ‘quality’ and profit margins, thus reinforcing the idea that perceived quality is of primary importance in the Easter Caribbean. In this context, where quality counts more than price and condoms are already perceived to be affordable, it is clear that a new price-subsidized brand is not necessary. Instead, the project should focus on working with existing social marketing projects and commercial distributors to increase the number of traditional and non-traditional sales outlets, improve condom visibility in the outlets and focus efforts on demand creation. Sales Volume It is exceedingly difficult to collect information on sales volume in the Eastern Caribbean countries. The condom market is competitive, and most distributors were reluctant to provide annual sales figures for their particular brands. Record-keeping for condom sales is generally incomplete, and in many cases records are thrown away or stored after an auditing period is completed. Trade statistics departments have little information on condoms, as quantity is often reported in kilograms and lumped into a category with other rubber products. While figures are not available, discussions with distributors and others involved in private sector distribution and sales indicate an upward trend in imports and/or plateau over the past several years. The only country for which an estimate of annual sales volume was available was Barbados, citing sales for 2001 at 1.1 million units. This translates to approximately roughly 4.2 condoms per capita, or 17 condoms per sexually active male per year. Product Turnover. In the absence of overall market figures consumer patterns and product turnover as reflected by average sales per week provide some information on sales volumes. In St. Lucia the volume of condom sales at outlets visited ranges from an average of 9 packs per week at a barbershop to 280 packs per week at a gas station. In Trinidad the highest volume of sales reported was in a pharmacy (an average of 480 packs per week), whereas the largest volume of weekly sales in Barbados was reported to be 110 packs per week at a mini-mart. One pharmacy in St. Vincent reported sales of 560 packs of condoms per week and a supermarket in St. Maarten estimated weekly sales of 335 packs. Sales volume varies greatly by outlet location, however these figures indicate that certain strategically placed outlets do experience high product rotation. Market Trends. The general consensus among distributors is that the condom market grew significantly in the late 1980’s due to the rise of the AIDS scare and advertising by the Panther social marketing project. Once funding for the Panther social marketing project was discontinued by USAID, sales fell, very few other brands launched promotional campaigns and the overall market appeared to stabilize. It appears that less shelf space is being given to condoms than in the past in many sales outlets. Several of the outlets surveyed by PSI stated that they sold condoms previously but no longer do so due to lack of visits by condom sales representatives or distributors, and lack of consumer demand. It is clear that more effort can be made through advertising and intensified efforts by sales agents to increase the number of outlets and overall condom sales. It is strongly recommended that PSI launch a non-brand specific condom social marketing campaign and that it work closely with all national and regional distributors to develop a comprehensive sales tracking system to monitor trends in overall sales by country and estimate annual sales volume. These figures could also serve to evaluate the project impact on condom use in the region. Condom Visibility and Accessibility Very few sales outlets had promotional items displayed to draw attention to the fact that condoms were available in the outlet. There were a few notable exceptions: a rum shop with condom posters covering the back wall in St. Lucia and a “Slam” poster at a bar in Trinidad, a mini-mart in St. Vincent had condom packs stretched across the ceiling on a string for promotion. The pharmacies in St. Vincent openly displayed their condoms while every other condom outlet visited displayed the condoms in closed glass cases or on the back wall behind the counter. Not a single outlet visited in St. Maarten had any promotional displays. In all countries the vast majority of condom outlets stocked the products on a low shelf on the back wall behind the cashier, requiring potential customers to ask for the condoms by name and also request the prices of the product. In most outlets doing so would bring attention to the customer, thus creating a barrier for youth who are already be timid about making such a purchase. This issue was highlighted by focus groups in Barbados where several youth stated that confidentiality is a key issue and they fear being seen purchasing a condom by an adult who knows them. The exception to this observation was gas stations where condoms were generally displayed in a place that was highly visible and accessible to customers. However, the KAP findings revealed that gas stations are not generally cited by youth as places to purchase condoms. Much more can be done in the region to promote visibility and availability of condoms in different sales outlets. Sales agents can work with outlets to increase visibility of their condoms and reduce barriers related to asking for the condoms in front of other customers. Tactful point-of-sale promotional items such as posters, display boxes and brochures can be developed and distributed to outlets. Additionally, availability of condoms in gas stations, vending machines and other less intimidating sales points can also be promoted to target audiences. While condoms may be widely available in the region, there is much work to be done to make them more accessible at the time of purchase. REGIONAL BARRIERS TO CONDOM USE Behavior Change Components Influencing Condom Use PSI has developed a behavior change framework to represent the various factors influencing condom use based on many years of experience with condom social marketing for HIV/AIDS prevention in diverse countries throughout the world. PSI’s framework illustrates how condom attributes (brand appeal, affordability, availability) and psycho-social attributes (social support, risk assessment, solution efficacy, self-efficacy) are all necessary to bring about the desired behavior change, i.e. correct and consistent condom use. TABLE 9: PSI Behavior Change Framework PSI has used this model for behavior change throughout the world in its condom social marketing projects, and has found it well-adapted to most contexts. It must be recognized that different countries or regions are at different stages in the epidemic and thus experience barriers related to different components of the framework. The following analysis of barriers to condom use summarizes the assessment findings according to the components that influence condom use, and highlights those areas that are weakest. This analysis will facilitate the development of key messages and strategies that are tailored to the unique context and needs of these region. Condom Affordability, Availability, and Accessibility Access to condoms includes several aspects: affordability, market availability, and point-of-sale accessibility. While the findings of the assessment determined that condoms were largely affordable and geographically accessible to the primary target population (youth), there were several barriers that remained at the points of sale. Affordability. According to the results of the PSI/Earle and Phillips youth KAP survey, presented in Section V, Regional Condom Accessibility (Brands and Pricing) the majority of youth sampled stated that they did not find condoms to be expensive. Quality was the number one attribute youth felt was important in choosing to purchase condoms, and perceptions of quality were largely linked to higher prices. If a condom were priced substantially below general market prices, chances are sales would be low due to the quality perception factor. Availability. An overwhelming 91% of the youth surveyed knew of a place where condoms could be obtained, and those who did not were among the youngest of the survey sample. With 75% of the sample within a 10-minute walk from a condom sales point, availability does not constitute an important barrier to condom purchase and subsequent use. Point-of-Sale Accessibility. While many outlets may sell condoms, they may not always be readily accessible to the consumer. First, the condoms may be out of stock, as was the case of several sales outlets visited during PSI’s condom distribution survey. Those that were out of stock generally cited lack of visits from a condom sales agent as the reason for their stock-out. Secondly, consumers may visit an outlet but not see any evidence that condoms are available. Lack of promotional items and visibility of the product may keep the consumer from making a purchase due to the belief that condoms are not sold at the outlet and fear of inquiring aloud. The majority of sales points that did stock condoms placed them on shelves behind the counter or in a closed display case. Prices were not readily displayed either. Potential consumers are thus required to ask for the condoms by brand name, and request the price of the product aloud. In most outlets, this brings attention to the customer and constitutes a barrier to purchase and subsequent use. Condom Appeal There are several aspects of “condom appeal” that can represent barriers to use: brand appeal, condom attributes and perceived condom efficacy. The appeal of the brand (largely based on brand image created through marketing and advertising), attributes of the condom, and general perceptions of condom efficacy and comfort should all be examined. Brand Appeal. The PSI/Earle and Phillips KAP survey asked youth whether they had heard or seen advertisements for condoms. While PSI’s condom distribution survey found that few of the local commercial brands are currently advertising, more than 50% of the sample responded that they had heard a radio advertisement for condoms. Almost 72% reported having seen a TV advertisement for condoms. Many of these youth may be referring to PSAs or other mentions of condom use in the media rather than brand-specific advertising. Of the more than 25 different condom brands available in the region, “Rough Rider” has the strongest brand appeal. The name, the packaging and perhaps some advertising have built a brand image that youth are drawn to and most youth will ask for Rough Rider by name. Of youth surveyed who had purchased a condom, 42% bought Rough Rider. Durex, Panther, Slam, and other brands also appeal to youth, although none come close to Rough Rider. Brand appeal and positioning for youth do not appear to be a barrier in the Eastern Caribbean region. Condom Attributes. This refers to the inherent qualities of the condoms themselves. The commercial condom market in the Eastern Caribbean offers a variety of textures, sensitivity, size, thickness, flavor, color and strength. According to a Population Council study conducted in Barbados and St. Lucia (1989) with men, the following attributes were cited as most and least attractive: Table 10. Condom Attributes Most Attractive Condom Attributes Least Attractive Condom Attributes Barbados St. Lucia Barbados St. Lucia Lubrication 78% 58% Extra thin 63% 53% Extra strength 50% 75% Color 15% 11% Ribbed (textured) 41% 3% Extra strength 20% 8% Reservoir tipped 37% 47% Lubrication 2% 11% Spermicide treated 13% 19% It should be noted that many of the qualities considered to be most attractive are also considered to be least attractive, indicating a wide range of opinions about condom attributes. According to PSI’s condom distribution survey, the desired options are generally available and do not appear to be a barrier to condom use in the region. Perceived Condom Efficacy. Of those youth surveyed by PSI/Earle and Phillips, 68% believed that condoms are effective, however 34% responded that they think condoms break easily. Breakage and fear of breakage affecting performance were also cited in the Population Council study as disadvantages of condom use. There is evidence that condoms are not always used correctly in the region, which could increase the risk of breakage. This point should be addressed through correct condom use demonstrations and messages, to be expanded upon in the discussion of Self-Efficacy and Solution Efficacy, Section VII. Condom Comfort. Comfort and sensitivity are important characteristics to examine when determining barriers to condom use. 25% of the youth surveyed felt that condoms suppressed sensation during sex, while 47% did not know. When explaining why they did not use a condom in their last sexual act, 25% of the sample stated that it was because “I don’t like condoms” and 16% replied “my partner doesn’t like condoms.” The Population Council study found that primary disadvantages of condom use (by order of importance) were: reduction of sensitivity, interruption of lovemaking, irritation and dislike of residual smell of condoms. To reduce barriers to condom use among youth with these perceptions, the condom image (mass media campaigns), risk perception and social support should be strongly emphasized to outweigh the various “comfort” arguments against condom use. Social Support for Condom Use Social support refers to the general support for condom use found among peers, parents, and society in general. The domain of social support in the Eastern Caribbean is rather complex as there are strong conservative religious factions on many islands that are adamantly opposed to condom use, particularly use among youth. These groups believe that promoting condom use condones promiscuous sexual activity, and would prefer to restrict youth access to condoms. As a result youth do not want anyone to see them purchasing condoms, nor do they want to openly discuss sex or plan for it. Only 37% of youth stated that they would feel comfortable buying a condom. The reasons given for why they would feel uncomfortable included the social pressure of “no sex before marriage” (55%), “it is embarrassing” (42%), “someone might tell my family” (34%) and “someone might see me buying it” (33%). Each of these responses are clear indications of lack of social support for condom use that potentially inhibits purchase and use. According to youth interviewed in Tobago, society dictates that sex is not something you should think about, and you shouldn’t plan to have sex. While wider societal pressures and perceptions play an important role in the Eastern Caribbean in creating an environment that is not supportive of condom use, the opinions of partners, peers and parents (in the case of youth) play an important role. The PSI/Earle and Phillips KAP survey with youth provides insight into perceptions of peer, partner, and parental approval of condom use. The first step to actual condom use is open discussion of condom use. Well over half (62%) of the youth surveyed stated that they had discussed using a condom for STI/HIV/AIDS prevention with someone in the last month. Overwhelmingly, of those youth who discussed condom use with another person, 70-90% spoke with a friend and 10-25% spoke with a stable partner. Very few of the youth had discussed the issue with their parents or an adult. Perceived social support for condom use is strong among peers and stronger than expected among parents. 51% of the youth surveyed reported that if their friends saw them with a condom they would approve, and 36% responded that their parents would approve. Not surprisingly, responses varied with age. The older the youth, the greater the chance they were to report approval of friends and parents. Table 11. Reactions to youth being seen with a condom Reactions if respondent seen with a condom Overall Barbados St. Vincent Trinidad St. Kitts Friends approval 51.1% 61% 54% 44% 41.5% Parents approval 35.8% 50% 30% 27.5% 29.2% Rates of disapproval of condom use are also important to examine: While very few youth responded that their peers would disapprove if they were seen with a condom (13%), almost 50% of the youth stated that if seen with a condom their parents would either disapprove or strongly disapprove. When asked what the best way to protect oneself from HIV/AIDS would be, 77% of youth replied the use of condoms 67% felt comfortable asking their partner to use a condom, indicating that among youth, partner approval of condom use is not a significant issue. MSM appear to find high approval of condom use among their partners and peers, while CSW negotiations of condom use with a partner face more barriers. Much more must be done to increase general social support of condom use, particularly with youth and CSWs. Lack of an environment supportive of condom use leads to barriers in purchasing condoms and planning for safe sexual activity. Condemning condom use has not been shown to keep youth from engaging in sexual activities, rather it puts them at risk of unplanned pregnancies, STIs and HIV/AIDS. Personal Risk Assessment Personal risk assessment is an essential and complex component of behavior change. There are many different elements that influence personal risk assessment including awareness and knowledge of STI/HIV/AIDS and transmission routes, perception of severity of the problem within one’s immediate community, assessment of partner’s risk of STI/HIV/AIDS, and accurate self-risk assessment. Awareness of STI/HIV/AIDS. The analysis of levels of awareness and knowledge is based primarily on the PSI/Earle and Philips KAP survey with youth. 99.8% of the sample had heard of HIV/AIDS, and 88% had heard or seen information about it in the past month. 76% had heard discussion or messages via TV, 45% via radio, 39% in the newspapers, 20% from friends or relatives, and 15% in a magazine. 98% of the sample had heard of other diseases or infections that can be transmitted through sexual intercourse. These results indicate that there are high levels of awareness of the problem. Knowledge of STI/HIV/AIDS and Transmission Routes. Knowledge is very high among youth in the Eastern Caribbean, though there are variations by island. Table 12. Correct Responses to Knowledge Based Questions AIDS can be spread through injections with an unsterilized needle 92% Someone who looks healthy can be infected with HIV 97% HIV can be transmitted from a mother to her child 93% There is no cure for AIDS 86% A person cannot be infected with the AIDS virus from mosquito bites 54% It is possible to have an STI and not have any symptoms from it 54% Knowledge is generally high regarding HIV transmission routes, however myths related to a cure for AIDS and infection via mosquito bites or Obeah (witchcraft) should be addressed. Youth displayed less knowledge of STIs: when were asked to list the STIs they had heard of, knowledge of certain STIs was over 50% while others were barely mentioned. Table 13. Spontaneous recall of STIs: HIV/AIDS 96% Gonorrhoea 64% Herpes 56% Syphilis 54% Chlamydia 9% Genital warts 17% Only 41% of the youth recognized that genital discharge or an ulcer is a sign of an STI, while 25% believed that it was not and another 35% were unsure. 46% either believed that STIs always manifested with symptoms or were unsure. This is cause for concern, since STIs affect many more youth than HIV/AIDS and can lead to serious complications. In addition, youth who are unaware of the risks of more prevalent STIs and feel that they are not at risk of HIV/AIDS have very little motivation to protect themselves. Perception of Severity. When asked how serious a problem AIDS was in their community, 27% of the youth surveyed responded that it was not a problem while 15% did not know. However, 31% in Barbados and 41% in Trinidad believed that HIV/AIDS was a serious problem in their community. Similarly, when youth were asked if they knew someone who has died of AIDS, 41% replied affirmatively . More must be done to increase awareness of STI/HIV/AIDS in these communities so youth understand the reality of their personal risk. Accurate Self-Risk Assessment. When asked the likelihood of whether or not they would contract HIV/AIDS, most youth replied that they were either at no risk or low risk. In fact, only 12% thought they could be at some risk of contracting HIV/AIDS. Those who believed they could be at risk gave reasons such as not always using a condom (47%), having many partners (15%), and being with a partner who has had many partners (14%). Each of these reasons is quite valid and should be emphasized for all youth as key risk factors. Those who stated that they are not at risk provided reasons such as not being sexually active (59%), having only one partner (18%), always using condoms (16%), and trusting their partner (13%). It appears that personal risk assessment as it relates to condom use, abstinence, and fewer partners is relatively understood and accurate. Other aspects, notably partner risk assessment, are lacking however. Accurate Partner Risk Assessment. The “trusted partner syndrome” is based on individuals rationalizing their limited risk due to “trust” in their partner. Unfortunately, this “trust” usually has nothing to do with knowledge of their partner’s actual HIV and STI status, but rather is based on vague feelings that their partner is “a good person”, “doesn’t run in the streets”, “treats me well”, etc. There is a tendency to forget or ignore that even though one’s partner may be faithful, that partner had other partners in the past, those partners had other partners, and so on. This is a difficult phenomenon to address, as it means recognizing your partner’s past sexual history and making a rational rather than emotive assessment of his or her risk of infection. When youth were asked why they did not use a condom in their last sexual act, 55% of the sample responded that it was because “I trust my partner.” This was the single most widely cited reason. However, very few of the youth had ever actually been tested for HIV and it is likely that very few of those who responded that they trust their partner were aware of their partner’s HIV status. Another important aspect is the perception that using a condom or suggesting condom use with a partner implies that one does not trust his or her partner. Only 15% of the youth surveyed believed that suggesting condom use means that you do not trust your partner. This figure was highest in Trinidad, 24% and ranged between 10-12% in the other countries. Since these figures are not too high, the issue of risk perception can be addressed indirectly through messages related to accurate partner risk assessment. These findings demonstrate that some aspects of personal risk assessment are indeed significant barriers to condom use. Accurate knowledge of STI morbidity, prevalence, and symptoms must be emphasized. The prevalence of STI/HIV/AIDS must be made more visible at the local level in order for communities to recognize that these diseases are present. The risk associated with having multiple partners consecutively should be emphasized. Most importantly, campaign messages and educational materials should highlight the importance of accurate assessment of partner risk. Self-Efficacy and Solution Efficacy The term “self-efficacy” is used to describe the extent to which an individual feels comfortable taking the initiative to protect him/herself, whereas “solution efficacy” refers to an individual’s capacity to implement the solution. These terms include factors such as believing one can protect oneself and identifying solutions, purchasing a condom, negotiating condom use, asking a partner to get tested for HIV and using a condom correctly. Identifying Risk Management Solutions. Some individuals and societies have a predominantly external locus of control, believing that events occur for reasons outside of one’s control. Others with an internal locus of control believe that events that occur are primarily a result of one’s actions and initiatives. The youth of the Eastern Caribbean appear to have a strong internal locus of control, with the vast majority believing that it is possible to protect oneself from HIV/AIDS infection. 94% of youth surveyed by PSI/Earle and Phillips (2002) believed that there are things they can do to avoid infection. The actions spontaneously suggested by youth were the following: Table 14. Youth perception of how to protect oneself from HIV/AIDS infection Use condoms 78% Abstinence 51% Avoid injections with contaminated needles 22% Have fewer partners 22% Both partners have no other partners 20% No casual sex 20% Since youth feel that they can take STI and HIV/AIDS prevention into their own hands and act to protect themselves, this aspect of solution efficacy is not a significant barrier to condom use. Purchasing a Condom. While many youth may want to use condoms and intend to do so, they feel uncomfortable doing so due to social pressures and taboos. Of the youth surveyed, 40% would feel embarrassed buying condoms at a store in their neighborhood. The most inhibition was found in Trinidad (52% of youth embarrassed to purchase a condom) and the least in Barbados and St. Vincent (only 30% would be embarrassed to purchase a condom in their neighborhood). Female respondents were more than twice as likely as males to feel embarrassed, and inhibitions decreased with age. PSI’s condom distribution survey found that on most islands, sales outlets reported that only 0-20% of their condom customers were women. Most outlets in St. Lucia reported 10% or lower, while some outlets in Barbados estimated female customers at 40-70% of their condom clientele. Special attention must be given to breaking down barriers to purchase of condoms by females. This aspect of self-efficacy is a significant barrier to behavior change. Negotiation of Condom Use. Almost 70% of the youth surveyed stated that they would feel comfortable asking a partner to use a condom. Among those youth who had actually used a condom in their last sex act, 38% responded that they suggested the use of a condom while 45% responded “both my partner and myself.” These responses indicate that there is reasonable communication between partners, and negotiation is not a significant barrier to condom use. Gender Issues. As evident in female reluctance to purchase condoms, gender issues play an important role in condom use. Almost one-third of the youth surveyed believed that the decision to use a condom should be made by a man, in Trinidad almost 50% of the youth surveyed thought so. By contrast, 90% of the respondents felt that a woman should be able to suggest condom use. This implies that while women and men can equally propose condom use, the final decision will be made by the man and it may not be easy for a woman to negotiate condom use if her partner is firmly against it. Condom Preparedness. An important aspect of condom use is condom preparedness—keeping a condom on hand in case it will need to be used. Many youth gave testimony that “you shouldn’t plan for sex” or that a woman who carries condoms is considered “loose”, etc. Yet a common reason provided for not using a condom was “not having one on hand”. This issue is critical and must be addressed by any BCC campaign. HIV/AIDS Testing. More than 90% of the youth surveyed felt it is appropriate to ask a partner to have an HIV test before having sex or before having sex without a condom. The youth surveyed expressed interest in being tested for HIV if they could receive the results confidentially; 78% replied that they would like to be tested and 77% knew of a place where they could be tested. An average of 13% of the sample has ever been tested for HIV, ranging from almost 20% in Barbados to 6% in Trinidad. Correct Condom Use. A problem with condom breakage has been reported in the Eastern Caribbean, most likely due to improper use. In a study conducted in 1989 in Barbados and St. Lucia, breakage rates of condoms used in the study were 10-13%. In over 90% of the cases, breakage occurred during vaginal sex and approximately 50% of the condoms that broke did so near the closed end. The study concluded that breakage is primarily related to incorrect use. A study conducted in 1990 revealed a significant lack of information about correct condom use. 56% of respondents believed that using Vaseline for lubrication with a condom was appropriate practice, 38% thought it was necessary to unroll the condom fully before putting it on the penis, and 42% thought that the correct way to wear a condom was without a space left at the tip. Campaign messages and materials should also include a focus on correct condom use. Barriers to Condom Use Summary Based on the previous analysis, it is clear that efforts should be concentrated in a few key areas to address barriers to condom use. These include: Availability Point of Sale Accessibility Social Support Parents Health Care Providers Greater Society Personal Risk Assessment Knowledge of STI morbidity, prevalence, symptoms Perception of local severity of STI/HIV/AIDS “Trusted Partner Syndrome” and importance of testing Solution Efficacy Gender differences in access to condoms and negotiations Condom preparedness Correct Condom Use These priorities for intervention are highlighted below in the PSI behavior change framework: RECOMMENDATIONS Based on the findings of the condom social marketing assessment, PSI recommends a regional condom use campaign with several different components. Branded Regional Condom Use Campaign Targeting Youth A “branded” campaign, not linked to a particular condom brand, would promote condom use with a fun, upbeat image and a youthful slogan and logo. The campaign logo and slogan would be used on billboards, posters, radio and television ads, and printed on point-of sale materials for outlets selling condoms. T-shirts and promo items bearing the slogan and logo would provide additional publicity. The campaign would emphasize STI and HIV/AIDS prevention in particular, with messages highlighting trusted partner issues, testimonies from youth with HIV or other STIs, the importance of making careful decisions about sexuality, and gender equality in condom access and condom negotiation. The short, targeted campaign messages would be complemented by several other mass media venues providing a forum for more in-depth discussion of complex issues. It is recommended that the project develop a live, interactive regional talk show for youth, a television or radio drama, and/or a documentary on the life of one or more PLWHA. These efforts will reach not only youth, but also members of the wider community and opinion leaders as well. Local Capacity Building in Behavior Change Communication Many countries have requested support from PSI specifically in the areas of behavior change communication and youth materials. There is also a lack of support materials for organizations working with other high-risk groups such as MSM, CSWs, uniformed populations, migrant populations, beach boys, and tourists. It is recommended that PSI provide support for regional institutions in the following areas: Training of public sector, NGO staff, journalists and other members of the press in behavior change communication techniques, strategies, and key messages; Development of print materials for various populations including: High-risk groups (targeted materials for each group) Community leaders Parents Health care providers Development of guides and support materials for educators working with: Youth MSM CSW Uniformed populations These materials will address the key issues related to STI and HIV/AIDS prevention, including a special emphasis on correct condom use. PSI has extensive experience working with these target groups in many different locations, but will conduct additional research and work with local institutions to ensure the materials are culturally appropriate and adapted to the Eastern Caribbean setting. The training sessions and support materials will reinforce existing efforts and activities at the local level, raise local capacity and help to standardize messages in the region. The materials will provide support to National AIDS Programmes and local institutions to work with community leaders, parents and health care providers and local media to increase social support for condom use, high-risk groups and PLWHA. This local coordination will be critical in raising the visibility of issues related to STIs and HIV/AIDS in local communities and increasing perception of the severity and prevalence of these diseases. Targeted Interventions for High-Risk Groups As very few programs appear to be working with vulnerable groups other than youth, i.e. MSM, CSWs and uniformed populations, and minimal interest has been expressed in doing so, PSI proposes to coordinate regional interpersonal activities for these groups. PSI has extensive experience working with MSM, CSWs and uniformed populations throughout the world (including Eastern Europe, Africa, Central America, South America and Haiti) and has already developed a vast array of dynamic education approaches and materials. Existing materials would be tested and adapted to the Eastern Caribbean context, and new materials would also be developed. Health educators &/or peer educators (drawn from MSM, CSW and PLWHA communities) from the various islands would then be trained by PSI staff to implement activities. A centrally based monitoring and evaluation system would be established to record activities and impact, and the trained educators would provide support to implementing agencies or individuals. Private Sector Partnerships Private sector condom brands such as Rough Rider, Durex, Long Love, and others already enjoy strong brand name recognition and appeal in the Eastern Caribbean. Over 25 different brands are currently sold throughout the region and often more than 5 brands are available in each sales outlet. In this context creating a new condom brand to compete with established brands may only undercut sales of these brands. Given the importance of perceived brand quality, often directly linked to price, and perceptions that brands currently on the market are affordable, PSI has concluded that the typical condom social marketing model is unjustified. PSI recommends a generic condom social marketing project to significantly grow the market of existing brands. This would include some cost-sharing of non-brand specific condom-related advertising, and sponsorship of special events and/or BCC activities by commercial condom brands. Given the multitude of condom brands on the market and the initial interest expressed by distributors in participating in a broad-based condom social marketing program with an emphasis on BCC, PSI considers this to be a viable and desirable option. It may also help to reduce the burden on international donors and shift a higher percentage of expenses to the private sector. PSI would work with local condom distributors to increase the number of sales outlets, ensure that interested sales outlets are regularly visited by sales people and continually stocked, and to increase point-of-sale visibility and accessibility of the condoms. It is also recommended that PSI build partnerships with local distributors to develop and maintain an electronic tracking system for condom sales in order to measure growth in the overall condom market and collect accurate data related to annual sales volume by country. In addition to building partnerships with private sector condom manufacturers and distributors, the project would be well positioned to draw support from major local and multinational corporations operating in the region. According to local advertising agencies, several large companies are already pursuing cause-related marketing strategies and are looking to sponsor high-profile public service activities. It is recommended that PSI pursue this approach in collaboration with local advertising agencies. Sentinel Surveillance, Monitoring and Evaluation There is a significant lack of data in the Eastern Caribbean on HIV/AIDS and STI prevalence among the general population and high-risk groups. If institutions in the region are serious about prevention efforts, it is imperative to develop the capacity to track health impact over time and gauge the efficacy of activities. CAREC is well placed to coordinate this effort, and PSI recommends that regional donors and other institutions support CAREC in this endeavor as such statistics will be vital to all HIV/AIDS prevention activities conducted in the region. In order to measure changes in behavior, social support, solution efficacy, risk perception and perception of severity (all of the critical areas identified in the assessment) it is recommended that a follow-up KAP survey be conducted every 2-3 years. The results will enable all partners to modify interventions as needed and measure efficacy of ongoing activities. It is also recommended that a condom distribution survey be conducted every 2-3 years to measure changes in accessibility and availability, sales volume, brand preferences, and point-of-sale access. APPENDICES APPENDIX A List of Persons Contacted PSI would like to extend its thanks to the following people and institutions who participated in the social marketing assessment: ANGUILLA Mrs. Patricia Beard, National AIDS Program Coordinator ANTIGUA and BARBUDA Ms. Felicity Aymer, National AIDS Program Coordinator BARBADOS Ms. Alies Jordan, Director, National HIV/AIDS Commission Dr. Carol Jacobs, Chairman, National HIV/AIDS Commission Ms. Carmeta Douglin, Assistant Director National HIV/AIDS Commission The Honorable Mr. Phillip Goddard, former Minister of Health Dr. Beverly Miller, Chief Medical Officer, Ministry of Health Mrs. Veta Brown, Caribbean Program Coordinator, PAHO / CPC Dr. William Adu-Krow, Advisor, Family and Reproductive Health, PAHO/CPC Mrs. Pat Brandon, Adolescent Health Advisor, PAHO/CPC Mrs. Claire Forrester,, Media Communications Advisor, PAHO/CPC Ms. Amy Christofferson, CIDA Intern, PAHO/CPC Mr. Michael Phillips, Director, The Earle and Phillips Group DOMINICA Joan Henry, Coordinator Health Promotion, Ministry of Health and Social Security GUYANA Mr. Stephen Sandiford, Program Planner, CIDA Ms. Violette Pedneault, Consultant, Health and Population, CIDA Dr. Ed Greene, Assistant Secretary General, CARICOM Dr. James St. Catherine, Manager Health Desk, CARICOM Cynthia Eledu, Rgional Advisor, Pan-Caribbean Partnership Against HIV/AIDS, CARICOM JAMAICA Joan E. Atkinson, Caribbean Regional HIV/AIDS Program Advisor, USAID/Kingston SABA Mr. Carl Bunchamper, Coordinator, AIDS Group Saba SAINT EUSTATIUS Astrid York, Strategic Plan Saint Eustatius Viola van Zanten, Chairwoman, HIV/AIDS project group ST. KITTS AND NEVIS Mrs. Mavis Huggins, Former National AIDS Program Coordinator, Ministry of Health SAINT LUCIA Egbert Andrew, National AIDS Program Coordinator, Ministry of Health Sonia Alexander, Health Educator, Ministry of Health Dr. Stephen King, AIDS Action Foundation SINT MAARTEN Dr. Rachel Eersel, Head Preventive Health Department Maria Henry, Preventive Health Department Dr. Gerard Van Osch ST VINCENT AND THE GRENADINES Ms. Severina Layne-Cupid, National AIDS Program Coordinator, Ministry of Health Mrs. Anne Anderson, Health Planner, Ministry of Health TRINIDAD AND TOBAGO Mrs. Muriel Douglas, National AIDS Program Coordinator The Honorable Dr. Hamza Rafeeq, Minister of Health Dr. David Picou, Director of Research, Caribbean Health Research Council Dona Da Costa Martinez, Executive Director, Family Planning Association of Trinidad and Tobago Ms. Yolanda Simon, Executive Director CRN+ Ms. Claudette Francis, CARe (People living with HIV/AIDS) Dr. Bilali Camara, Medical Epidemiologist, Head, Special Programme on STIs, CAREC Dr. James Hospedales, Director, CAREC Dr. Ruben del Prado, Inter-Country Programme Advisor, UNAIDS Angela Trenton Mbonde, Team Leader for the Caribbean, UNAIDS Maylene Lou-Bent, Programme Officer, UNAIDS Ozzi Warwick, Youth Officer, UNAIDS Hans Geiser, UNDP Resident Representative Dr. Claudette Harry, PAHO/WHO Representative, Trinidad and Tobago Michiko Tajima, HIV/AIDS Specialist, Caribbean HIV/AIDS Prevention Control, JICA Mr. Erik Klipp, Ambassador of the Kingdom of the Netherlands, Trinidad and Tobago/OECS countries TURKS AND CAICOS ISLANDS Mrs. Cherylann Sanderson-Jones, National AIDS Program Coordinator, Ministry of Health CARIBBEAN INTERNATIONAL CONTACTS Hans Moerkerk, Special Adviser for the Caribbean, UNAIDS Luiz Loures, Associate Director, Europe and Americas, UNAIDS Nina Ferenic, UNAIDS LAC Jacob Gayle, UNAIDS Liaison, CDC Global AIDS Program APPENDIX B Caribbean Organizations CARICOM The Caribbean Community (CARICOM) was established in 1973 and comprises all of the independent states and dependencies of the Caribbean, with the exception of Cuba. CARICOM’s objective is to promote regional integration in the Caribbean through economic cooperation, foreign policy coordination among independent member states, development of common services and cooperation in health, education, culture, communication, and industrial relations. CARICOM operates through an annual conference of Heads of Governments, an annual meeting of the Community Council of Ministers and four Inter ministerial Councils. One of these, the Council of Human and Social Development (COHSOD) promotes regional cooperation in the area of human development and health, including HIV/AIDS/STIs. Regional cooperation relates to policy, program development, financing and external cooperation. The CARICOM Secretariat is based in Georgetown, Guyana and headed by a Secretary General. CARICOM’s annual budget is US $7.4 million, 85% of which is contributed by member states. The remaining 15% is contributed by the United Nations and the Inter America Development Bank (IDB). CAREC (Caribbean Epidemiology Center) The Caribbean Regional Epidemiological Centre (CAREC) was established in 1975 as a result of a decision of the Regional Ministers of Health. CAREC serves 21 member countries in the Caribbean (Anguilla, Antigua & Barbuda, Bahamas, Barbados, Belize, Bermuda, British Virgin Islands, Cayman Islands, Dominica, Grenada, Guyana, Jamaica, Montserrat, St. Kitts & Nevis, St. Lucia, St. Vincent, Suriname, Trinidad & Tobago, Turks & Caicos) and is administered by PAHO. The mission of CAREC is to improve the health status of the Caribbean people. The center is organized into 3 divisions (epidemiology, laboratory, administration) and several units and programmes including the Special Programme on Sexually Transmitted Diseases (SPSTD). The SPSTD aims to reduce the spread and to minimize the impact of HIV/AIDS/STIs by behavioral modification and improved surveillance diagnosis and treatment capabilities. CAREC has been particularly active in the areas of advocacy, policy planning, capacity building and resource mobilization. Priority areas of CAREC include youth, communications, mother-to-child transmission, voluntary counseling and testing, and networks of PLWHA. UNAIDS The Joint United Nations Program on HIV/AIDS (UNAIDS) is a co-sponsored program of 8 agencies (UNDCP, UNDP, UNESCO, UNFPA, UNICERF, WHO, ILO and the World Bank). It brings together the expertise of a range of sectors. Its mission is to guide, strengthen and support the expanded response aimed at preventing the transmission of HIV, providing care and support to PLWHAs, reducing the vulnerability of individuals and communities, and alleviating the impact of the epidemic. The Caribbean UNAIDS regional office was established in 1998 and is located in Port of Spain, Trinidad. It funded projects in 18 territories (including DR, Cuba and Haiti), totaling $3.2 million from 1996 – 1999. UNDP The United Nations Development Program (UNDP) is the largest provider of grants for economic and social development, and is the main coordinator of the UN’s operational activities for development at country level. UNDP has implemented HIV/AIDS related activities through a variety of mechanisms—country programming, regional and sub-regional projects, including those in the Caribbean. The UNDP HIV and Development Program (HDP) is set up to provide policy guidance to the institution. In the Caribbean, the UNDP is carrying out HIV and Development workshops designed to increase awareness of the nature and impact of the epidemic, and to promote approaches to strengthen community and national responses. WHO/PAHO Within the context of HIV/AIDS/STI, the World Health Organization/Pan American Health Organization (WHO/PAHO) works with numerous partners to strengthen the response to the epidemic. Through its regional bureau, PAHO/CPC provides health sector specific assistance to countries to improve their health policies, planning and implementation of interventions. In the Eastern Caribbean PAHO/WHO is involved in strengthening national capacity in health planning, gender issues in health, adolescent health, HFLE, health promotion, nutrition and HIV/AIDS and prenatal care. UWI The University of the West Indies (UWI) has campuses in Jamaica, Trinidad and Barbados. UWI provides teaching to over 7,000 undergraduates and 3,000 post-graduates. The UWI Medical School, the Caribbean Institute of Mass Media and Communication (CARIMAC), and the Department of Economics provide technical and intellectual guidance to the region in their respective fields. With respect to HIV/AIDS, UWI aims to implement a long-term initiative to expand skills base, whereby a new focus on the various aspects of the HIV/AIDS epidemic will be integrated into current curricula in the various departments of the University. CHRC The Caribbean Health Research Council (CHRC) was established in 1981 to promote, support, facilitate and coordinate research in the Caribbean and advise Caribbean Governments on health research matters. It promotes the establishment of essential national health research in member countries and operates a competitive grants award scheme for researchers. It conducts workshops, organizes scientific meetings and facilitates collaboration between researchers in the region and internationally. UNESCO The main objective of the United Nations Educational, Social and Cultural Organization (UNESCO) is to contribute to peace and security in the world. In the Caribbean, UNESCO has recently organized a youth HIV/AIDS and media forum in collaboration with CAREC. In addition UNESCO is interested in studying the implications of culture for HIV/AIDS and exploring initiatives to use cultures as a vehicle for attitude and behavior change. IPPF The objective of the International Planned Parenthood Federation (IPPF) is to promote the concept of planned family and to provide family planning services on the widest possible scale. The Caribbean Family Planning Association is affiliated with the IPPF, with regional headquarters in Antigua and representation on most other islands in the region. Among other activities, the FPA has condom social marketing projects on some islands, though they are better positioned for family planning than HIV/AIDS prevention. ILO The objectives of the International Labor Organization (ILO) are to raise working and living standards throughout the world. ILO has developed a series of brochures and guidelines relative to HIV/AIDS in the work place. ILO’s workplace and AIDS initiatives can be built upon in the Caribbean in sectors such as tourism and mobile working populations. CARIMAC CARIMAC is a teaching department of the University of the West Indies, Mona Campus, Jamaica. CARIMAC’s overall program is designed to upgrade academic standards and skills in the field of communication, with the focus on media professionals in the region. CATIN CATIN was established in 1996 with resources from the US Centers for Disease Control (CDC), CIDA and DFID. CATIN’s role is to provide critical health information on HIV/AIDS/STIs to member countries and to coordinate and promote prevention and control programs in conjunction with regional National AIDS Programs within each participating country. C-FLAG The general objectives of the C-FLAG network are to formulate human rights advocacy to end all forms of oppression and marginalization of sexual minorities in the Caribbean, and to promote general health within the Gay and Lesbian communities. One of its principal focus points is addressing ongoing concerns for HIV/AIDS as a problem among the community. UNICEF UNICEF is a semi-autonomous agency of the UN that works for sustainable human development of the lives of children. A major focus of UNICEF in the Caribbean is the regional health and family life initiative (HFLE). The project re-orients and re-designs HFLE programs at primary and secondary schools. An important component of this is the focus on HIV/AIDS and its impact on children and youth. Another important focus of UNICEF is MTCT in collaboration with WHO/PAHO/CAREC. CRN+ The Caribbean Regional Network for persons living with HIV/IADS (CRN+) was established in 1996 and is the regional arm of the Global Network of HIV Positive people (GNP+). It advocates for the rights of the PLWHA Community focusing on issues such as discrimination, providing moral support to the community of infected persons and acting as a resource for training counselors and care givers. Health and Family Life Education (HFLE) This initiative brings together CARICOM, PAHO/WHO, UNFPA, UNICEF, UNDCP, UNDP, UNIFEM, FMU, UWI AND ECLAC. HFLE is implemented through a partnership arrangement and provides the basis for a proactive approach to reach young people with information in areas of HIV/AIDS, sexual health, substance abuse, environmental health, safety and nutrition. The initiative is to be implemented through schools to empower students with skills, values, attitudes and knowledge to ultimately create behavior change. Horizontal Technical Collaboration Group (HTCG) National AIDS Programs have been established in all territories in the region. They are responsible for policy, guidance and execution of government HIV/AIDS efforts including management, planning, and coordination of an expanded national response to HIV/AIDS. The Horizontal Technical Collaboration Group (HTCG) was established by NAP managers in Latin American and the Caribbean to facilitate national strategic planning epidemiological networks, evaluation of interventions, counseling and communications. Pan Caribbean Partnership on HIV/AIDS The Pan Caribbean Partnership grew out of a Task Force established in 1998 and the development of a regional strategic plan. It was clear that there was a need for partners to assist with the implementation of the strategic plan, and thus the Pan Caribbean Partnership for HIV/AIDS was launched in February of 2001. To date the partnership is a non-binding partnership comprised primarily of regional donors, UN agencies, CARICOM, and regional institutions such as UWI, CAREC, CRN+, CHRC. APPENDIX C References “1998 Barbados KAP Survey: Preliminary Findings.” Ernest Massiah. 1998. “An Assessment of PLWHA Self-Support Groups & AIDS Service Organizations in Barbados, Grenada, St. Vincent and St. Kitts.” PAHO/CPC, UNAIDS. January 2001. “The Caribbean Regional Strategies Plan of Action for HIV/AIDS”. Caribbean Task Force on HIV/AIDS. August 2000. “Condom Distribution Survey.” Systems Caribbean Limited. CAREC. 1998. “Defining Indicators to Evaluate National AIDS Programs in the Caribbean.” Caribbean Health Research Council. Proceedings of Workshop July 28, Trinidad. September 2001. “Final Report: Development of a Strategic Planning Framework, National AIDS Programme.” Ministry of Health, Anguilla. CAREC, Trinidad. March 2001. “Focus groups: HIV/AIDS: Listen and Respond to young people’s concerns.” Amy Christofferson. PAHO/WHO/CPC, Shantal Munro-Knight, UNECTG on HIV/AIDS. 2001. “HIV/AIDS Policy Guidelines for the Caribbean Tourism Sector.” CAREC/PAHO/WHO. Published by Quality Tourism for the Caribbean. June 2001. “Inventory and Assessment of Religious Groups and their Responses to HIV/AIDS.” Dr. Brader Braithwaite. Trinidad and Tobago National AIDS Programme, MOH Trinidad and Tobago, CAREC/GTZ, UNAIDS. June 2001. “Needs Assessment among People Living with HIV/AIDS in the Caribbean.” Dr. Dorothy Blake. CRN+, CAREC. 2000. “A Portrait of Adolescent Health in the Caribbean.” PAHO/CPC, WHO, WHO Collaborating Centre on Adolescent Health, Division of General Pediatrics and Adolescent Health, University of Minnesota, Minneapolis, MN. 2000. “PSI Youth KAP Survey in the Eastern Caribbean.” The Earle and Phillips Consulting Group. 2002. “PSI Qualitative Research with Vulnerable Groups in the Eastern Caribbean.” The Earle and Phillips Consulting Group. 2002 “PSI Eastern Caribbean Condom Distribution Survey.” Carmen Chan, April 2002. “The Sexual Health Needs of Youth in Tobago.” Family Planning Association of Trinidad and Tobago, Tobago AIDS Society with technical assistance from CAREC and GTZ. Final Report. April. 2000. “A Sexual Health Promotion Intervention among Caribbean Men who have Sex with Men.” Alex P. Vega, Caroling Allen and Geoffrey Standforde. The CAREC Leadership and Facilitation Project. CAREC. 2001. “Situation and Response Analysis of HIV/AIDS in Trinidad.” UWI, CAREC. 2001. “St. Maarten’s Strategic HIV/AIDS Plan 2001-2005.” Sector Health Care Affairs, Department of Preventative Health. “Strategic Plan for the National Response to HIV/AIDS, St. Kitts and Nevis 2001-2005.” “The Caribbean Regional Strategic Framework for HIV/AIDS 2002-2006.” Pan-Caribbean Partnership on HIV/AIDS. March 2002. 2.2% of adults in the Caribbean are infected with HIV. 700,000 people are living with HIV/AIDS in the Caribbean. Conservative estimates predict that more than half of all deaths in the under 5 population will be due to AIDS by 2010. This will result in negative population growth of 8% by 2020. 2 Of the religious groups interviewed: Only 38.5% stated that they would accept condom use as an effective method of prevention of the spread of HIV/AIDS. Over 80% stated they would only condone abstinence before marriage and staying with only one partner. Common Misperceptions about transmission of HIV/AIDS “[T]he possibility of the virus being able to breach the condom is a very real thing…it is wrong to tell people it is safe to use condoms.” Spokesman from the Roman Catholic Church. “[T]hey say that in India there is no AIDS because people eat spicy food, and those who eat spicy food here cannot get AIDS either.” East Indian Trinidadian “Sometimes before you get to the place, government workers pointing to you and telling you where to go (reference to the HIV/AIDS center)… and sometimes you can tell how they look at you how they feel about you. That is why I prefer to go to a private doctor to discuss anything to do with my health.” MSM interviewed by PSI/Earle and Phillips “Yes, I’ve had friends die of AIDS. If I were to get it my family would not be supportive, apart from an aunt of mine. I don’t think anyone would support me at all… I would probably commit suicide.” CSW interviewed by PSI/Earle and Phillips Knowledge about HIV/AIDS among youth: Unsure whether HIV/AIDS could be transmitted through mosquito bites: 25% Unsure whether HIV/AIDS could be transmitted through witchcraft: 25% Believe or unsure a cure exists: 15% PSI/Earle and Phillips (2002) � EMBED Excel.Sheet.8 ��� � EMBED Excel.Sheet.8 ��� “I have had sex with about ten partners besides my girl in the past six months and yes, I insist on using condoms with them and if the other party don’t want to use it… nothing doing. I’ve lost too many friends to AIDS, in fact I feel that if somebody don’t want to wear a condom, they probably want to spread something… But I don’t use condoms with my girl…she safe …” MSM interviewed by PSI/Earle and Phillips “Getting AIDS is the biggest fear…I know women that have sex with men [without condoms] for extra money but as far as I’m concerned, no rubber, no flubber, no extra money is worth my life…not even a million dollars.” CSW interviewed by PSI/Earle Phillips. “Beside the side effects of medication…the most difficult part of living with HIV is the constant awareness that if the wrong person finds out, it will immediately become public knowledge. In this small and judgmental community this means the loss of respect from the public, being judged and condemned by people you don’t know…The few friends and family from whom one might receive sympathy do not deserve to have to bear this burden…” HIV+ person in St Maarten. St. Maartens’s Strategic HIVAIDS Plan 2001-2005. Sector Health Care Affairs, Department of Preventative Health. P. 21. � EMBED Excel.Sheet.8 ��� � EMBED Excel.Sheet.8 ��� � EMBED PowerPoint.Slide.8 ��� � EMBED PowerPoint.Slide.8 ��� � The Caribbean Regional Strategic Plan of Action for HIV/AIDS. Caribbean Task Force on HIV/AIDS. August 2000. � Caribbean Health Research Council. September, 2001. “Defining Indicators to Evaluate National AIDS Programs in the Caribbean” Proceedings of Workshop July 28-28, Trinidad. � Caribbean Health Research Council. September, 2001. “Defining Indicators to Evaluate National AIDS Programs in the Caribbean” Proceedings of Workshop July 28-28, Trinidad. � The Caribbean Regional Strategic Plan of Action for HIV/AIDS. Caribbean Task Force on HIV/AIDS. August 2000. � The Caribbean Regional Strategic Framework for HIV/AIDS 2002-2006. Pan-Caribbean Partnership on HIV/AIDS. March 2002. � The Caribbean Regional Strategic Framework for HIV/AIDS 2002-2006. Pan-Caribbean Partnership on HIV/AIDS. March 2002. � HIV/AIDS Policy Guidelines for the Caribbean Tourism Sector. CAREC/PAHO/WHO. Published by Quality Tourism for the Caribbean. June 2001. � The Caribbean Regional Strategic Framework for HIV/AIDS 2002-2006. Pan-Caribbean Partnership on HIV/AIDS. March 2002. � The Caribbean Regional Strategic Framework for HIV/AIDS 2002-2006. Pan-Caribbean Partnership on HIV/AIDS. March 2002. � The Sexual Health Needs of Youth in Tobago. Final Report, April 2000. Family Planning Association of Trinidad and Tobago (FPATT) and Tobago AIDS Society (TAS), with technical assistance from CAREC and GTZ. � The Sexual Health Needs of Youth in Tobago. Final Report, April 2000. Family Planning Association of Trinidad and Tobago (FPATT) and Tobago AIDS Society (TAS), with technical assistance from CAREC and GTZ. � 1998 Barbados KAP Survey: Preliminary Findings. Ernest Massiah. � Dr. Brader Brathwaite. Inventory and Assessment of Religious Groups and their Responses to HIV/AIDS. June 2001. Trinidad and Tobago National AIDS Programme, MOH TT, CAREC/GTZ, UNAIDS. � Situation and Response Analysis of HIV/AIDS in Trinidad. 2001. University of the West Indies Health Economics Unit, CAREC � � Dr. Dorothy Blake. Needs Assessment among People Living with HIV/AIDS in the Caribbean. CRN+, CAREC. 2000. � � Dr. Dorothy Blake. Needs Assessment among People Living with HIV/AIDS in the Caribbean. CRN+, CAREC. 2000. � The Sexual Health Needs of Youth in Tobago. Final Report, April 2000. Family Planning Association of Trinidad and Tobago (FPATT) and Tobago AIDS Society (TAS), with technical assistance from CAREC and GTZ. � The Sexual Health Needs of Youth in Tobago. Final Report, April 2000. Family Planning Association of Trinidad and Tobago (FPATT) and Tobago AIDS Society (TAS), with technical assistance from CAREC and GTZ. � Caribbean Health Research Council. September, 2001. “Defining Indicators to Evaluate National AIDS Programs in the Caribbean” Proceedings of Workshop July 28-28, Trinidad. � The Caribbean Regional Strategic Framework for HIV/AIDS 2002-2006. Pan-Caribbean Partnership on HIV/AIDS. March 2002. �� PAHO/CPC, WHO. A Portrait of Adolescent Health in the Caribbean. 2000. WHO Collaborating Centre on Adolescent Health, Division of General Pediatrics and Adolescent Health, University of Minnesota, Minneapolis, MN. � PSI Youth KAP Survey conducted by the Earle and Phillips Consulting Group, 2002. � The Sexual Health Needs of Youth in Tobago. Final Report, April 2000. Family Planning Association of Trinidad and Tobago (FPATT) and Tobago AIDS Society (TAS), with technical assistance from CAREC and GTZ. � Ibid. pp 14-16 � The Caribbean Regional Strategic Framework for HIV/AIDS 2002-2006. Pan-Caribbean Partnership on HIV/AIDS. March 2002. � PAHO/CPC, WHO. A Portrait of Adolescent Health in the Caribbean. 2000. WHO Collaborating Centre on Adolescent Health, Division of General Pediatrics and Adolescent Health, University of Minnesota, Minneapolis, MN. Pp. 15-16. � Alex P. Vega, Caroling Allen and Geoffrey Stanforde. A Sexual Health Promotion Intervention among Caribbean Men who have Sex with Men. The CAREC Leadership and Facilitation Project. CAREC, 2001. � 1998 Barbados KAP Survey: Preliminary Findings. Ernest Massiah. � 1998 Barbados KAP Survey: Preliminary Findings. Ernest Massiah. � PAHO/CPC, UNAIDS. January 2001. An Assessment of PLWHA Self-Support Groups & AIDS Service Organizations in Barbados, Grenada, St. Vincent & St. Kitts. � Dr. Dorothy Blake. Needs Assessment among People Living with HIV/AIDS in the Caribbean. CRN+, CAREC. 2000. � The Sexual Health Needs of Youth in Tobago. Final Report, April 2000. Family Planning Association of Trinidad and Tobago (FPATT) and Tobago AIDS Society (TAS). Technical support from CAREC and GTZ. � 1998 Barbados KAP Survey: Preliminary Findings. Ernest Massiah. � Strategic Plan for the National Response to HIV/AIDS, St. Kitts and Nevis. 2001-2005 � The Caribbean Regional Strategic Framework for HIV/AIDS 2002-2006. Pan-Caribbean Partnership on HIV/AIDS. March 2002. � Sint Maarten’s Strategic HIV/AIDS Plan 2001-2005. Sector Health Care Affairs, Department of Preventive Health. � The majority of information about St. Maarten was provided by Dr. Gerard van Osch, a significant figure in St. Maarten in the fight against HIV/AIDS. He has been responsible for much of the testing, administration of antiretroviral drugs, and coordination and documentation of prevalence rates. � Caribbean Health Research Council. September, 2001. “Defining Indicators to Evaluate National AIDS Programs in the Caribbean” Proceedings of Workshop July 28-28, Trinidad. � Ministry of Health, Anguilla. Final Report: Development of a Strategic Planning Framework, National AIDS Programme. CAREC, Trinidad. March 2001. � Focus group: HIV/AIDS: Listen and respond to young people’s concerns. 2001. Amy Christofferson PAHO/WHO/ CPC and Shantal Munro-Knight, UNECTG on HIV/AIDS. � Population Council, MOH and FPA St. Lucia, FPA Barbados. A Study of the Determinants and Quality of Condom Use in Two Eastern Caribbean Countries: Barbados and St. Lucia. Nov. 15 1988 – July 15, 1989. The Population Council. � The Sexual Health Needs of Youth in Tobago. Final Report, April 2000. Family Planning Association of Trinidad and Tobago (FPATT) and Tobago AIDS Society (TAS), with technical assistance from CAREC and GTZ. � The responses varied widely by country: Barbados (42%), St. Vincent (52%), Trinidad (43%), and St. Kitts (26%). � Population Council, MOH and FPA St. Lucia, FPA Barbados. A Study of the Determinants and Quality of Condom Use in Two Eastern Caribbean Countries: Barbados and St. Lucia. Nov. 15 1988 – July 15, 1989. The Population Council. � A Survey of Knowledge, Attitudes and Practices with Regard to the Use of Condoms for AIDS and STD Prevention in Barbados. Tissa Wickramasuriya and William Adu-Krow. Paper presented at the Regional Meeting on Behavioral Interventions in Kingston, Jamaica. 1990 � The Caribbean Regional Strategic Framework for HIV/AIDS 2002-2006. Pan-Caribbean Partnership on HIV/AIDS. March 2002. PAGE 64 _1090070862.xls Chart5 86 60 51 Why youth use condoms Table 4. Why youth use condoms Sheet1 Printed youth materials 100 Youth training materials 90 Materials for MSM 90 Brochures 78 Videos for youth 78 Provider training manuals 78 Materials for Uniformed Men 78 Posters 67 Materials for CSW 67 Materials for Migrants 56 Materials in Spanish 56 Materials in Creole 44 Condoms 76 Pill 15 Withdrawal 11 Implants 2 Why youth use condoms Pregnancy Prevention 86 HIV/AIDS Prevention 60 STI Prevention 51 Sheet2 Sheet2 100 90 90 78 78 78 78 67 67 56 56 44 Sheet3 76 15 11 2 Method % Usage Method of Contraceptive Use 86 60 51 Why youth use condoms _1090070887.xls Chart9 100 90 90 78 78 78 78 67 67 56 *based on % of countries requesting support in each subject area Table 3. Support requested of PSI* Sheet1 Printed youth materials 100 Youth training materials 90 Materials for MSM 90 Brochures 78 Youth Videos 78 Provider training manuals 78 Materials for Uniformed Men 78 Posters 67 Materials for CSW 67 Materials for Migrants 56 Condoms 76 Pill 15 Withdrawal 11 Implants 2 Why youth use condoms Pregnancy Prevention 86 HIV/AIDS Prevention 60 STI Prevention 51 Priorities for potential interventions Youth 100 General population 78 Uniformed populations 56 People living with HIV/AIDS 56 MSM 44 Tourist industry 44 CSW/Migrants 33 Sheet2 Sheet2 100 90 90 78 78 78 78 67 67 56 % Support requested of PSI Sheet3 76 15 11 2 Method % Usage Method of Contraceptive Use 86 60 51 Why youth use condoms 100 78 56 56 44 44 33 Priorities for potential interventions % of countries responding that prioritized interventions with target group _1090070907.xls Chart1 100 78 56 56 44 44 33 Table 4. Priorities for potential interventions *based on countries that prioritized interventions with each target group Table 6. Priorities for potential interventions* Sheet1 Printed youth materials 100 Youth training materials 90 Materials for MSM 90 Brochures 78 Youth Videos 78 Provider training manuals 78 Materials for Uniformed Men 78 Posters 67 Materials for CSW 67 Materials for Migrants 56 Condoms 76 Pill 15 Withdrawal 11 Implants 2 Why youth use condoms Pregnancy Prevention 86 HIV/AIDS Prevention 60 STI Prevention 51 Table 4. Priorities for potential interventions Youth 100 General population 78 Uniformed populations 56 PLWHA 56 MSM 44 Tourist industry 44 CSW/Migrants 33 Sheet2 Sheet2 100 90 90 78 78 78 78 67 67 56 % Support requested of PSI Sheet3 76 15 11 2 Method % Usage Method of Contraceptive Use 86 60 51 Why youth use condoms 100 78 56 56 44 44 33 Table 4. Priorities for potential interventions *based on countries that prioritized interventions with each target group Table 4. Priorities for potential interventions* _1088170090.ppt Personal risk assessment Condom use Availability Affordability Social support Solution efficacy Self efficacy Brand appeal Awareness of problem Awareness of transmission Perception of severity Behavior Change Framework Let’s say one of our target groups is young girls living in urban areas who have multiple partners. Let’s assume that we used maybe some quantitative research and some focus group research to understand what influences their behavior. We may end up with something like this. Within each bubble there are positives and negatives. Together, these specific issues form a unique behavior change framework. Notice that if research is going to be of any use to a marketer, it needs to highlight specific issues. Big words like self-efficacy and social support are great for sociologists and anthropologists but marketers need concrete issues. _1090070852.xls Chart3 76 15 11 2 Method % Usage Table 3. Most Common Methods of Contraceptive Use Among Youth Sheet1 Printed youth materials 100 Youth training materials 90 Materials for MSM 90 Brochures 78 Videos for youth 78 Provider training manuals 78 Materials for Uniformed Men 78 Posters 67 Materials for CSW 67 Materials for Migrants 56 Materials in Spanish 56 Materials in Creole 44 Condoms 76 Pill 15 Withdrawal 11 Implants 2 Sheet2 Sheet2 100 90 90 78 78 78 78 67 67 56 56 44 Sheet3 Sheet3 76 15 11 2 Method % Usage Method of Contraceptive Use _1072117159.ppt Personal risk assessment Condom use Availability Affordability Social support Solution efficacy Self efficacy Brand appeal Awareness of problem Awareness of transmission Perception of severity Behavior Change Framework Let’s say one of our target groups is young girls living in urban areas who have multiple partners. Let’s assume that we used maybe some quantitative research and some focus group research to understand what influences their behavior. We may end up with something like this. Within each bubble there are positives and negatives. Together, these specific issues form a unique behavior change framework. Notice that if research is going to be of any use to a marketer, it needs to highlight specific issues. Big words like self-efficacy and social support are great for sociologists and anthropologists but marketers need concrete issues.

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