HIV in the Land of Baseball and Bachata
In the Dominican Republic, two nongovernmental organizations offer comprehensive, integrated HIV and other health services that serve the special needs of high-risk and vulnerable populations: sex workers, migrant workers, young people, and people with disabilities.
Traducción en español (Spanish Translation) (PDF, 470 KB).
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HIV in the Land of Baseball and Bachata
By Edward Scholl
Dominican NGOs Provide Comprehensive Services to Those Most at Risk
Rosa parks her motorbike outside the El Mamey bar in downtown La Romana, on the southeast coast of the Dominican Republic. Lively Bachata music blares from the speakers as men on the sidewalk in front of the bar play dominoes. Inside the bar, 20 women seated on bar stools and benches smile and greet Rosa as she enters. She is well known to the women, and she hugs them before unpacking her backpack.... (continued on the next tab)
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Disclaimer: The authors' views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
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These women serve drinks to customers at El Mamey, occasionally dance with them for tips, and leave with those willing to pay to take them to nearby motels that rent rooms by the hour. This is one form of commercial sex work in La Romana. Other sex workers work in brothels, nightclubs, or even car wash businesses. Rosa knows them all, and regularly visits about 60 establishments where sex is sold in La Romana. Today, Rosa gives a talk about HIV and sexually transmitted infections (STIs) to the women at El Mamey, demonstrating the correct use of condoms and reminding the women to come for their monthly medical checkups at the Clínica de Familia La Romana (La Romana Family Clinic). At the end of her talk she answers questions, addresses common misunderstandings about HIV, and hands out educational materials and condoms.
Rosa is one of many outreach workers that La Romana Family Clinic uses to reach sex workers, youth, Haitian immigrants, and other populations at higher risk of HIV. But the clinic does far more than HIV prevention work. It also provides comprehensive HIV prevention, care, and treatment to the population of La Romana Province and has the highest number of HIV patients on treatment in the eastern part of country. Besides being a comprehensive program modeled on high-quality, family-centered care, it has achieved great success in HIV treatment adherence and has a close, symbiotic relationship with a large public sector hospital in La Romana, a model of a public-private partnership.
Another Dominican nongovernmental organization (NGO) working with a vulnerable population considered to be at special risk of HIV, sexual abuse, and unintended pregnancies is PROBIEN, a private foundation working with people with disabilities. The United Nations estimates that some 1 billion individuals—about 15 percent of the world’s population—live with one or more disabling conditions (World Health Organization [WHO] and the World Bank 2011). In the Dominican Republic, as in most developing countries, people living with disabilities are a forgotten segment of society, stigmatized and largely excluded from educational and employment opportunities. They also lack access to health care information and services, especially in the areas of reproductive and sexual health and HIV. PROBIEN is one organization working to change this, both through education and advocacy.
Both La Romana Family Clinic and PROBIEN receive financial and technical support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), through the U.S. Agency for International Development (USAID)/Dominican Republic, under grants provided by the AIDSTAROne Project. Both organizations are examples of how to provide HIV services to vulnerable populations using a family- and community-centered model. Both recruit volunteers from the vulnerable populations that they work with, and both partner with other community and government organizations to have regional and national impact. Although they serve different populations, both implement innovative approaches to HIV prevention, care, and treatment that can provide valuable lessons for other programs addressing similar needs.
HIV in the Dominican Republic
The Dominican Republic has the second highest number of people living with HIV in the Caribbean after Haiti (Joint United Nations Programme on HIV/AIDS [UNAIDS] 2010). For many years, its HIV epidemic was described as generalized, with prevalence fluctuating between 1 and 2 percent of the adult population. It now stands at 0.9 percent (UNAIDS estimate for 2009) and is classified as a concentrated epidemic, with the highest prevalence found among sex workers and men who have sex with men.
La Romana Province, a major sugar, manufacturing, and tourism industry center in the eastern part of the country, is the region with the highest HIV prevalence. A recent study among women giving birth in La Romana found HIV prevalence to be 2.6 percent (Roman-Poueriet et al. 2009). In addition to the sex workers in La Romana, another group considered to be at high risk of HIV is the large population of Haitian immigrants who live in bateyes (sugar cane plantation communities). The aforementioned study found sex workers in La Romana to be eight times as likely to be HIV-positive as the general population of childbearing women, while Haitian immigrants were 1.6 times as likely to be infected with HIV.
To address the HIV prevention needs of both sex workers and Haitian immigrants living in the bateyes, La Romana Family Clinic began HIV prevention as well as testing and counseling programs for both of these target populations, anchored by their clinic in the middle of the city of La Romana. Other programs include a teen clinic and school-based sex education program, and a program for prevention of mother-to-child transmission (PMTCT) in collaboration with the Ministry of Health hospital in La Romana. Together these programs make up the comprehensive HIV services offered by the La Romana Family Clinic.
La Romana Family Clinic
La Romana Family Clinic is an NGO established in 1999 as a collaboration between the International Family AIDS Program of Columbia University, the Hermanas Adoratrices of the Complejo Micaleano (a Spanish order of nuns), and the MIR Foundation (a Dominican foundation based in La Romana). Its purpose was to improve the quality of life of people living with HIV and marginalized populations, particularly sex workers.
The clinic began the first PMTCT program in La Romana and, in 2004, began offering antiretroviral treatment to people living with HIV, one of the first clinics in the country to do so.
La Romana Family Clinic prides itself on being part of an extended family. “We are family” is its slogan, and, as Executive Director Mina Halpern explains, all of the patients and staff are considered to be part of a family. Clinic staff do not view HIV as just another disease to be treated, but rather try to provide holistic care that goes beyond the medical care they offer.
Although it is known as one of the largest HIV facilities in the country and for pioneering triple antiretroviral therapy (ART) for pregnant women, the clinic is also known for what it does outside its clinic walls: HIV prevention with most-at-risk and vulnerable populations, community-based testing and counseling, a satellite clinic for teens, a summer camp for young people living with HIV, and a cadre of home visitors that ensure treatment adherence and provide care and support to those living with HIV and their families. Indeed, given the breadth and scope of its services, La Romana Family Clinic can be described as a comprehensive HIV prevention, care, and treatment program.
Adult care and treatment: At the end of 2011, the clinic had 1,581 adults enrolled in its HIV care and treatment program, of which 1,247 were receiving ART. This is an increase of 12 percent over the number of clients receiving treatment in 2010, and of 37 percent over the number on treatment in 2009. Ninety percent of patients on ART are on first-line therapy. The clinic carefully monitors patient outcomes in its treatment program and reported 48 deaths in 2011, representing 3 percent of all enrolled patients. About 12 percent of patients—188 total—were lost to follow-up in 2011. For comparison purposes, a study of patients on ART in lower-income countries found that, on average, 21 percent were lost to follow-up in the first six months after starting ART (Brinkhof et al. 2008).
Although the clinic’s record of treatment adherence compares favorably to programs in lower-income countries, staff began several new interventions in the second half of 2011 to improve treatment adherence and reduce loss to follow-up. In August 2011 they began a new program of treatment adherence counseling adapted from a similar program used at New York Presbyterian Hospital. This structured program includes regularly scheduled counseling sessions, initially once per week, and later once per month, followed by once every six months. In September 2011 they also began a “Rescue Plan” that deploys additional home visitors to enroll people living with HIV in the treatment program, encourage them to come to their clinic appointments, find out how they are doing with their medications, provide palliative care, and bring medications to them if they cannot get to the clinic. With support from AIDSTAR-One, the number of home visitors increased in 2011, and a total of 2,167 home visits were conducted during the year. The clinic credits the Rescue Plan with locating 28 HIV-positive patients in 2011 who had stopped taking their antiretroviral (ARV) medications and getting them to resume treatment.
Yet another intervention begun in the second half of 2011 was a quality improvement plan modeled on the “client-oriented, provider-efficient” (COPE) methodology. COPE is a process that helps health care staff continuously improve the quality and efficiency of services provided at their facility, and make services more responsive to clients’ needs (EngenderHealth 2003). Clinic staff completed self-assessments, undertook a survey of client satisfaction, and conducted a patient flow analysis to analyze patient waiting times and time spent with providers. After making changes based on the client survey and patient flow analysis, patient waiting times were reduced from an average of 127 minutes to 89 minutes, and time spent with providers increased from 19 minutes to 31 minutes.
Pediatric care and treatment: A total of 132 children were enrolled in the clinic’s HIV care and treatment program in 2011, with all but two receiving ART. This represents a 12 percent increase over the number of children receiving treatment in 2010. Four children on treatment died during 2011 (three percent of the total on treatment at the beginning of the year), and five were lost to follow-up (four percent).
PMTCT program: The clinic’s PMTCT program began in 1999 and was the first facility in the country to offer ART to pregnant women. In 2006, the clinic began offering triple therapy during pregnancy. The positive results from the clinic in reducing the transmission of HIV from mother to baby, coupled with cost-effectiveness data collected with the help of Columbia University, helped persuade the Ministry of Health to change its national protocols from single-dose nevirapine during labor to triple therapy throughout the pregnancy. In 2011, the clinic’s PMTCT program reported only one baby born HIV-positive out of 92 births, a transmission rate of only one percent (down from five percent the year before). Similar to the adult treatment program that uses home visitors to increase treatment adherence, the PMTCT program also has home visitors who provide in-home education, counseling, support, and reminders for upcoming clinic appointments.
The clinic also has a long-standing PMTCT collaboration with Hospital Francisco Gonzalvo, the largest public hospital in La Romana Province. This collaboration takes many forms, including referrals to the clinic for prenatal care and ART during pregnancy for pregnant women at the hospital who test positive for HIV, followed by counterreferral from the clinic to the hospital for cesarean delivery, followed by a referral back to the clinic for postpartum follow-up and pediatric care for the baby. To strengthen the hospital’s own PMTCT capabilities, the clinic currently covers the salaries of HIV counselors at the hospital who provide HIV testing and counseling for pregnant women, and is providing technical assistance to strengthen prenatal care that the hospital can provide to HIV-positive expectant mothers. The clinic and hospital also share some staff. For example, the head of the HIV/AIDS program at the hospital also works at the clinic two days per week.
Other clinical services: Another HIV service offered at the clinic is testing and counseling using rapid testing. In 2011, the clinic provided HIV testing and counseling to 3,128 individuals. It also has one of three CD4 machines being used by government or nonprofit laboratories in the country to assess treatment eligibility and monitor progress for those who are HIV-positive. Another service available to the general public at the clinic is family planning, which provides oral contraceptives, intrauterine devices, injectables, and condoms. The clinic also provides general outpatient medical care, as well as gynecological, prenatal, and pediatric care, and it operates a laboratory and pharmacy.
All HIV-related services are free, and all other clinical services are free for those who are HIV-positive and their families. Other patients pay a small fee for non-HIV services. The clinic covers about 10 percent of its budget through these user fees, especially fees for laboratory services and ultrasound.
Sex worker program: Commercial sex work in La Romana is widespread, in part due to the large number of migrants in the area who work in the sugar cane fields and refineries, free trade zone manufacturing plants in the region, and the tourist industry in and around La Romana. The clinic’s sex worker program is its oldest program, founded in 1989 by a group of Catholic nuns. The clinic eventually took over the program in 2006, though the nuns continue to work closely with the clinic and have a program in a building next door that offers sex workers occupational training.
The sex worker program includes a combination of prevention and clinical services. The latter include gynecological exams at the clinic every month (mandated by the government), along with HIV and syphilis screening every three months, and a Pap test every six months. In 2011, the clinic provided 2,320 exams to sex workers, identified 200 cases of STIs (in nine percent of all exams), and provided treatment to each using the syndromic management protocol of the WHO.
The prevention component of the program includes education on HIV, STIs, and family planning and counseling on condom use, as well as distribution of condoms and family planning methods. This education and counseling takes place at the clinic, but also in the negocios (places where sex workers work, including brothels, bars, and nightclubs). The clinic has an educator who regularly visits the negocios in La Romana (about 60 in total) and coordinates with owners to give educational talks during the day to the women who work there, and sometimes to men who happen to be there (negocios are typically open for business day and night). At one such talk at El Mamey bar, the educator began by giving 20 sex workers a pre-test of their knowledge about HIV and STIs, followed by a post-test after the talk. This is one way that the educator can focus her message on topics about which the sex workers are least informed and document the increase in knowledge as a result of the talk. In 2011, this educator gave 166 talks in various negocios, reaching 1,202 sex workers and clients.
Bateyes program: Another population at higher risk of HIV is the immigrant Haitian population residing in the many bateyes in La Romana. These residents, including seasonal migrants, permanent migrants, and second-generation immigrants from Haiti, live in company-owned homes, typically one- or two-room cinder block dwellings without electricity or indoor plumbing. Besides poor housing and limited schooling for the children (if schools exist in the batey, they go only through the fifth grade, with few exceptions), residents of bateyes also have to contend with chronic underemployment when the cutting season ends, or migrate elsewhere in search of jobs.
The clinic began a program in 2007 to reach the many bateyes in La Romana Province with HIV testing and counseling, prevention education, and access to the clinic’s services. The program uses a group of Creole-speaking promoters from the clinic (many from Haiti themselves) who regularly make home visits in the bateyes and schedule testing and counseling days. On these days, a team from the clinic will drive through the community and announce via loudspeaker that testing and counseling will soon begin in a designated community location, such as a church or school. Batey residents will then gather at the site for a group talk about HIV and STIs, followed by HIV rapid testing, and then individual posttest counseling. After the post-test counseling, clients receive a package of basic foodstuffs as an incentive to get tested and stay for the results. Anyone testing positive is enrolled in the clinic’s HIV treatment program. In 2011, the program conducted 4,117 HIV tests in 59 different bateyes, with 77 testing positive (a rate of 1.9 percent, over twice as high as the adult prevalence in the general population).
Adolescent program: The clinic’s adolescent program began in 2008 as a collaboration with the Hospital Francisco Gonzalvo in La Romana. The program grew out of the desire to prevent unintended pregnancies among teens (30 percent of all births occurring at the hospital are to adolescent mothers) and to improve their access to gynecological/prenatal care and HIV and STI testing and counseling. The program also sought to reach adolescents in school before they become sexually active and at risk of unintended pregnancies or HIV and other STIs.
The program opened a teen clinic next to the hospital that offers gynecological and prenatal care to adolescents, as well as psychological consultations. HIV and STI testing and counseling are provided as well, with enrollment in the clinic’s ART program for anyone testing positive for HIV. Family planning counseling and methods are also offered.
The teen clinic is implementing several innovative approaches to prenatal care. One of these is a modified version of the centering-pregnancy model, where groups of adolescents meet together once a month for their prenatal care and attend educational sessions together. The goal of the model is to create friendships and trust among the teens and the teen clinic staff, and make them feel more comfortable at the clinic. Another innovative approach is the Five Star Program that the teen clinic introduced last year where pregnant teens receive a star for each goal they reach during their pregnancy and postpartum periods. For example, one star is given for obtaining the required immunizations and ultrasound, another star for getting two HIV tests during pregnancy, another for attending five prenatal visits, another for attending all of the educational sessions, and a fifth star for attending a family planning consultation after birth. Upon receiving the fifth star, the teen mother receives a gift and a certificate.
Besides the services and counseling given in the teen clinic, the adolescent program seeks to raise awareness and understanding of sexuality, reproductive health, pregnancy, HIV, and STIs through a school-based education program in secondary schools in La Romana Province, including schools in the bateyes. The program has two full-time educators and several groups of volunteer peer educators. The educators visit a school for an entire week, which allows them to take a much more intensive approach than most school-based sex education/HIV awareness programs. For several hours each day a different topic is introduced, including the physiology of puberty and pregnancy, pregnancy prevention and contraception, STIs, and HIV. For the year ending May 2012, a total of 4,300 students received this five-day curriculum.
The educators feel that their efforts make a difference in promoting healthy behaviors among students, pointing out that the number of teens accessing contraceptives at the teen clinic doubled in the last year, which they feel is a result of their educational efforts. They also give credit to the growing number of youth they have trained as peer educators, as well as to promotion of the teen clinic through Facebook.
A growing body of literature indicates that individuals with disabilities are at equal or increased risk of exposure to HIV as people without disabilities (World Bank 2004). A United Nations Policy Brief (UNAIDS, WHO, and OHCHR 2009) notes the following reasons for this:
- Many persons with disabilities engage in behaviors that place them at risk of HIV infection.
- A large percentage of persons with disabilities will experience sexual assault or abuse during their lifetime, with women and girls, persons with intellectual impairments, and those in specialized institutions at particularly high risk.
- Persons with disabilities often have limited access to HIV education, information, and prevention services. They may not be invited to HIV education forums, or be visited by outreach workers, who may assume that persons with disabilities are not sexually active or do not engage in other high-risk behaviors.
- Services offered at health facilities may be physically inaccessible or fail to provide information in alternative formats such as Braille or audio.
People with disabilities are a hidden population in most countries. They tend to go uncounted in census and survey data, have limited physical and social mobility, and are less likely to attend school or find employment. In health care programs, they are too often hidden as well, both as clients and as co-participants in program design and implementation. The PROBIEN Foundation is a Dominican NGO formed in 1994 to promote the rights of people with disabilities in the Dominican Republic. PROBIEN seeks to change the old paradigm, still prevalent in the country, of a paternalistic, charity-focused approach to supporting people with disabilities, and replace it with a new paradigm based on social inclusion and respect for the human rights of people with disabilities. This approach mirrors international efforts to gain greater recognition of the rights of people with disabilities to adequate health care, education, and social participation (Stein et al. 2009), which culminated in the 2008 UN Convention on the Rights of Persons with Disabilities.
In the Dominican Republic, PROBIEN works with other organizations to advocate on behalf of people with disabilities and to ensure better access to educational, health, and employment opportunities. One of its significant lobbying successes was to convince the government to include people with disabilities as beneficiaries of the national health insurance program (Seguro Nacional de Salud). As a result, since 2008, people with disabilities have been able to obtain free medical care and subsidized prescription drugs.
PROBIEN has a special concern for the sexual and reproductive health of people with disabilities and recognizes their vulnerability to sexual abuse, unintended pregnancies, HIV, and STIs. PROBIEN has a cadre of 30 peer educator promoters—people with disabilities who have been trained to give talks to their peers about sexual and reproductive health, including HIV and STI prevention. Rather than segregate these promoters by type of disability, PROBIEN has preferred to integrate teams of promoters to give talks to persons with disabilities and their families. Recently, for example, a group of promoters giving a talk on HIV to students at the National School for the Deaf in Santo Domingo consisted of three men: one blind from birth, another who is deaf, and a third who has only one leg and uses a wheelchair. PROBIEN feels that this approach helps people with disabilities learn from each other and builds solidarity and understanding.
PROBIEN's educational efforts are not only directed to people with disabilities, but to their families as well. As PROBIEN Director Magino Corporan explains, the problem of lack of education and access to services often begins in the family. Many parents are ashamed of their child with a disability and may not register the birth, obtain a national identification card, or send them to school. They feel that the disability makes their child less of a person, and less worthy, and that feeling becomes internalized by the child as he or she grows up. For this reason, PROBIEN invites family members to participate in the educational workshops and talks they provide to people with disabilities. PROBIEN also offers education to health care staff at maternity hospitals and in other health facilities so that they do not discriminate against people with disabilities and so they can provide better counseling and support (e.g., to parents of babies with Down Syndrome).
From December 2011 (when PROBIEN's HIV education outreach began in earnest with support from AIDSTAR-One) through April 2012, PROBIEN has conducted 15 workshops on sexual/reproductive health, STIs, and HIV that have reached 350 people with disabilities and family members. These workshops were led by PROBIEN's peer educator promoters. PROBIEN expects to reach 1,200 people through these workshops before the end of 2012.
In addition to these direct educational interventions, PROBIEN promoters also use innovative approaches to extend the reach of their messages. For example, one promoter, Maximo (with two amputated legs following a vehicle accident in 2000), hosts a weekly radio program on a community radio station that reaches the residents of Villa Altagracia (population 100,000). His talk show, combined with musical interludes and listener call-in, discusses topics of interest to people with disabilities and frequently focuses on HIV and reproductive health. In a recent program, Maximo made the point that others often mistakenly assume that people with disabilities have no sex life, "But we know we do!" he said, and told his listeners about the importance of using condoms and getting tested for HIV.
What Has Worked Well
Linkages with government, universities, and other programs: Both La Romana Family Clinic and PROBIEN have created many linkages with government and with other programs. In the case of the clinic, the close collaboration with Hospital Francisco Gonzalvo in La Romana enables effective referrals and counter-referrals, especially for PMTCT services and even joint ownership of programs, such as the teen clinic located a block from the hospital. The director of the hospital, Dr. Leonardo Feliz, describes the relationship between La Romana Family Clinic and the hospital as a “marriage” and proudly refers to the teen clinic as their “child.” The clinic also has linkages with the Ministry of Health that provides donated commodities to the clinic (e.g., HIV test kits, ARVs, drugs for opportunistic infections, and contraceptive methods), as well as some staff salaries for Ministry of Health employees who work at the clinic. Another effective partnership is with Columbia University, whose International Family AIDS Program helped establish the clinic in 1999 and conducted an influential cost-effectiveness study on triple ARV therapy that helped convince the government to provide it to pregnant women with HIV. The clinic also has partnerships with other universities in the United States, including the University of Illinois, with whom it is about to conduct a study on male circumcision for HIV prevention.
PROBIEN also has many linkages with government ministries and agencies, including the National Disability Council, the government agency responsible for coordinating government assistance and policies related to people with disabilities. PROBIEN is an active member of the National Federation of the Disabled and the National Network for the Rights of People with Disabilities. This network was instrumental in the government’s passage of the UN Convention on the Rights of People with Disabilities. PROBIEN also has a good relationship with La Romana Family Clinic and later this year will provide orientation to clinic staff and volunteers on engaging and working with the disabled population of La Romana.
Monitoring and evaluation: To improve quality and effectiveness, La Romana Family Clinic maintains good service delivery data that show the volume of clinical services over time and allow staff to conduct periodic evaluations. For example, the clinic has carefully monitored the outcomes of its HIV treatment program and adherence to treatment. The clinic uses the data it collects to guide decision making and, as described earlier, instituted its Rescue Program so that fewer patients are lost to follow-up. It also undertook an evaluation of its clinical services and incorporated client feedback to reduce the waiting time of patients in the clinic and increase their time with providers.
Comprehensive and family-centered services: “Family-centered, comprehensive care” is the way La Romana Family Clinic describes itself. There is probably no other facility in the country, public or private, that provides HIV care as comprehensively while also providing general medical care to the public. Its HIV services include the full spectrum of HIV prevention, care, and treatment, with a special focus on reaching mostat- risk and vulnerable populations. HIV care is provided free of charge, and clients with HIV and their families can also receive free medical care at the clinic, including pediatric care. The clinic also recently began a program to help HIV clients and their families with their non-health needs, recognizing that about 80 percent live in extreme poverty. Social workers at the clinic work with each client to assess needs and help where they can, whether with food assistance, school fees, or help in getting a child’s birth certificate. They also help link families up with other government programs that can assist them. This comprehensive, familycentered approach means people living with HIV and their families can have multiple health and non-health needs met in one visit to the clinic.
PROBIEN also takes a family-centered approach in its work. The organization recognizes that respect for the value of individuals with disabilities and recognition of their potential must start with the family, so family members are invited to PROBIEN’s many educational and social activities. PROBIEN staff also help parents provide sex education and HIV prevention information to their children with disabilities.
Peer-driven interventions: Both organizations rely on peer educators for many of their educational interventions. For example, La Romana Family Clinic uses promoters who are HIV-positive or personally affected by HIV in its home visitation program and as counselors for HIV-positive mothers in its PMTCT program. The clinic also uses adolescent peer educators to help provide sex education and HIV information in its school-based adolescent program. Peer educators complement the work of clinic staff in providing education and counseling throughout its various programs. Most of PROBIEN’s HIV education outreach is done by its 30 peer educators, all of whom have a disability of one kind or another.
Linking community- and clinic-based services: La Romana Family Clinic is an excellent model for linking community- and clinic-based services, which allows the clinic to have broader impact and achieve greater adherence in its HIV treatment and PMTCT programs. Though the clinic has used home visitors for a number of years, it increased the number of home visitors last year to reduce the number of HIV patients lost to followup. It also uses home visitors to make sure HIV-positive women come to their clinic appointments and receive ARVs during pregnancy. These home visitors are typically HIV-positive themselves.
The bateyes program described earlier is another example of how the clinic links services in the sugar cane plantation communities with its facilities in the city of La Romana. Community-based HIV testing and counseling takes place in the bateyes, and anyone testing HIV-positive is enrolled in the clinic’s treatment program. The clinic’s sex worker program is yet another example of community-clinic linkages, whereby education and outreach in the brothels and negocios are linked to gynecological exams and HIV/STI testing at the clinic.
Commitment of staff and solidarity with vulnerable populations: One of the strongest impressions that a visitor to La Romana Family Clinic or PROBIEN leaves with is that these organizations are committed to their work and have a strong sense of solidarity with the vulnerable populations they serve. At the clinic, this can be seen in the waiting room, where patients now spend less time waiting and more time with providers; in the way bathrooms are kept clean for patients; in client-provider interactions, such as the large number of Creole-speaking staff and volunteers who can better communicate with their Haitian clientele; and in the respectful way staff treat sex workers who come to the clinic for their monthly medical exams.
PROBIEN’s commitment and solidarity are visible throughout the organization, from its director, who is himself living with a disability, to its peer educators, all of whom have a disability and volunteer their time to help others, regardless of type of disability.
Sustainability: A common challenge for most NGOs in developing countries is financial sustainability, and this is certainly the case for La Romana Family Clinic and PROBIEN. PROBIEN, in particular, operates on a very small budget with mostly volunteer staff. For many years it has received a government grant (subvención) that provides funding for its educational and advocacy work. This grant is renewed every year and appears to be semi-permanent, providing PROBIEN with a reliable, albeit very modest source of revenue. Most of the HIV prevention work described in this case study is funded through the AIDSTAR-One grant that will be ending in late 2012. Therefore, PROBIEN must look for additional sources of funding to sustain its HIV prevention work, or find ways of incorporating this work into the activities supported by their government grant.
La Romana Family Clinic’s financial sustainability outlook is stronger, though still a challenge. The clinic has many sources of funding, including grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria through the Dominican government’s National Council of HIV/AIDS (CONAVIHSIDA), the Ministry of Health, and several United States foundations. It also receives support from USAID/Dominican Republic (through the AIDSTAR-One Project) that has allowed the clinic to expand its outreach work for prevention and follow-up on care and treatment for people with HIV. The clinic also receives many donations, including in-kind donations of contraceptives, ARVs, and drugs for opportunistic infections. The clinic receives frequent volunteers from universities and medical schools in the United States. As noted earlier, the clinic covers about 10 percent of its budget through clinic user fees for non-HIV services, especially fees for laboratory services and ultrasound, and hopes to increase this percentage in the future. Though the clinic has a diverse and growing base of support, it hopes to increase its fundraising from private United States and Dominican sources. Its five-year strategic plan details goals in this regard.
AIDSTAR-One has provided technical assistance and support to both PROBIEN and the La Romana Family Clinic in the area of sustainability. The project has helped facilitate connections between PROBIEN, La Romana Family Clinic, and other organizations and potential allies, so as to be able to advocate together on important issues such as inclusion of people with HIV and people with disabilities in the national health insurance system. AIDSTAR-One has also helped organize PROBIEN, the clinic, and other stakeholders to advocate on issues such as the distribution of key commodities like HIV rapid test kits and condoms. Finally, AIDSTAR-One has provided technical assistance to PROBIEN to strengthen its management and administrative practices.
Structural challenges: The Dominican Republic presents several structural challenges that affect both of these organizations as they seek to address HIV among most-at-risk and vulnerable populations. One is the economy of the country and of the eastern part of the country in particular, which is based on tourism, free trade zones, and sugar production. While the region has long depended on sugar cane production for its livelihood, the growth of free trade zones (especially after the Dominican Republic-Central American Free Trade Agreement launched in 2007) and tourism during the past decade accelerated migration to the area, especially of young people. Then, the earthquake in Haiti in 2010 increased the traditional migration of Haitians to the region to cut sugar cane. The influx of many young, single migrants, coupled with a growing tourist industry, much of it sexual in nature, has inevitably given way to risky sexual behaviors and commercial sex. Further fueling the commercial sex industry is the high unemployment rate in the country, significantly higher than the Latin American average (Economic Commission for Latin America and the Caribbean 2011). Despite the best efforts of programs like La Romana Family Clinic and PROBIEN to educate most-atrisk and vulnerable populations about HIV and STIs and implement other prevention activities, these structural factors will continue to make their work very challenging.
Recommendations and Future Programming
Build public-private partnerships: One of the most important lessons learned from the experiences of La Romana Family Clinic and PROBIEN is the importance of public-private partnerships to increase coverage, improve quality, and ensure greater long-term sustainability. The mutually beneficial relationship between La Romana Family Clinic and the large public hospital is a case in point. The clinic and hospital receive referrals from each other, collaborate on joint projects, and share some staff. A common shortcoming of innovative pilot programs implemented by NGOs with international support is that they are not scaled up for wider impact, nor are they financially sustainable. The partnership between La Romana Family Clinic and Francisco Gonzalvo Hospital demonstrates how a public-private partnership can expand access to high-quality care in the areas of PMTCT, HIV services, and adolescent reproductive health, while increasing long-term financial sustainability.
Integrate programs: Increasing impact through strategic coordination and integration is one of the principles of the U.S. Global Health Initiative, recently reorganized as the Office of Global Health Diplomacy in the Department of State. The integration of HIV, family planning, and maternal, newborn, and child health programs is an especially important strategy for addressing high infant and maternal mortality and the unmet need for family planning services. La Romana Family Clinic provides a good model for integrating these services because it offers pediatric, gynecological, obstetric, and HIV-related care through its clinic and community-based services. For example, a client coming to the clinic for HIV testing or treatment is able to access pediatric services or prenatal care as well as family planning services. Likewise, all patients attending the clinic for whatever reason are offered HIV testing.
Include people with disabilities: HIV programs, like all public health programs, should explicitly take the needs of people with disabilities into account when designing programs or offering services. This should include ensuring physical access to health facilities and providing communication materials that are accessible to those with sensory disabilities. Thanks to the Section 508 Amendment of the Rehabilitation Act of 1973, federal agencies such as USAID (and projects supported by USAID) must make their electronic and information technology accessible to people with disabilities. For example, this case study, available on the AIDSTAR-One website, is accessible for those with hearing or visual impairment. Yet much more needs to be done by PEPFAR implementing organizations to ensure that people with disabilities have equal access to HIV prevention, care, and treatment services. PROBIEN also provides a good example of how people with disabilities can direct and implement HIV prevention programs for others with disabilities, while also advocating for greater social inclusion and respect for the human rights of people with disabilities.
Monitoring adherence: One of the most daunting challenges of HIV treatment programs is getting individuals who test positive for HIV to enroll in treatment programs and return periodically for clinical checkups and CD4 monitoring, and then, for those who begin receiving treatment, to stay on treatment for the remainder of their lives. Treatment adherence is vitally important, not only for the health and survival of the patient, but also to prevent the spread of drug-resistant virus requiring treatment with more costly second- or third-line ARV drugs. Monitoring treatment adherence, therefore, is a very important undertaking for HIV treatment programs. Even more important is taking action to improve treatment adherence, as La Romana Family Clinic did by recruiting Rescue Plan home visitors and improving service quality and waiting time in the clinic.
Brinkhof, M. W., F. Dabis, L. Myer, D. R. Bangsberg, et al. 2008. Early Loss of HIV-Infected Patients on Potent Antiretroviral Therapy Programmes in Lower-Income Countries. Bulletin of the World Health Organization 86(7):559-67.
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AIDSTAR-One would like to thank the staff of La Romana Family Clinic and PROBIEN who generously provided their time and insights in the development of this case study, especially Mina Halpern and Magino Corporan. Special thanks to Derek Sedlacek and Michele Russell of the U.S. Agency for International Development (USAID)/ Dominican Republic for their support, guidance, and review of the case study, and to Kristin Bork of USAID/Washington for her review of the study.
Scholl, Edward. 2012. HIV in the Land of Baseball and Bachata: Dominican NGOs Provide Comprehensive Services to Those Most at Risk. Case Study Series. Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.