Jamaica’s Most-At-Risk Populations: AIDSTAR Two reports by International HIV/AIDS Alliance

AIDS Support and Technical Assistance Resources

HEALTH SYSTEM STRENGTHENING FOR HIV/AIDS: Reaching Jamaica’s Most-At-Risk Populations

Submitted to USAID by Management Sciences for Health

DATE: July 13, 2011 This document is made possible by the generous support of the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the US Agency for International Development (USAID) under contract No. GHH-I-000700068-00. The contents are the responsibility of the AIDSTAR-Two Project and do not necessarily reflect the views of USAID or the US Government.

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Table of Contents TABLE OF CONTENTS ............................................................................................................................................ iii ACKNOWLEDGEMENTS ........................................................................................................................................ iv ACRONYM LIST ...................................................................................................................................................... V EXECUTIVE SUMMARY ......................................................................................................................................... vi 1. INTRODUCTION ................................................................................................................................................. 1 1.1 Most-at Risk populations (MARPS) ................................................................................................... 3 1.2 Redefining the approach to health system strengthening for HIV/AIDS .......................................... 4 1.3 Linkages between Community and Health Systems ......................................................................... 6 2. METHODOLOGY................................................................................................................................................. 7 2.1 The analytic methodology utilized: Causal pathway analysis ........................................................... 9 2.2 Nine Steps for Conducting a Causal Pathway Analysis...................................................................... 9 3. COUNTRY ANALYSIS: SUPPORTING JAMAICA’S MOST-AT-RISK POPULATIONS THROUGH A HEALTH SYSTEM STRENGTHENING APPROACH........................................................................................................................... 10 3.1 Overview of Jamaica’s HIV/AIDS Situation and Most-At-Risk Populations ..................................... 36 3.2 Evidence-Based Prevention Interventions ...................................................................................... 15 3.3 System requirements ...................................................................................................................... 23 3.4 Systems Bottlenecks and required health system strengthening actions ...................................... 25

4. SUMMARY GUIDANCE ..................................................................................................................................... 31 1. Recommendations on methodology ................................................................................................. 31 2. Recommendations on the availability and use of evidence.............................................................. 31 3. Recommendation on gender issues .................................................................................................. 32 4. Recommendation on legal and regulatory issues and private sector engagement .......................... 32 5. Recommendation on financing ......................................................................................................... 33 6. Recommendation on demand issues ................................................................................................ 33 7. Recommendation on scaling up what works .................................................................................... 33 BIBLIOGRAPHY .................................................................................................................................................... 34 APPENDIX I OVERVIEW OF JAMAICA’S HIV POLICY ENVIRONMENT, EPIDEMIOLOGY OF HIV, AND RISK AND CHARACTERISTICS OF MOST-AT-RISK POPULATIONS .......................................................................................... 35 APPENDIX II CAUSAL PATHWAY ANALYSIS GUIDELINES ...................................................................................... 56 INTRODUCTION ............................................................................................................................................ 57 PRINCIPLES ................................................................................................................................................... 57 CONDUCTING A CAUSAL PATHWAY ANALYSIS ............................................................................................. 58 Step 1: Identify the problems to be overcome and the causes of those problems .............................. 58 Step 2: Determining the characteristics of the population(s) at risk .................................................... 59 Step 3: Selecting the vital few evidence based interventions............................................................... 60 Step 4: Health system requirements and system bottlenecks.............................................................. 61 Step 5: Health system strengthening actions........................................................................................ 62 APPENDIX III PERFORMANCE BASED FINANCING ................................................................................................ 63

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Acknowledgements This report is the result of a joint effort undertaken by the PEPFAR Health Systems Strengthening Technical Working Group, the USAID Mission in Jamaica, and the AIDSTAR-Two Project, a HIV/AIDS organizational capacity building project that is funded by the USAID Global Health Bureau/Office of HIV/ AIDS. The AIDSTAR-Two Project, led by Management Sciences for Health (MSH) in partnership with the International HIV/AIDS Alliance, would like to express its gratitude to the many people who provided input and guidance for this report. We are particularly grateful to Dr. Kevin Harvey, Senior Medical Officer and Acting Director, Health Promotion and Protection Unit, of Jamaica’s Ministry of Health, and Catherine Zilber and Jennifer Knight-Johnson of USAID. Thanks also go to the staff of the Jamaica National HIV Programme; Sally Moore, the American Red Cross Caribbean HIV/AIDS Delegate; and Stacy-Ann Jarrett, Executive Director of The Underlined Response. We’d also like to recognize the following organizations for their assistance: Jamaica AIDS Support for Life (JASL); the Jamaica Red Cross; AED C-Change Programme in Jamaica; Caribbean Vulnerable Communities Coalition(CVC); Jamaica Youth Advocacy Network (JYAN); Jamaica Forum on Lesbian, All Sexual and Gays (JFLAG); Pride in Action; World Learning; CHART-ERTU; Sex Work Association Jamaica (SWAJ); National Council on Drug Abuse (NCDA); Jamaica Network for Seropositives (JN +) Special thanks to the Caribbean HIV&AIDS Alliance Technical Support Hub and its manager Denise Chevannes-Vogel as well as the local consultant in Jamaica, Renee Johnson, who contributed significantly to this entire assessment process. We would like to recognize the report’s primary author, Elden Chamberlain, HIV/AIDS and MARPS Specialist with AIDSTAR Two/Alliance, as well as the contributions of Dan Kraushaar. Alyson Clark, Ummuro Adano and Sarah Johnson, the AIDSTAR-Two team in the USA, provided much needed ongoing administrative and technical support, and reviewed the final report. Elizabeth Walsh provided skillful editorial, formatting and production assistance. Finally, we thank Pamela Rao, Senior Health Systems Advisor, Office of HIV/AIDS, USAID Washington, for her insightful technical feedback, commitment to, and encouragement and support of this initiative.

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Acronym List AIDSTAR ART ARV BCC CE CSO CRSF CSS CSW FSW HSS MARP MMT MOH MOHSNP MOU MSM NGO NEMP NSP PEPFAR PIOJ PMTCT PWID SOW STI SW TB THE UMI UNAIDS UNODC USAID VCT WHO

AIDS Support and Technical Assistance Resources Antiretroviral therapy Antiretroviral Behavior change communications Cost effective Civil society organization Community system strengthening Caribbean Strategic Framework Commercial sex worker Female sex worker Health system strengthening Most-at-risk population Methadone Maintenance Therapy Ministry of Health Ministry of Healthâ&#x20AC;&#x2122;s National Strategic Plan Memorandum of understanding Men who have sex with men Nongovernmental organization National Monitoring and Evaluation Plan National HIV Strategic Plan for 2007-2012 Presidentâ&#x20AC;&#x2122;s Emergency Plan for AIDS Relief Planning Institute of Jamaica Prevention of mother-to-child transmission People who inject drugs Scope of work Sexually transmitted infection Sex worker Tuberculosis Total Health Expenditure Upper Middle Income Country Joint United Nations Program on HIV/AIDS United Nations Office on Drugs and Crime United States Agency for International Development Voluntary counseling and testing World Health Organization

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Executive Summary Recognizing there is no single prescription for a multitude of diverse HIV epidemics around the world, UNAIDS led a rally “Know your epidemic, Know your response” in 2009 to build awareness on the importance of designing evidence-driven strategies based on the analysis of transmission sources in a given setting. This rally was initiated after the sobering realization that for every case that is put on treatment, there are four to five cases that are newly infected. This pattern is particularly pronounced in countries with concentrated epidemics driven by people who inject drugs, men who have sex with men, sex workers and other Most-at-Risk Populations. This lays bare the fact that there are many barriers to reach universal coverage of key prevention, treatment and care interventions for these groups. Health systems strengthening is a process of improving policies and health sector management to meet the needs of all populations. Given that health systems operate as open systems, it is important to understand their context, using an analytical approach to manage the dynamic relationships between all the various components of the health system. To plan, monitor and evaluate health system functioning, the World Health Organization (WHO) developed a framework to define health systems by six core building blocks: finances, health workforce, information, governance, medical products and technologies, and service delivery. The health systems building blocks are complex, adaptive systems as opposed to stand alone mechanical systems which draw resources from each other and must be responsive to their users in order to deliver health results, especially for hard to reach or vulnerable subgroups like the most-at-risk populations described above. By analyzing a health system across the six building blocks, governments can get a better idea of gaps in health interventions, particularly as they pertain to Most-at-Risk Populations. HSS interventions to reach these groups will likely result in higher demand and access to health services to improve overall health outcomes. This report is the result of a joint effort undertaken by the PEPFAR Health Systems Strengthening Technical Working Group, the USAID mission in Jamaica, and the AIDSTAR-Two Project, a HIV/AIDS organizational capacity building project that is funded by the USAID Global Health Bureau/Office of HIV AIDS. The Technical Working Group, working in close coordination with the USAID mission in Jamaica, asked the AIDSTAR-Two Project to conduct an in-country assessment in Jamaica, supplemented by a literature review, to answer the question: How should program managers in USG country teams worldwide invest their HSS funds to maximize the impact on Most At-Risk Populations? To respond to this question, AIDSTAR-Two applied a causal analytical framework (also known as the “causal pathway”) to determine how to make health systems more responsive to the needs of Most-atRisk Populations (MARPs); this report presents the key findings and recommendations for Jamaica based upon the application of this causal framework. Causal pathway analysis is an analytic approach which focuses on designing projects to achieve maximum attributable health outcome. Its application in project design maximizes the probability that projects and programs will achieve desired health outcomes, helps managers make appropriate choices among competing technical interventions, programmatic approaches, inputs, processes and outputs. It also helps managers focus on the most important health system strengthening efforts and identify the most appropriate indicators for monitoring progress. Tracing the causal pathway to health impact requires a nine-step process which includes:

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1. 2. 3. 4. 5.

6. 7. 8. 9.

Identifying the health impact goal (in this case, reduce AIDS related deaths) Identifying and quantifying health problems to be overcome (reduce HIV transmission) Identifying and quantifying direct and indirect causes and risk factors Determining the characteristic of the populations that are most at-risk (time, place, geographic distribution, socioeconomic status and who have most of the problems) Identifying the full range of cost effective evidence-based clinical and programmatic interventions and then identifying the vital few health interventions, their current coverage levels and coverage levels required to achieve the goal Determining health system requirements to achieve the needed coverage levels Identifying the few critical health systems bottlenecks to achieving required coverage levels Identifying critical health system strengthening Interventions that improve the functioning and integration of the six building blocks necessary and sufficient to improve coverage levels Identifying the most appropriate and key M&E indicators along the causal pathway that need to be monitored over time.

The AIDSTAR-Two assessment team was comprised of a health system strengthening expert from Management Sciences for Health and a Most-at-Risk Populations/HIV/AIDS expert from the International HIV AIDS Alliance. Experienced local consultants were engaged in Jamaica to assist in the analysis and support was provided by the U.S. Government. The analysis was conducted between September 2010 and January 2011, with two visits made to Jamaica during this time. Over 100 reports and assessments were analyzed and interviews and discussions held with key stakeholders in each country, including UN agencies, international development organizations, local HIV implementing organizations, MARPs groups and government agencies. The country analysis covered here presents the background on Jamaicaâ&#x20AC;&#x2122;s HIV/AIDS situation, through the lenses of policy, funding, and targets. It examines the epidemiology of Jamaica, where the adult prevalence rate for HIV/AIDS is 1.7%. There has been a slight increase from 1.5% over the past decade. Although the epidemic is generalized, it is also concentrated among some sub-populations, including men who have sex with men (a 31.8% prevalence rate) and sex workers (5%), the two most-at-risk populations. The report examines the characteristics of these two most vulnerable groups in-depth, and then looks at evidence-based prevention interventions that can meet the needs of these groups. It also examines the system requirements to support these interventions, as well as the bottlenecks that are present to their implementation. Given what is known through the causal pathway analysis, and based on the evidence presented in the report, the assessment determined that the greatest impact on the epidemic in Jamaica will be had by focusing on the following sub populations and interventions: Younger less educated (possibly homeless) MSM who are the receptive partners in what could be termed transactional sex in the areas of Kingston, Montego Bay and Ochos Rios, focusing on consistent condom use for anal sex through condom promotion and marketing and peer support. Younger women engaging in non formal sex work (and using drugs) and their partners in the parishes of Kingston, St. Catherine, St. Ann and St. James, focusing on consistent condom use via condom marketing and peer support.

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Among the summary guidance provided, the report recommends: While current health system analysis approaches offer good input into broad health system strengthening needs at a national level, a much more specific, detailed and analytic approach to health system analysis which is focused on identifying specific system bottlenecks for specific interventions targeted at the needs of specific populations is required to scale up evidencebased interventions. Operations research is needed to define the effectiveness of approaches that need to be developed to address country-specific issues. The lack of evidence across the board is one of the most formidable obstacles to selecting and implementing the most cost effective approaches to reducing HIV transmission. Existing evidence needs to be synthesized and made much more readily accessible to those that need it. Support needs to be provided to policy makers, planners and implementers to apply existing evidence in the design of tailored approaches which address specific country needs. It is important to understand more about the risks to women, the factors that influence that risk, the systems response to those risks, and the uptake of interventions which address those risks. In addition, more effort needs to be made to create information systems which provide disaggregated data on health system performance related to the delivery and uptake of effective interventions. A specific focus is needed to understand which legal and regulatory issues are health system bottlenecks constraining a countryâ&#x20AC;&#x2122;s response on both the supply and demand side, in both the government and private/NGO sector. An understanding of the potential for private sector engagement and the legal and regulatory and systems issues that impede this engagement is needed. More attention needs to be placed on the current and future trends in the use of resources, the mix of donor, public, private and out of pocket spending, and the management of financial resources. More attention needs to be paid to the transition from USAID/PEPFAR funding to funding from domestic resources and the effect of that transmission on the scale up of effective approaches targeting specific populations, risk factors and interventions. More attention needs to be paid to factors that affect the demand for effective interventions by specific high risk populations. Effective programmatic strategies need to address both supply and demand issues; building the evidence base on how to influence demand is greatly needed. There are many technical interventions whose efficacy and effectiveness is known, such as the effectiveness of male condoms in reducing HIV infections. The current evidence base on effectiveness of technical and programmatic interventions needs to be more widely disseminated and that evidence base is used to determine the most effective combination of interventions.

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1. Introduction PEPFAR’s current five-year strategy outlines several principles that will drive US government funding for HIV/AIDS.1 The first principle is to expand the emphasis on HIV prevention, and match interventions and investments with epidemiological trends and needs in order to improve impact. This principle points to the need for a combination of interventions that are tailored to the needs and risks of different target populations. Given that the epidemic is not static, changes within countries and regions – including the beneficial impact of prevention efforts – require a prevention response that identifies and deploys interventions to meet these new “The best measure of a conditions. This principle also calls for support to countries in reassessing prevention portfolios in order to ensure that they are targeting for maximum impact, assuring intervention strategies are aligned to existing and emerging situations. By working with countries to identify current drivers, including epidemics among subpopulations that may not be reached by general behavioral prevention messages, PEPFAR can target investments to greatest needs.

health system’s performance is its impact on health outcomes.” Margaret Chan WHO Everybody’s Business 2007

Finally, this principle calls for implementing, evaluating and expanding innovative, analytic programmatic approaches and interventions which will advance the science around HIV prevention. A second principle of PEPFAR’s five-year strategy calls for expanding access to high quality prevention, care and treatment services as well as immediate health needs, tailored to conditions in host countries, while laying the groundwork for future sustainability. Among other implications of this principle is that prevention and treatment efforts are focused on the specific drivers of the epidemic and lead to identification and testing of new methods and approaches. Finally, this principle calls for PEPFAR’s programs – prevention, care, treatment, and linkages to larger health care services – to be evidence based and driven by the needs of the people impacted by this epidemic. The greatest challenge we face is to address the following question: How can we maximize the impact on the HIV/AIDS epidemic within the context of rising demands for health care, limited system capacity, the push for greater country ownership, and potentially declining donor resources? Paraphrasing the principles outlined in the five-year strategy, we must build a “fit for purpose” health system, specifically targeted at the problems, causes, interventions and approaches required by specific population groups that are driving the epidemic. It is important that health system strengthening 1

The U.S. President’s Emergency Plan for AIDS Relief Five-Year Strategy Plan for AIDS

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include both supply and demand side approaches, as well as focus on government, NGO and private sector actions and recognize the contributions that community systems strengthening makes to ensuring that a sustainable response can be delivered at scale. The above principles and approaches are also reflected in the Global Health Initiative. The U.S. Government’s 2010 Global Health Initiative Consultation Document states that “Building functioning systems will, in some cases, require a new way of thinking about health investments, with increased attention to the appropriate deployment of health professionals, improved distribution of medical supplies and improved functioning of information and logistics systems – all while maintaining a focus on delivering results. In the end, success will be measured not by the robustness of the health system itself, but by a country’s ability to meet the needs of key populations and improve health conditions.” Jamaica faces unique challenges in addressing HIV/AIDS. As it has evolved into a “middle income” country, its ability to attract donor funding for HIV/AIDS programs is diminishing. The current HIV/AIDS National Plan remains 63.7% unfunded in an environment where there are serious HIV epidemics in MARPs populations, and these vulnerable groups are not being served by interventions at a scale large enough to reverse the epidemic. It is important, therefore, for those working in the health sector in Jamaica to consider what the most cost effective interventions for the right MARP sub populations are, in order to have the greatest impact on the epidemic; as well as determine what the system requirements are, in order to deliver those interventions to those populations. This report is the result of a joint effort undertaken by the PEPFAR Health Systems Strengthening Technical Working Group (TWG), the USAID mission in Jamaica, and the AIDSTAR-Two Project, a HIV/AIDS organizational capacity building project that is funded by the USAID Global Health Bureau/Office of HIV AIDS. The TWG, working in close coordination with the USAID mission in Jamaica, asked the AIDSTAR-Two Project to conduct an in-country assessment, supplemented by a literature review, to answer the question: How should program managers in USG country teams worldwide invest their HSS funds to maximize the impact on Most At-Risk Populations? To respond to this question, AIDSTAR-Two applied a causal analytical framework (also known as the “causal pathway”) to determine how to make health systems more responsive to the needs of Most-atRisk Populations (MARPs); this report presents the key findings and recommendations for Jamaica based upon the application of this causal framework. The report builds on the desire to develop a “fit for purpose” health system by: 1. Making a case for the importance of understanding the health system to design sustainable responses for MARPs 2. Applying a framework in Jamaica that can provide a health system lens to program managers to prioritize health system strengthening interventions 3. Highlighting the need for creative health system strengthening strategies to attain HIV/AIDS program goals in MARP settings. The report consists of four parts: an introduction that looks at the general context of MARPs, the health systems strengthening approach to HIV/AIDS and the linkages between the community and health systems. The second part looks at the methodology of this assessment, including a more detailed look at

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the causal pathway analysis. Section three, provides the in-depth analysis and findings of the study. The report concludes with guidance and recommendations in section four. A review of the report was undertaken by the US Government (USG) prior to publication, specifically the HSS PEPFAR Technical Working Group and the USAID mission in Jamaica. Input was also provided by the National AIDS Commission in Jamaica.

1.1 Most-at Risk populations (MARPS) According to UNAIDS, Most-at-Risk Populations include people who inject drugs (PWID), men who have sex with men (MSMs), persons engaged in sex work (CSWs), and clients of persons engaged in sex work, and are the main drivers of the epidemic(s) in countries with concentrated epidemics. These populations are the ones most likely to be exposed to HIV and most likely to be affected. Risk is defined as the probability or likelihood that a person may become infected with HIV. Certain behaviors create, increase, and perpetuate risk. Examples include unprotected sex with a partner whose HIV status is unknown, multiple sexual partnerships involving unprotected sex, and injecting drug use with contaminated needles and syringes. Most-at-risk populations are most often also vulnerable due to social and institutional rejection and discrimination. Depending on the context, in addition to the examples cited above, these populations might also include transgender people, prisoners, and other groups. To look at one most-at-risk group: Millions of people worldwide are injecting drugs, and blood transfer through the sharing of non-sterile injecting equipment is an extremely effective way of transmitting HIV. Around 30% of global HIV infections outside of sub-Saharan Africa are caused by risk behavior related to the use of injecting drugs, and it accounts for an increasing proportion of those living with the HIV virus. Harm reduction programs such as clean needle exchange programs and opioid substitution therapy (e.g., methadone) were introduced some 25 years ago in European cities like Rotterdam and Liverpool and in countries such as Australia and the United States. These programs were among the first successful measures to prevent HIV infection through injecting drug use. Harm reduction practices were widely adopted as public health policy in many countries and, along with safe sex campaigns, are considered a major factor in the relatively low HIV infection rates in those countries. Nearly three decades later, injecting drug use is now driving the fast growing HIV/AIDS epidemic in Eastern Europe. Some 65% of HIV infections in Russia, for instance, are through injecting drug use. In Vietnam, 70% of people who inject drugs are living with HIV. But the universal adoption of harm reduction strategies has not happened resulting in expanding epidemics amongst people who inject drugs around the globe. It is estimated that the global average is fewer than two clean needles a month per injector and only four percent of people who inject drugs living with HIV are on HIV treatment. The factors that put sex workers at risk also vary between contexts. Evidence shows, for instance, that risk factors can include sexual violence on the part of clients or sex workers accepting higher payments for engaging in unprotected sex. In some places, sex workers commonly use drugs and share needles. The overlap between sex work and injecting drug use is linked to growing HIV epidemics in a number of countries, such as China, Indonesia, Kazakhstan, Ukraine, Uzbekistan and Vietnam.

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Gay men and other men who have sex with men (MSM) bear a disproportionately heavy burden of the HIV pandemic. In low- and middle-income countries, MSM are 19 times more likely to be infected with HIV than the general population. Despite elevated HIV prevalence rates and heightened vulnerability to factors that drive HIV transmission, MSM have been under-recognized, under-studied, under-funded, and under-served historically in the global response to HIV & AIDS. It is estimated that HIV prevention services reach only 9% of MSM worldwide. Additionally, the detrimental effects of stigma and discrimination on sexual health have been well documented in the global north, where HIV infection rates among MSM in large urban centers are unacceptably high and in some places steadily increasing. Furthermore, as of May 2009, criminal penalties for same-sex acts between consenting adults were executed in at least 80 countries, driving the epidemic underground. There is, therefore, an urgent need to prioritize outreach to MSM with HIV-related services and information that effectively meet their needs in the context of global public health and human rights. Most-at-Risk Populations are often among those who are most affected by poverty, gender inequity, stigma and discrimination in law and practice, harmful cultural and religious practices, lack of access to credit, property or inheritance rights and other factors that contribute to HIV risk and vulnerability. Sex workers, transgender people, drug users and men who have sex with men are especially vulnerable to social and State discrimination. Criminalizing these groups’ activities erects major barriers to accessing HIV and other health and support services and programs. Laws and social customs in many countries condone discrimination against the populations who are most at risk of HIV, complicating efforts to deliver lifesaving services to engage affected populations as essential partners in the HIV response.2

1.2 Redefining the approach to health system strengthening for HIV/AIDS Recognizing there is no single prescription for a multitude of diverse HIV epidemics around the world, UNAIDS led a rally “Know your epidemic, Know your response” in 2009 to build awareness on the importance of designing evidence-driven strategies based on the analysis of transmission sources in a given setting. This rally was initiated after the sobering realization that for every case that is put on treatment, there are four to five cases that are newly infected. This pattern is particularly pronounced in countries with concentrated epidemics driven by PWIDs, MSMs, Sex Workers and other MARPs. This lays bare the fact that there are many barriers to reach universal coverage of key prevention, treatment and care interventions for MARPs.3 Health systems strengthening (HSS) is a process of improving policies and health sector management to meet the needs of all populations. Given that health systems operate as open systems, it is important to understand their context, using an analytical approach to manage the dynamic relationships between all the various components of the health system. To plan, monitor and evaluate health system functioning, the World Health Organization (WHO) developed a framework to define health systems by six core building blocks: finances, health workforce, information, governance, medical products and technologies, and service delivery. Weaknesses at one level may be the consequence of a root cause at another level. These are complex, adaptive systems as opposed to stand alone mechanical systems and 2 3

Enabling Legal Environments, International HIV AIDS Alliance 2011 Rao, Concept Note, Health System Strengthening for MARPs Programs

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they all need to draw resources from each other and be responsive to their users in order to deliver health results, especially for hard to reach or vulnerable sub-groups like MARPs. As such, even the best thought-out service delivery system cannot operate independent of the other components of the health system. By analyzing a health system across the six building blocks, governments can get a better idea of gaps in health interventions, particularly as they pertain to MARPs. HSS interventions to reach these groups will likely result in higher demand and access to health services to improve overall health outcomes. The need to meet Millennium Development Goals targets for health, including HIV/AIDS, has brought “Universal Coverage” and “Health Systems Strengthening” to center stage. Increased attention to HSS has brought many health system specialists to program HIV/AIDS funds for HSS. While this move is timely, there is a tremendous need to orient and sensitize HSS experts and program managers to program interventions to address systems barriers to reach MARPs. With increased attention to health system strengthening (HSS), both in the context of the epidemic and in general, many health system specialists and donors are programming HIV/AIDS funds in this area. While these funding decisions are timely and desirable, there is a tremendous need to orient and sensitize HSS experts and program managers to program interventions that will actually strengthen systems to increase the access to and quality of services to reach MARPs, to learn from successful HSS and community strengthening system (CSS) methodologies, and to identify key service delivery areas where the linkages between HSS and CSS interventions need to be strengthened. As program managers start to apply guidance on universal coverage, there is a need to provide appropriate technical guidance on health system strengthening and community system strengthening to countries tackling MARPs in concentrated epidemics. Current approaches to health system strengthening (HSS) tend to focus on achieving normative standards for inputs and processes and focus on broad indicators of system performance. These efforts may place more emphasis on inputs, outputs and processes rather than outcomes and impact. For example, some country standards call for achieving a ratio of one doctor per 10,000 people or an investment of a certain percent of GDP in health. This focus on inputs (doctors/population, money), outputs (enhanced production of doctors, spending) and processes (improved pre-service and in-service training), if uniformly applied, frequently exceeds available resources and furthermore, the degree to which these inputs, outputs and processes contribute to goal attainment is most often unclear. Current HSS efforts are often vertical and focused on individual health system building blocks.4 Such a vertical focus may lead to well functioning system components (e.g., a well functioning supply chain or a robust health information system or a stronger workforce) but the combined functioning of the entire health system may, in fact, remain sub optimal. Optimizing individual sub systems may not optimize effectiveness of the system as a whole. Given resource constraints, input, output and process oriented HSS efforts focusing on optimizing individual sub systems are less likely to achieve HIV/ AIDS service delivery and health goals. A focus on “good enough” vs. “ideal” system components working together and “tuned” to a common goal is what

WHO’s “Everybody’s Business” defined six building blocks that define a health system: health workforce; health information; service delivery; health financing; leadership & governance; medical products, vaccines and technologies.

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will maximize the return on HIV investments and will facilitate a sharper focus on prevention as well as attaining the objective of putting more people on treatment.

1.3 Linkages between Community and Health Systems The WHO defines health systems as “all organizations, people and actions whose primary intent is to promote, restore or maintain health.”5 The WHO’s Building Blocks Framework identifies six building blocks that form the basis of a well-functioning health system: service delivery; health workforce; information; medical products, vaccines and technologies; financing; and leadership/governance. Health systems strengthening is defined by WHO as improving these six building blocks and managing the way they interact with each other to achieve more equitable and sustained improvements across health systems and health outcomes. The WHO’s definition of a health system and health system strengthening relates primarily to the development of national public health systems. However, health care is not exclusively the domain of organizations whose primary intent is to promote, restore or maintain health. Other key sectors of society are also involved. In the final report of the WHO’s Commission on Social Determinants of Health (2008), the Commission points out that “the high burden of illness responsible for appalling premature loss of life arises in large part because of the conditions in which people are born, grow, live, work, and age…Policies and programs must embrace all key sectors of society not just the health sector.” The WHO Health System framework does not make explicit the role of communities in supporting the delivery of health services and ensuring equitable access to these services for all who need them. It does not take into account the critical challenges of stigma and discrimination within health systems and communities, a key barrier to accessing health services, especially for MARPs. The critical role that communities play in providing health services in the absence of, or in partnership with, government services, as well as providing care and support to community members, has been increasingly recognized by key agencies supporting health systems strengthening, such as the Global Fund to Fight AIDS, TB and Malaria, UNAIDS, WHO, UNICEF, USAID, UNDP, and the World Bank as well as by developing country governments. As a result, the Global Fund, in collaboration with other stakeholders, developed the “Community Systems Strengthening Framework” (2010) which highlights six key elements that need to be in place for health and community systems to function well: 1. Preparing community-based organizations to contribute to national responses on HIV, tuberculosis & malaria 2. Building the organizational capacity of community organizations 3. Building human and technical capacity for community-based service delivery 4. Establishing and strengthening networks and partnerships 5. Establishing sustainable financing 6. Creating and maintaining an enabling environment There is no inherent conflict between a health care systems approach and a community health systems approach. Community organizations and networks have a unique ability to interact with affected communities, react quickly to community needs and issues and advocate for improved programming and policy environments. This enables them to build a community’s contribution to health and health systems strengthening, and to influence the development, reach, implementation and oversight of 5

WHO Framework for Action for Strengthening Health Systems 2007

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public systems and policies. Community systems strengthening is an integral component of HSS and should not be seen as a separate stand alone activity or system.

2. Methodology Three core principles guided the methodology used by the AIDSTAR-Two Project in conducting this assessment. First, health system strengthening efforts should be directed at health goal attainment as defined by the individual countries. Second, in the face of severe resource constraints, countries must make rational and hard choices about how their scarce resources should be allocated among competing investment options. Third, countries should focus their system strengthening efforts not only on improving the volume of inputs, outputs and processes, but by the manipulation of those variables which most directly affect health system performance. Goal oriented health system strengthening Health systems exist and function in order to achieve a country’s health goals. In that light, health systems strengthening should have three objectives: achieve desired health goals more quickly, achieve them more effectively and achieve them more efficiently. Framing health system strengthening actions in this light means that we must first understand the health goals, the problems that must be overcome to achieve these goals, and the system constraints to scaling up delivery of the most effective interventions to address those problems. In other words, we must start with the goal and work backward to identify constraints that must be overcome through health system strengthening for improved delivery of interventions addressing major health problems. A more traditional focus on inputs, outputs and processes may expand the health system’s capabilities but may not improve effectiveness, efficiencies or goal attainment. Making rational and hard choices – the 80/20 Rule Human and financial resources are severely constrained in Jamaica as in many countries. Jamaica’s National AIDS Strategy is only 30% funded, with few resources coming to Jamaica from the donor community. Jamaica has a national AIDS strategy with aggressive targets and one major challenge: how to allocate scarce resources to achieve the greatest reduction in HIV transmission. This includes identifying and then investing in the most critical health system interventions that would most rapidly achieve Jamaica’s health goals. Faced with this challenge, it is important that Jamaica focus on the vital few investments that will make the greatest possible impact on reducing HIV transmission. Thinking about investments must start with: identifying the most important causes of HIV transmission identifying the population groups in which HIV transmission is greatest identifying the most cost effective interventions identifying and overcoming the most important system bottlenecks to the scaled up delivery of those interventions.

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The methodology used in this assessment is guided by the “principle of the vital few” otherwise known as the 80/20 principle or the “Pareto Principle.” Based on the observations of Italian Vilfredo Pareto, this principle was first stated by Joseph M. Juran (1904-2008), an early quality improvement expert. The 80/20 principle means that in any situation, a few (20 percent) are vital and many (80 percent) are trivial. In Pareto's case, it meant 20 percent of the people owned 80 percent of the wealth. In Juran's initial work, he determined that 20 percent of the defects caused 80 percent of the problems. Project managers know that 20 percent of the work (the first 10 percent and the last 10 percent) consume 80 percent of your time and resources. It is possible to apply the 80/20 Rule to almost anything, from the science of management to the physical world. In the methodology for this assessment, we use this principle to identify the “vital few” problems, causes, population groups, interventions, health system constraints and health system strengthening interventions. By focusing on the “vital few,” it is not only possible to define a critical path to reducing HIV transmission in Jamaica – as well as in other countries for that matter – but it also provides a justification for making hard investment choices in the face of competing demands and declining inflows of external resources. For HIV prevention, the value of the Pareto Principle for country policy makers and managers is that it reminds them to focus on the 20 percent that matters most since that 20 percent produces 80 percent of the results. Focus HSS actions on variables influencing health system performance As noted previously, a health system strengthening approach with a focus on inputs, outputs and processes may expand the size and capacity of a health system but may not maximize health system performance as measured against a specific health outcome or goal. In other words, examining a health system as a series of inputs and outputs may provide a descriptive understanding of a health system but it does not explain how a system performs or how a system produces a set of outcomes. For this reason, the methodology used here considers the input based approach to describe the health system using the WHO’s six building blocks framework but bases the assessment’s health system strengthening recommendations on a framework developed at Harvard by W. Hsiao called the “control knob” framework.6 The control knob framework provides an analytic basis for looking at the performance of the health system as a whole, examining the major components and the relationships among them in a way that explains how they produce health outcomes. This causal model focuses on the variables that can be manipulated by policy makers and managers and which, when applied, can largely account for observed health outcomes. These policy control knobs are: financing and its organization, macro organization of service delivery, regulation, provider payment and its incentive structure, beliefs and preferences formation that influences consumer demand.

Hsiao, Inside the Black Box of Health Systems: What Are the Policy Control Knobs?

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2.1 The analytic methodology utilized: Causal pathway analysis Causal pathway analysis (see diagram at right) is an analytic approach which focuses on designing projects to achieve maximum attributable health outcome. Its application in project design maximizes the probability that projects and programs will achieve desired health outcomes, helps managers make appropriate choices among competing technical interventions, programmatic approaches, inputs, processes and outputs. It also helps managers focus on the most important health system strengthening efforts and identify the most appropriate indicators for monitoring progress.

Box 1. Causal Pathway Analysis By allowing the desired health goal to dictate system requirements…

System requirements and system bottlenecks

Evidence based interventions & coverage levels

Problems, causes, populations, places, times

Measurable health goal

…we can optimize health systems to reduce HIV transmission Right inputs & processes

More outputs through improve system performance

Higher coverage

Outcomes, impact achieved

This analysis will result in a defined causal pathway linking measurable health impact to key programmatic inputs. Developing this causal chain requires users to deconstruct their project, working “backward,” starting by defining a measurable health goal and prompting a critical thought process about the linkages between the causes of poor health, populations affected, effective interventions, and systems strengthening actions. Tracing the causal pathway to health impact requires a nine-step process as follows. Working through the analysis, assumptions are challenged and local data collected if it is available.

2.2 Nine Steps for Conducting a Causal Pathway Analysis 1. 2. 3. 4. 5.

6. 7. 8. 9.

Identify the health impact goal: reduce AIDS related deaths. Identify and quantify health problems to be overcome: Reduce HIV transmission. Identify and quantify direct and indirect causes and risk factors. Determine the characteristic of the populations that are most at-risk (time, place, geographic distribution, socioeconomic status and who have most of the problems). Identify the full range of cost effective evidence-based clinical and programmatic interventions and then identify the vital few health interventions, their current coverage levels and coverage levels required to achieve the goal. Determine health system requirements to achieve the needed coverage levels. Identify the few critical health systems bottlenecks to achieving required coverage levels. Identify critical health system strengthening Interventions that improve the functioning and integration of the six building blocks necessary and sufficient to improve coverage levels. Identify the most appropriate and key M&E indicators along the causal pathway that need to be monitored over time.

This methodology is outlined in more detail in Appendix II.

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The AIDSTAR-Two assessment team was comprised of a HSS expert from Management Sciences for Health and a MARPs/HIV/AIDS expert from the International HIV AIDS Alliance. Experienced local consultants were engaged in Jamaica to assist in the analysis and support was provided by the USG. The analysis was conducted during the period between September 2010 and January 2011, with two visits made to Jamaica during this time. Over 100 reports and assessments were analyzed and interviews and discussions held with key stakeholders in each country, including UN agencies, international development organizations, local HIV implementing organizations, MARPs groups and government agencies.

3. Country Analysis: Supporting Jamaica’s Most-at-Risk Populations through a Health System Strengthening Approach For a detailed analysis of the current national HIV policies, programs, and the epidemiology of HIV/AIDS in Jamaica, see Appendix I. Jamaica faces unique challenges in addressing HIV/AIDS. As it has evolved into a “middle income” country, its ability to attract donor funding for HIV/AIDS programs is diminishing. The current HIV/AIDS National Plan remains 63.7% unfunded in an environment where there are serious HIV epidemics in MARPs populations, and these vulnerable groups are not being served by interventions at a scale large enough to reverse the epidemic. It is important, therefore, for those working in the health sector in Jamaica to consider what the most cost effective interventions for the right MARP sub populations are, in order to have the greatest impact on the epidemic; as well as determine what the system requirements are, in order to deliver those interventions to those populations.

3.1 Overview of Jamaica’s HIV/AIDS Situation and Most-At-Risk Populations Background on Jamaica’s HIV/AIDS Situation One of the biggest health and developmental issues in the Caribbean is HIV/ AIDS, where there is a prevalence rate of approximately 1%. In Jamaica, the adult prevalence rate is higher, at 1.7%. Jamaica is the largest English speaking Caribbean island, with a population of 2,692,400.7 By World Bank standards, Jamaica is considered an upper middle income country (UMI). In 2006, it spent approximately 5% of its gross domestic product on healthcare. HIV stands to affect not only the health of the Jamaican people but also the country’s development as a result of reduced productivity and lost time due to the morbidity of the illness. In a declining global economy Jamaica has to identify cost effective means of mitigating the impact of HIV and AIDS. Epidemiology of HIV in Jamaica The adult prevalence rate for HIV/AIDS in Jamaica is 1.7%. There has been a slight increase from 1.5% over the past decade. This increase is due in part to the fact that more people are living longer with the illness due to greater access to anti-retrovirals (ARVs). Although the epidemic is generalized, it is also concentrated among some sub-populations. These include MSM at 31.8% prevalence and sex workers at 5% prevalence rate.8 Other vulnerable populations include crack cocaine users at 5% and incarcerated 7

Planning Institute of Jamaica 2009 It should be noted that the numbers given for sex workers do not include those involved in informal sex work (the intimate entertainment industry) and so the real number of those involved in sex work could be a lot higher. The 8

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persons at 3.3%.9 The number of new HIV cases has increased over the past 10 years from 1,436 in 1999 to 1,738 in 2009. This increase is due to several factors: new HIV infections, increased surveillance, increased access to HIV testing, increased awareness by health care workers, and increased awareness by the general population. Figure 1. Jamaica HIV Transmission by Category 1982-2009

Source: Harvey 2010

MSM prevalence is based on one study conducted in 2007 of just over 200 MSM and so may not be statistically significant/accurate. 9 UNAIDS 2009.

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Framework 2008-2012 (CRSF) and the NSP have strategic objectives under their priority areas which focus on MARPs. The President’s Emergency Fund for AIDS Relief (PEPFAR) also focuses on MARPs. PEPFAR started a new five year cycle in 2009 partnering with twelve Caribbean islands, including Jamaica. The goals and objectives of the PEPFAR II Framework are closely linked to the five priority areas of the Caribbean Strategic Framework 2008-2012 (CRSF). Under its partnership with Jamaica, the PEPFAR II general objective states that, “The primary, shared goal of PEPFAR ... is to support the Government of Jamaica’s efforts to reduce the transmission of HIV over the next five years, with a focus on most-at-risk populations (MARP) and other vulnerable populations.” Undoubtedly all strategic plans and partnerships are focused on the reduction of HIV transmission in the MARPs, as they have been recognized locally and globally to carry the burden of the illness. UNAIDS considers MARPs to be: sex workers (SW), clients of sex workers, people who inject drugs (PWIDs) and men who have sex with men (MSM). In Jamaica, however, MARPs are considered to be MSM and SW, crack cocaine users, prison inmates, STI clinic attendees and out of school youth. PWIDs are not considered MARPs in Jamaica as their number is extremely small. Table 1. MARP Groups as classified by UNAIDS and the NHP UNAIDS MARPs Sub-groups NHP MARPs Sub-groups MSM MSM SW SW Clients of Sex Workers Crack Cocaine Users PWID Prison inmates STI Clinic attendees Out of School Youth Source: UNAIDS, the NHP

The definition for sex workers is also narrow and only reflects self identified sex workers. It does not cover what is now termed in Jamaica “intimate entertainment workers.” These are women who work as masseuses, hostesses and other jobs of this type, and they do not self identify as sex workers. Similarly, clients of sex workers are not considered a MARP sub population in Jamaica. This is a significant oversight given the high rates of multiple sex partners and limited condom use of sex workers, their regular partners and their clients. Although the prevalence among crack cocaine users, especially those who are homeless, is approximately 5%,10 very little is documented about the population’s characteristics. Crack cocaine use in itself does not transmit HIV but it is a risk factor. There is not enough data available to determine what the route of transmission of HIV for crack users is. An inference can possibly be drawn that some of the HIV positive drug users may be SW and MSM or both. Similarly, while prevalence rates for prison inmates are high at 3.4%, this has been based on limited data that did not determine where transmission occurred – either before entering the prison system or while incarcerated. It is also difficult to determine the route of transmission, as this data was not collected. 10

National HIV/STI Programme 2010

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Therefore it is hard to draw any conclusions about what exactly is the important factor to address when designing prevention interventions for this population. In this report we will be focusing on the characteristics of two of the most at risk populations. These are MSMs, with 31.8% prevalence and SW (including intimate entertainment workers) with 5% prevalence. The rationale for this is that crack cocaine use, STI’s and incarceration are risk factors that increase sex workers and MSM’s vulnerability to HIV, and are not direct routes of transmission. An estimate of the size and prevalence for each MARP group is given in the table below: Table 2. MARPS Size and Prevalence Estimate Population Estimated Number Sex workers 7,000 – 18,000 MSM 9,000 – 27,000 Crack cocaine users 4,000 Prison inmates 5,000 STI clinic attendees 45,000 Out of school youth unknown

HIV Prevalence 5% 32% 5% 3.5% 3.4% unknown

Source: Harvey 2010

Men who have sex with men The population of MSM is estimated to be between 9,000 and 27,000.11 A 2007 survey of 201 MSM found that the HIV prevalence was 31.8%. Condom use among this population was fairly low and inconsistent. Approximately 30% reported always using condoms with regular partners within the last 3 months. This group, like the general population, has a fairly high number of multiple sex partners. Over a quarter of the MSM had two or more male partners in the four weeks prior to the survey. Thirty-three (33) % reported having sex with more than one female in the last 12 months.12 This statistic is also indicative of the intersecting of MSM and the general heterosexual population. MSM can also be categorized by their biological characteristics. That is to say an MSM who is a “bottom” or receiver is at greater risk of being HIV positive. The study estimated that 73.4 % of the men who were HIV positive were receivers as compared to 64.1% who were givers or “tops.” On the other hand, men who both give and receive had 57.8% prevalence. These results speak to the fact that receivers are more at risk from a biological and physiological standpoint A part of the MSM culture in Jamaica is the phenomenon of “gay for pay” men.13 These men only sleep with men for financial gain and are not gay but heterosexual. This MSM group is one which engages in sexual activity with women. Condom use with male partners by MSMs who have sex with females is higher than their male counterparts who don’t engage in sex with females. It should be noted though that this does not translate into condom use with the females.

Harvey 2010 National HIV/STI Programme 2008 13 Ibid 12

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Sex Workers It is estimated that there are 7,000-18,000 sex workers in Jamaica.14 The HIV prevalence within this group is approximately 5%. Sex work in this context is defined by persons who receive cash, in kind or food in exchange for sex. Further to this, sex workers can be put in categories of hidden or overt. Overt includes SW who work on the streets, while hidden includes those who work in bars, massage parlors and exotic clubs.15 The 2008 KAPB sex worker survey also revealed that condom use with regular partners was low among sex workers in both the below 25 age group and the over 25 age group. In the under 25 age group, the percentage condom use was 30.8%. In the over 25 age group, 27.7 % used a condom with their regular partners. However, there was virtually 100% condom use with new clients. This percentage decreased to about 90% with younger sex workers who were more likely not to use a condom with regular clients and main partners. This behavior puts the younger SW at risk, albeit the risk may be a little less than that of older sex workers considering other socio-economic factors such as education and not being street based. The issue of multiple sex partners is highlighted among this group. Not only do more than 70% of the SW have main partners, but at least 53% of these main partners have other partners. This is exacerbated by the fact that there is less than 40% condom use with main partners.16 Of the SWs interviewed, 48.5% were male sex workers. Approximately 25% of all SW twenty-five and under had both male and female sex clients.17 This indicates how the virus is transmitted in the general population. Transmission routes from MARPs to the non-MARP population There are two general directions of transmission from the MARP to the non-MARP population. One is from HIV+ MSM to identified MSM, then from identified MSM to general men (non- identified). The other is from FSW into the general population of men and from men to their other sexual partners. Men, in particular older men with multiple sex partners and those who visit FSW, are the source of infection in young women who are engaged in nontraditional sex work (they don’t identify as sex workers but are offering sex in exchange for cash or in kind). The issue for FSW is that many of them have a regular (non client) partner with whom they are less likely to use a condom. These men also have other (regular) partners that don’t use condoms. Street based workers are already being reached by programs. However, the SWs who are not being reached are the massage workers/informal sex workers, who in Jamaica are known as “intimate entertainment workers.” In other words, informal sex workers drive new cases in non-MARPS populations. In terms of total volume of cases and the risk of spreading HIV outside the MARPs community, it is the relationship between identified/non identified MSM and the relationship between SWs, their primary partner and their clients that will drive future cases. Figure 2, below, shows an illustration of the routes of transmission between MARPs and non-MARPs.

Harvey 2010 Weir 2009 16 Weir 2009 17 Ibid 15

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Figure 2. Routes of transmission and risk factors

3.2 Evidence-Based Prevention Interventions When epidemiologic data is analyzed, several gaps in the programmatic interventions are observed. There is a gap in the collection of information in the Jamaican HIV/AIDS epidemic, thus there is limited information on evidence based interventions. However, to offset this, recently evidence from other countries is being used in HIV interventions, especially those targeted at MARPs. Global approaches In Jamaica HIV transmission for both SWs and MSMs is directly linked to multiple sex partners and inconsistent or no condom use. Indirectly, however, socio-economic and psychosocial issues, such as poverty, lack of education and drug use also impact on transmission. This means that a holistic approach to prevention that addresses both direct and indirect causes of the epidemic need to be implemented. The challenge in a holistic approach is to determine which of the suite of interventions is most cost effective and has the most impact to better direct resources, while realizing that often it is the combination of interventions that ultimately leads to greatest impact. Holistic prevention intervention programs have been implemented in several parts of the world including India18 and Eastern Europe and Central Asia.19 This encompassing or empowerment approach has several facets. It includes various methods to assist the sex worker and the MSM. 18 19

Maria Laga 2010 UNAIDS 2006

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In the case of the SW, the program has components such as outreach, peer education, and increased access to SW-friendly medically services. It also includes the strengthening of community organizations to assist in the empowerment and the needs of sex workers. From this holistic approach, the Ukraine saw in an increase in HIV knowledge and safer sex practices among sex workers from 40% in 2001 to 80% in 2003. The project staff also reported that there was a decrease in anal and vaginal intercourse, intimating that sex workers had reduced their risky sexual behaviors. The success of such programs is dependent on the trust built between HIV workers and the SW community. The project in the Ukraine also facilitated the increase of medical uptake as previously sex workers had not been willing to access health services. Similar programs have been conducted in Calcutta, India. The results of this program saw a drop in syphilis from 25% in 1992 to 8.76% in 2001. HIV rates were also reduced from 11.7% to 4.6%. The prevention unit of the NHP has started to implement similar programs in Jamaica based on the programs in India. However, no evaluations have been done yet on these programs. The NHP expects that a similar program in Jamaica will address the issues and the risks surrounding SW HIV transmission from a holistic perspective.20 There is documentation from Bolivia, Cote D’Ivoire and the Dominican Republic which indicates that targeted interventions for SW resulted in a decline in the prevalence rate amongst the group. The interventions also included risk-reduction messages, as well as creating an enabling environment.21 A similar holistic approach is necessary to reach MSM. In the case of MSM, the important thing is not only to access condoms but also lubricants. The use of social networks of MSMs to provide peer support to increase condom use has been seen to work both in the Black American and Latino communities in the USA22 and in MSM community in Bulgaria.23 This method involves the empowerment of key leaders in the various MSM networks and communities to provide the necessary HIV information. In the case of the Black American and Latino groups community leaders were chosen by the groups. The NHP has started to implement a men’s health program aimed to empower MSM thus increasing HIV and STI knowledge and condom use. As with the program for SW this program is in its preliminary stages and no evaluation has been done as yet. Of note is that these holistic approaches are expensive to implement as they take both time and money to be successful.24 Measuring impact Over the years in Jamaica, there has been little measurement of the impact of their HIV programs There are however evaluations on a programmatic level both by NHP and NGOs. Elsewhere, very few countries have looked at the effectiveness of HIV programs either in the government or non-government sectors. However, one country which has measured its program effectiveness to a point is Thailand.25 However,

National HIV Programme 2009 Maria Laga 2010 22 Carlos 2010 23 Amirkhanian 2003 24 UNAIDS 2006 25 Celentano et al 1998 21

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targeted population interventions for MARPs have not been measured.26 It should be noted that when speaking of effectiveness, the true intention is determining the impact on HIV mortality, morbidity and incidence.27 Jamaica has undertaken knowledge, behavior, attitude and practices studies in the past. However none of them have been SW or MSM specific. What is known, though, is that SW use condoms over 90% of the time with non-regular paying clients, thus the prevalence within this group seems to have decreased from 9% in 2005 to 5% in 2008. Nonetheless, this information was garnered from studies which may not be truly representative of the SW community in Jamaica. Cost effectiveness Thirty years into the epidemic there are still 33 million people globally living with HIV. In a shrinking global economy it is imperative to spend funds on the most cost effective HIV interventions. In Jamaica approximately 70% of the 2007-2012 NSP for HIV is unfunded, thus meaning more novel and costeffective interventions need to be implemented to reduce HIV transmission and incidence. The figure below lists interventions according to how effective they are on a population basis as well as how costly they are. The most effective, least costly interventions are peer education, male and female condoms, VCT with STI, and blood screening. Condom social marketing, although more costly than other interventions, is also highly effective. Figure 3. Cost effectiveness of interventions

Condom social marketing STI control Male circumcision Mass community Rx for STI HIV treatment as prevention

Peer education for SW & MSM Male condoms Female condoms VCT with STI and condoms Screening blood products

Social marketing on TV & radio Soap operas Mass media campaigns School based sex education Oversight of private sector providers

Microfinance PMTCT Community based education for low income women Abstinence campaign Be faithful campaign Family planning Disinfecting medical equipment Disposal of biohazards

Low cost

High cost

Effective on population basis

Less effective on population basis

26 27

Pattanapheaj and Teerwattananon 2010 Pattanapheaj and Teerwattananon 2010

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Cost effective interventions Consistent condom use is not only effective in reducing HIV transmission and incidence but is also costeffective. This has been consistently identified in both MSM and SW programs worldwide. In the Dominican Republic, where a 100% condom policy for brothels was implemented, there was reduction in STI and HIV prevalence. In Thailand, where the 100% condom policy was also enforced, it led to an 80% reduction in the five leading STIs28 and a tenfold decrease in incidence in new military recruits.29 The Thai policy was for the general population and no data is available specifically for MSM or SW. The literature indicates that when male condoms are used correctly and consistently, they are 80-95% effective in reducing the risk of HIV infection. Further to that, the use of the female condoms is also being promoted especially for SW as this gives the FSW more control over her sexual encounter. Additionally, clinical trials of female condoms reduce the risk of HIV transmission by 94-97% when used consistently and correctly and are able to protect one against microbes which are even smaller than those which transmit STIs.30 Figure 4. Graph comparing rates of infection if prevention method is used perfectly as opposed to typically

Source: Coates, Richter and Caceres 2008

Effectiveness of programs is also seen when there is a combination of a range of interventions plus different depths of. This is called multi-level and combination interventions respectively.31 Multi-level interventions speak to targeting several levels in a community. For example, peer education can be done amongst the individual groups such as MSM as well as in the community such as at the health centre or through street side interventions. Combination interventions include the promotion of several types of HIV activities. For example, if peer education is used as an intervention, the message would not only include 100% condom use but it would also include the uptake of VCT services, the uptake of STI services and where necessary the uptake and use of ARV. 28

Shahmanesh et al. 2008 Celentano et al. 1998 30 Blumenthal 2005 31 Coates, Richter and Caceres 2008 29

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Table 3. A multilevel approach to behavioral strategies for HIV prevention with HIV counselling and testing as an example Examples Applied to HIV counseling and testing Individual Education; drug-related or HIV testing and counseling for individuals sexual risk reduction counseling; skills building; prevention case management Couple Couples counseling HIV counseling and testing for couples Family Family-based counseling Home-based family HIV counseling and programs testing Peer group/network Peer education; diffusion of Voluntary counseling and testing for all innovation; network-based network members strategies Institution (e.g., Institution-based programs Services for voluntary counseling and testing school, workplace, available within workplaces and other prisons) institutional settings Community Mass media; social marketing; Community-based voluntary counseling and community mobilization testing (e.g., Project Accept) mobilization and media to promote HIV counseling and testing Source: Coates, Richter and Caceres 2008

Proposed sub-populations and interventions for Jamaica Target MARP groups In order to better target interventions it is important to determine how easy it is to reach the groups most at risk of infecting others with HIV or being infected by others. Figure 5, on the following page, shows the different risk levels of MARPs and how easy or difficult they are to reach. Undisclosed or homeless MSM, FSW and their partners are among those most at risk, but hardest to reach.

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Figure 5. Risk of being infected vs. reach

Undisclosed MSM Spouses of undisclosed/untreated PLHIV Spouses of MSM Regular partners of F/MSW Homeless MSM /FSW Undisclosed informal sex workers (“intimate entertainment workers”) Beach/rasta boys having sex with female tourists (Homeless) Substance users

Venue based SW Open gay/MSM STD patients seeking treatment in facilities

Clients of substance using SW

Spouses of treated PLHIV

Easy to reach

Difficult to reach

High risk

Lower risk

Figure 6, on the following page, shows the risk of different groups to infect others. Positive MSM and SW, regardless of whether or not they know their status, informal sex workers and their partners, and substance using MSM and SW, are those most at risk of infecting others with HIV, while being the most difficult to reach.

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Figure 6. Risk of infecting others vs. reach

Positive MSM Undisclosed gay Positive SW PLHIV who donâ&#x20AC;&#x2122;t know status Undisclosed/untreated PLHIV Substance using SW, MSM Informal sex workers Regular partners of informal sex workers

Street/venue based SW Open gay/MSM STD patients seek treatment in clinics

Spouses of MSM Clients of SW

- Spouses of treated PLHIV

Easy to reach

Difficult to reach

High risk

Lower risk

Proposed interventions The key to any new program is to break transmission by strategically focusing different cost effective (CE) interventions along the causal pathway, as illustrated in the figures on the following page for FSW and MSM. For FSW, interventions include expanded use of condoms (100% condom campaign) and STI Rx for CSW and clients of sex workers.

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Figure 7. Interventions along the causal pathway for female sex workers (FSWs)

For MSM proposed interventions include expanded VCT services, a 100% condom campaign and STI Rx. Figure 8. Interventions along the causal pathway for men who have sex with men (MSM)

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Recommended Interventions and Sub Populations Given what is known and based on the evidence presented in the preceding sections of this report, the greatest impact on the epidemic in Jamaica will be had by focusing on the following sub populations and interventions: Younger less educated (possibly homeless) MSM who are the receptive partners in what could be termed transactional sex in the areas of Kingston, Montego Bay and Ochos Rios, focusing on consistent condom use for anal sex through condom promotion and marketing and peer support. Younger women engaging in non formal sex work (and using drugs) and their partners in the parishes of Kingston, St. Catherine, St. Ann and St. James, focusing on consistent condom use via condom marketing and peer support. These populations and interventions will be the focus of analyzing the system bottlenecks and constraints in the following sections of this report.

3.3 System requirements As noted above it is recommended that a focus on younger less educated (possibly homeless) MSM who engage in transactional sex in areas of Kingston, Montego Bay and Ochos Rios is important. It is also recommended to focus on younger women who are engaged in non formal sex work (and who use drugs) and their partners in the parishes of Kingston, St. Catherine, St Ann and St James. Direct (proximal) technical interventions for both groups include 100% condom use and, in the case of MSMs, lubricants. In addition, to reduce risk of HIV transmission, aggressive STI detection and treatment in these population groups is recommended. Along the causal pathway, there are other recommended interventions which have an indirect effect on demand for these interventions and the health systemâ&#x20AC;&#x2122;s ability to finance and deliver them to these population groups at the right times and places. Increasing coverage of these interventions to these target populations at the right times and places will require a health system strengthening approach which addresses multiple health system bottlenecks with cross-building blocks, integrated health systems strengthening actions. A summary of interventions and systems requirements can be found in table 4 below.

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Table 4: Interventions and system requirements for MSM and young female non-identifying sex workers (including those engaged in transactional sex) Intervention System System requirement building block 100% condom campaign (with lubricants for MSMS)

Information

Governance / Leadership

Delivery

Human resources

Medical products, vaccines and technologies, Financing

Data on current coverage levels for our specific target populations in our specific targeted geographic areas. Improved ability to monitor changes in coverage of condoms and lubricant during unsafe sex (and other chosen interventions) in our target populations. Data on incidence of HIV transmission in our target populations and different geographic locations. Improved documentation on routes of HIV transmission to assist in targeting interventions. Better understanding of reasons for inconsistent condom use by or target populations particularly on use of condoms with regular partners. Data on stock outs, prices and demand for condoms by our target populations in private pharmacies, government distribution sites and with NGOs, CBOs and other distribution points frequented by our target populations in priority geographies. Policies on free and subsidized condoms. Policy on engagement of private sector pharmacies, NGOs, CBOs and Public MSM friendly sites. Low cost or no cost condoms in areas where MSM and SW gather in our target locations. Increased number of non-traditional condom vending sites in areas where young female and MSM populations gather. Low cost condoms placed in accessible areas in pharmacies Cheap lubricants, perhaps married to condoms, in pharmacies Improved access to information on condoms and lubricants, prices, distribution points to improve demand. Adequate number of trained providers, including peer educators, with access to our target populations. knowledgeable of MSM and CSW and cadre of trained peer educators Engagement of workers in BGOs, CBOs and public sector providers. Access to trained providers in targeted geographic areas (e.g., urban centers) No stock out of condoms and lubricants in our target sites Improved procurement practices for better forecasting, bulk procurement for reduced prices and enhanced distribution to priority outlets. Improved monitoring of stock outs. In places where sex occurs. Subsidized condoms in pharmacies. Free condoms in public facilities. Full cost of purchasing and delivering condoms in MOHâ&#x20AC;&#x2122;s budget. Subsidies for condoms provided by specific private sector pharmacies and outlets to increase access. Improved public expenditure management to make sure there are no consistent overspending of budget and reduced leakage of resources to less high risk populations, geographic areas and less effective interventions.

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STI detection and treatment and VCT

Information

Improved detection of STI’s with a focus on identified high risk populations.

Governance / leadership

Policy allowing for free or subsidized testing in appropriate public and private facilities, including allowance for free kits for private providers. Regulations governing the pricing of STI and HIV testing and treatment. Policy on confidentiality. Policy on mandatory testing for HIV and STI in prisons and detention facilities Improved access to STI clinics (both public and private) for targeted populations. Testing and treatment approaches that are confidential and do not expose targeted populations to stigma and/or discrimination. (user friendly clinics) Potential use of mobile clinics. Adequate trained staff

Delivery

Human resources Medicine, supplies, logistics Financing

Adequate supply of testing kits distributed within each access to targeted populations through both public and private providers. Subsidized testing in private clinics and free testing in public facilities. Subsidized testing kits. Funding, e.g., per diem, for workers who carry out mobile testing (if appropriate)

3.4 Systems Bottlenecks and required health system strengthening actions The previous sections identified high risk target populations, geographic areas and interventions that if delivered at high coverage levels would significantly reduce HIV transmission, as well as the system requirements for scaled up delivery of these interventions to these target populations. In this section, the focus is on the system bottlenecks to scaling up delivery and the health system strengthening actions that are needed to overcome those bottlenecks. Information Here is what is not known but is very important to know: Incidence of transmission in our specific target populations in target geographies Use of condoms (coverage) by these groups in our target geographies Access these populations have to condoms What they know and don’t know about their risk and why they do or don’t use condoms, or get tested or when they listen to mass media and if they’ve heard condom social marketing messages and if they did, what behavior changed if any. We don’t know if they prefer special kinds of condoms or not We don’t know what other kinds of media they listen to or use (e.g., internet?) There is an information gap in the general HIV epidemic but also as it relates to MSM and to young females engaging in non-traditional sex work and their partners. This lack of information of the target audience makes it difficult to implement HIV activities which are geared to them because some of their

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behaviors and characteristics are not known. Over the last few years, more information has been collected on MSM however the specific characteristics of the sub-populations are limited. This could possibly affect the effective implementation of programs targeting sub-groups. With respect to young females engaging in non-traditional sex work it is difficult to identify these persons as they do not identify as sex workers and are not found at regular sites such as clubs and restaurants. In addition, they are not covered by the definition of sex work meaning that there are no means to identify informal sex workers in data collection and therefore provide specific programs for them. The information gap will affect human resources and the service providers needed to implement interventions, as it will be difficult to calculate the target numbers and sometimes the exact whereabouts of these groups, thus making the system unable to determine how many workers are needed. The lack of information will also affect the implementation of condom social marketing. It should be noted that work has been done by NHP and NGOs and CBOs with respect to MSM and out of school young females. It is therefore imperative that before any work or intervention is implemented, any relevant data from these organizations is gathered and analyzed to ascertain the real system gaps. Governance and leadership The ICASO 2009 report also highlights the stigma and discrimination faced by sex workers and MSM in public health facilities by health care workers.32 This stigma is fuelled by the Offences against the Persons Act which makes illegal both anal intercourse between persons and the selling of sex. In addition, because of stigma and discrimination, there are several MSM who are â&#x20AC;&#x2DC;down lowâ&#x20AC;&#x2122; (not open about their MSM behavior) therefore making it difficult to reach these men. These laws need to be amended but in lieu of that, sensitization of healthcare workers along with law enforcement personnel needs to take place to allow for non punitive actions for these sub-groups so that they are able to access healthcare. Under the Child Care and Protection Act, health care providers are required by law to report any health services rendered to children under the age of 16 to their parents. This includes testing for HIV and distributing condoms. This is significant, as the interventions recommended here target young females who are involved in non-traditional sex work, especially as females between the ages of 15-24 have a higher prevalence than their male counterparts; a prevalence that is higher than other age groups. Here policies or systems which will assist 15-16 year olds to access health care need to be put in place. Financing There are several obstacles in terms of financing, as it relates to effecting 100% condom use. These include economic, socio-cultural, and structural. In terms of economic reasons, many at-risk MSM who may possibly be participating in sex work are of the lower economic class. This is also true for young females who participate in transactional sex but do not identify as sex workers. The costs of condoms may become prohibitive for some of these persons. In 2008, a group of HIV positive persons were surveyed and they noted that many of them did not have a source of income and so buying condoms was not a priority.33 To counter this, partnerships need to be formed with the private sector, community organizations and the NHP to distribute condoms at low or no cost, especially in the areas of St. James, Kingston and Ocho Rios, which would make them more affordable for the target population.

32 33

ICASO 2009 Ibid

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As the National HIV Strategic Plan is underfunded, it will be difficult to adequately allocate funds to the interventions proposed here. It is against this backdrop that the abovementioned interventions are being recommended. They are not only cost effective but should be able to intercept or curb the HIV transmission in Jamaica. Delivery The interventions are condom use, condom marketing and peer support (education). Delivery bottlenecks include: Poor access to condoms when needed (night, weekends, city parks, etc) Financial barriers to demand for condoms (condoms that cost too much) Lack of focused peer counseling No access to female condoms or too high priced Current marketing campaigns may not reach target groups Effectiveness of current marketing campaigns is unknown Difficulty reaching MARPs for access to condoms and peer education Effectiveness of different types of peer counselors in reaching MARP groups is unknown There are several ongoing programs in Jamaica that target MSM and SW as well as the general population. However, there is still a need to improve the services geared towards MSM and SW as it relates to HIV and AIDS. Currently the NHP has approximately 35 sub-recipients under its Global Fund grant. Of this 35 only 7 % have programs with MSM and 4% with SWs. The majority of organizations have programs with youth.34 Some of the organizations which work with MSMs and SWs include Jamaica AIDS Support, the Jamaica Red Cross and Pride in Action. The NHP also has a program geared towards SW and MSM. These organizations, along with the NHP, have programs throughout the high prevalence areas of Jamaica such as Kingston, Montego Bay and Ocho Rios. These programs include peer education and condom access. However there needs to be an increase in service providers who are friendly to MSM and young females. Cultural factors affecting delivery A cultural bottleneck which affects demand for condoms is gender inequality. Many young females who enter into relationships with males for economic gain do not have power in these relationships. Condoms, especially the male condom, are not used when the man does not wish to use it. In order to overcome this issue, female condom accessibility and affordability needs to be assessed. Currently only NGOs involved in HIV programs and the public clinics distribute female condoms for free.35 Human resources There needs to be a cadre of peer educators who will be sufficiently trained to give risk reduction counseling and pass along HIV prevention messages. The number of necessary peer educators would be ascertained from knowing the numbers of persons in the target groups of MSM and SW. Therefore a comprehensive data and information collection and management system will have to be in existence. Additionally there will have to be adequate public and private service providers who are MARPs friendly, as relying on the traditional health workforce may not be an effective strategy. 34 35

National HIV/STI Programme 2010 ICASO 2009

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Medical products, vaccines and technologies, Access to the appropriate commodities (condoms, lubricants) is not always available where they are needed by our target populations. These commodities are available on a “pull” basis where supply and use is dependent on demand. There is no “push” system that makes sure condoms and lubricants are always available where and when needed. Bottlenecks: Condoms are not in adequate supply when and where needed Frequent stock outs Access through pharmacies is at a high price There are condoms but no lubricants Condoms are free in government facilities but no lubricants or there is discrimination or government facilities are closed when condoms are needed Table 5: Summary of health system bottlenecks and recommended health system strengthening actions. Health Systems

Bottlenecks

Results

Governance/ leadership

Offenses against the Persons Act makes anal intercourse and the selling of sex illegal. This leads to stigma and discrimination which reduced demand and coverage. No 100 % Condom legislation or policy It is against the law to provide RH services to children under the age of 16 Subsidizing condoms and lubricants through private sector outlets. No pricing policy allowing for distribution of free condoms and lubricants.

Prevents MSM and SW and other at risk persons to access health care as in there is a fear in being caught. Can also affect condom accessibility. Makes it difficult to provide services to children who are having high risk sex including selling sex and transactional sex.

Delivery

NGOs and CBOs have been delivering condoms and other interventions but the scope, quality and effectiveness of this work is unclear. Stigma and discrimination of services in public health services reduces demand and lowers coverage of interventions.

Persons not being adequately treated for STI as waiting lines are too long, public and private sector burdened

System Strengthening Needed The Offenses against the Persons Act needs to be amended to reduce stigma and discrimination. Government Policy /Legislation supporting interventions for MARPs Cooperation with law enforcement Reducing stigma and discrimination among healthcare workers by providing training and sensitization Amend laws which would allow for the provision of reproductive health services to girls and boys who are sexually active. Increased numbers of MSM and young female friendly services/access sites Expand the number of service providers focusing on delivering condoms and lubricants to our target populations and geographic areas.

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Health Systems

Bottlenecks

Results

Few private organizations deliver MSM/SW services Of the 35 recipients of the current global fund grant 7% have programs with MSM and 4% with SW. In spite of the existence of several organizations focusing on MSM and SWs, more service providers are needed to achieve needed high coverage in our target geographic areas and populations.

Human Resources

Not enough adequately trained peers/service providers and educators Low literacy among specific target group making difficult to train peers. The health workforce discriminates against MSM and sex workers.

Prevention intervention will not be implemented correctly, effectively and with efficacy.

Information

Lack of data (incidence, prevalence, demand, coverage of interventions) on specific high risk sub populations of MSM and young females in non-traditional sex work and their partners. No information on females engaged in non-traditional sex work not on the locations where they practice unsafe sex. Lack of knowledge on the incidence of STIs, the use of condoms and the behaviors that affect HIV transmission.

Will not have proper program design for prevention to be effective.

Medical supplies, vaccines and

Limited access to male and female condoms in some parishes.

100% condom policy can fail.

System Strengthening Needed Evaluate and if necessary improve the quality and scope of existing providers. Work with NGO, CBO, private sector and government workers to improve attitudes and behaviors towards MSM and SWs. Expand the number of providers obtaining funding from the global fund if government resources are not available. Expand the number of programs that include peer education along with the provision of interventions. Low literacy programs and materials to train peer educators/ supporters with relevant skills needed. Health workers and law enforcement officers need to be sensitized and monitored so as to reduce stigma and discrimination. Conduct surveys and baseline interviews before intervention. Review of any previously collected information on target groups

Partnerships with condom distributors to reduce costs of condoms.

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Health Systems technologies

Finance

Demand

Bottlenecks Costly condoms, especially female condoms. Culture of not using condoms Weak supply and distribution system for the subsidized delivery of condoms and lubricants to our target populations at the right times and places. Underfunded HIV Strategic Plan Lack of quantifying how much health system spends on HIV Poor targeting of interventions. Condoms and lubricants priced too high. Condoms sold at higher prices in private clinics and pharmacies. Donor funding is likely to decline in the near future which puts further pressure on the government to more effectively use available resources.

Cultural factors negatively influence demand for key interventions. Inequality, which affects a womanâ&#x20AC;&#x2122;s ability to negotiate with men and reduces her economic choices, pushes young girls into risky sexual relationships with older men.

Results

System Strengthening Needed Partnerships to distribute condoms more widely Assure a supply chain that goes out to venues where our target populations have high risk sex and make sure that there are no stock outs.

Not enough resources allocated to effectively implement intervention program Loss of effectiveness as interventions are not targeted to highest risk groups. Interventions priced beyond the ability of target populations to afford them thereby reducing demand Unanticipated declines in donor resources will further reduce the ability of this program to address the HIV epidemic in Jamaica.

Reduces access to and use of known effective interventions.

Spend funds and focus on few interventions. Allow subsidies for condoms and lubricants allowing them to be provided free of charge or within target populationsâ&#x20AC;&#x2122; ability to pay. Improve the allocation of available resources to adequately fund programs for MSM and SWs and giving priority to high risk geographic areas. Develop a strategy to address the looming financial crisis in HIV funding. This strategy should include not only how to raise additional domestic resources but also how to target the use of available resources more effectively. Develop programs that will eventually change these cultural practices.

Bottlenecks in the system will limit or block interventions which have efficacy. A 100% condom policy and condom marketing and peer support program for receptive partner MSM and young females engaging in non-traditional sex work will be highly dependent on redirecting funds to this intervention. This includes increased accessibility to and affordability of condoms (male and female), the appropriate training of adequate numbers of peer supporters and the increase in community and public health

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facilities which are friendly to the target groups. If this does not happen there will be little improvement in the health systems to impact the mitigation of the HIV transmission.

Summary Guidance 1. Recommendations on methodology Issue: Not all country programs are designed with a thorough understanding of the epidemiology, characteristics of the at risk populations, knowledge of the risk factors driving HIV transmission or the effectiveness of interventions but rather are designed on accepted best practice. Health system strengthening actions are not driven by an understanding of specific health system requirements or specific health system bottlenecks impeding delivery of the most effective combination of evidence based interventions. Recommendation: Much greater rigor and specific attention to epidemiological detail would allow a more finely tuned response to the epidemic. This will take time and energy and a specific focus placed on including more emphasis on research and data in program design and implementation. Issue: Interventions are addressing risk factors which are on different places on the causal pathway to transmission. Some interventions address indirect risk factors while most address direct risk factors. Some are systems focused while others are focused on indirect risk factors. In most cases it is unclear where the most important points of intervention might be along that causal chain. Recommendation: Using the causal pathway analysis approach allows planners to understand what risk factors they are targeting, which specific points in the transmission pathway would disrupt transmission the greatest, and what level of impact you could expect to have. Issue: Current health system assessment approaches, using normative standards and high level analysis are inadequately precise to identify the very specific health system bottlenecks that need to be addressed to scale up a very specific set of evidence based interventions targeting very specific population groups. Recommendation: While current health system analysis approaches offer good input into broad health system strengthening needs at a national level, a much more specific, detailed and analytic approach to health system analysis which is focused on identifying specific system bottlenecks for specific interventions targeted at the needs of specific populations is required to scale up evidence based interventions.

2. Recommendations on the availability and use of evidence Issue: The evidence base on incidence of HIV transmission, understanding HIV transmission-related risk factors in high risk sub populations, effectiveness of technical and programmatic interventions and effectiveness of health system strengthening actions at overcoming specific system bottlenecks is limited.

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Recommendation: Operations research is needed to define the effectiveness of approaches that need to be developed addressing country-specific issues. The lack of evidence across the board is one of the most formidable obstacles to selecting and implementing the most cost effective approaches to reducing HIV transmission. Issue: Those planning and implementing programs need access to and knowledge about what evidence is available to them to tailor their response. Evidence, although limited, does exist. The challenge is to make it accessible to policy makers, planners and implementers. The second challenge is to ensure these people have the capacity and skills to use that evidence to design their programs. Recommendation: Existing evidence needs to be synthesized and made much more readily accessible to those that need it. Support needs to be provided to policy makers, planners and implementers to apply existing evidence in the design of tailored approaches which address the specific needs of individual countries.

3. Recommendation on gender issues Issue: Universally, women are unable to afford or access preventive and curative interventions. They are also unable to negotiate with their male partners when it comes to use of effective interventions, such as condoms, and they are bound by social and cultural factors that make them susceptible to HIV infection. Finally, data are not disaggregated adequately in health information systems to fully understand the supply and demand for effective interventions by women. Recommendation: Specifically, it is important to understand more about the risks to women, the factors that influence that risk, the systems response to those risks in women and the uptake of interventions which address those risks. In addition, more effort needs to be made to create information systems which provide disaggregated data on health system performance related to the delivery and uptake of effective interventions. This may require sociological, anthropological analysis to understand some of these issues and how to address them.

4. Recommendation on legal and regulatory issues and private sector engagement Issue: A few specific legal and regulatory issues are system bottlenecks that need to be addressed. These are indirect risk factors that influence the behavior of specific MARPS populations (e.g., MSM) but also the financing, delivery and update of these interventions. This includes the effective engagement of the private sector in an appropriate HIV response. Recommendation: A specific focus is needed to understand which legal and regulatory issues are health system bottlenecks constraining a countryâ&#x20AC;&#x2122;s response on both the supply and demand side, in both the government and private/NGO sector. The legal and regulatory constraints will be different depending on the individual country, so a normative approach wonâ&#x20AC;&#x2122;t work. An understanding of the potential for private sector engagement and the legal and regulatory and systems issues that impede this engagement is needed.

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5. Recommendation on financing Issue: Significant attention has been paid to how vertical, well-funded HIV programs can affect the performance of the health system to address other issues. Less attention has been paid to what is financed, the role of municipalities, provinces and national governments in financing the response and how resources flow in the system. These are critical issues related to sustainability particularly in countries which have been dependent on high levels of donor funding. A significant issue, however, is that data on donor, government, out of pocket spending is not readily available and the effectiveness of the allocation, management and use of resources is limited. As a result of these shortcomings it was not possible to address this in the analysis. Recommendation: More attention needs to be placed on the current and future trends in the use of resources, the mix of donor, public, private and out of pocket spending, and the management of financial resources. More attention needs to be paid to the transition from USAID/PEPFAR funding to funding from domestic resources and the effect of that transmission on the scale up of effective approaches targeting specific populations, risk factors and interventions.

6. Recommendation on demand issues Issue: Significant attention has been paid to the supply side of the response but very little focus has been paid to the issues that affect the demand for evidence based interventions and approaches. Poor coverage is the result of both supply and demand side constraints and scaled up delivery requires both a supply and demand side strategy. Recommendation: More attention needs to be paid to factors that affect the demand for effective interventions by specific high risk populations. Effective programmatic strategies need to address both supply and demand issues and building the evidence base on how to influence demand is greatly needed.

7. Recommendation on scaling up what works Issue: There are a number of technical and programmatic interventions that are being implemented and the selection of many of these interventions and approaches is made without fully considering the evidence base that exists. Recommendation: There are many technical interventions whose efficacy and effectiveness is known, such as the effectiveness of male condoms in reducing HIV infections. The current evidence base on effectiveness of technical and programmatic interventions needs to be more widely disseminated and that evidence base is used to determine the most effective combination of interventions.

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Bibliography Anderson, Dr. Moji. Notes, Culturally Sensitive HIV Interventions for Men who Have sex with men, Prepared for the Director of Monitoring and Evalutation Unit and the Director of Prevention. Kingston: National HIV/STI Programme, 2010. Bethseda, MD. Health Systems Report:Jamaica. Health Systems 20/20 Project, Abt Associates Inc, 2010. Harvey, Dr. Kevin. "Epidemiology of HIV in Jamaica 2010." 2010. Hope Enterprises. "2008 HIV/AIDS Knowledge Attitudes and Behaviour Survey." Findings from HIV/AIDS Knowledge Attitudes and Behaviour Survey, Jamaica, 2008. "Jamaica National HIV/STI Programme Monitoring and Evaluation System 2007-2012, ." Monitoring and Evaluation Plan . 2007. Juli-Ann Carlos, Trista A. Bingham, Ann Stueve, Jennifer Lauby, George Ayala, GregorioA. Millet, Darrell Wheeler. "The Role of Peer Support on Condom Use among Black and Latino MSM in Three Urban Areas." Atypon, October 2010: 430-444. Maria Laga, Christine Galavotti, sundar Sundarama et al. "The importance of sex workers interventions the case of Avahan in India." Sexual Transmitted Infections, 2010: i6-i7. Ministry of Health. "Ministry of Health Strategic Plan 2006-2010." Strategic Plan. Ministry of Health, 2006. National HIV Programme. "CSW BCC Strategy." 2009. National HIV/STI Programme. "National HIV/STI Programme Annual Report 2009." Annual, Kingston, 2010. —. "National Strategic Plan 2007- 2012." 2007. —. "Power Point Presentatio on Men's Health." Kingston, 2008. Planning Institute of Jamaica. Economic and Social Survey 2008. Annual, Kingston: Planning Institute of Jamaica, 2009. —. "Vision 2030, Jamaica National Development Plan, Planning for a Secure and Prosperous Future, Popular Version." Vision 2030, National Development Plan, Popular Version. Kingston: Planning Institute of Jamaica, 2010. UNAIDS. HIV and Sexually tansmitted infection prevention among sex workers in Eastern Europe, UNAIDS Best Practice Series. Geneva, 2006. Weir, Dr. Sharon. "Are our sex worker programs preventing HIV transmission, Power Point Presentation." Jamaica, 2009. Yuri A. Amirkhanian, Jeffrey Kelly, Elena Kabakchieva, Timothy McAuliffe. "Evaluation of a Social Network HIV Prevention Intervention Program for Young Men Who Have Sex with Men in Russia and Bulgaria." Atypon, June 2003: 205-220.

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APPENDIX I Overview of Jamaica’s HIV Policy Environment, Epidemiology of HIV, and Risks and Characteristics of Most-At-Risk Populations

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Overview of Jamaica’s HIV Policy Environment, Epidemiology of HIV, and Risks and Characteristics of Most-At-Risk Populations Jamaica faces unique challenges in addressing HIV/AIDS. As it has evolved into a “middle income” country, its ability to attract donor funding for HIV/AIDS programs is diminishing. The current HIV/AIDS National Plan remains 63.7% unfunded in an environment where there are serious HIV epidemics in MARPs populations, and these vulnerable groups are not being served by interventions at a scale large enough to reverse the epidemic. It is important, therefore, for those working in the health sector in Jamaica to consider what the most cost effective interventions for the right MARP sub populations are, in order to have the greatest impact on the epidemic; as well as determine what the system requirements are, in order to deliver those interventions to those populations.

Background on Jamaica’s HIV/AIDS Situation One of the biggest health and developmental issues in the Caribbean is HIV/ AIDS, where there is a prevalence rate of approximately 1%. In Jamaica, the adult prevalence rate is higher, at 1.7%. Jamaica is the largest English speaking Caribbean island, with a population of 2,692,400.36 By World Bank standards, Jamaica is considered an upper middle income country (UMI). In 2006, it spent approximately 5% of its gross domestic product on healthcare. HIV stands to affect not only the health of the Jamaican people but also the country’s development as a result of reduced productivity and lost time due to the morbidity of the illness. In a declining global economy Jamaica has to identify cost effective means of mitigating the impact of HIV and AIDS. Policy The Ministry of Health’s National Strategic Plan (MOHNSP) for 2006-2010 identifies that health and development are ‘inextricably linked.’37 The plan also assumes that health determinants are not just biological and genetic but are also political, social and economical. The plan’s vision is ‘Better health, wellbeing and quality of life for all.´ The plan’s mission and policy outcome are illustrated in the box on the following page.

36 37

Planning Institute of Jamaica 2009 Jamaica’s Ministry of Health 2006

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Box 1. Mission and Policy Outcome of the Ministry of Health's 2006-2010 Strategic Plan Mission Ensure access to a sustainable, responsive and effective health system that is stakeholder focused and facilitates the health, productivity and well being of Jamaicans. Policy Outcome The Ministry of Health shall, in keeping with the development goals and philosophies of the Government of Jamaica as well as regional and international guidelines, formulate, monitor and evaluate policies, plans and programs that: Promote well being and health in the society so that the population enjoys sustained, optimum levels of health. Ensure health systems that are well managed and sensitive to the health needs of the population. Continue further improvement and modernization of the health system to promote equitable access to appropriate, affordable, effective services.

The MOHSNPâ&#x20AC;&#x2122;s vision and mission are akin to the Vision 2030 plan set out by the Planning Institute of Jamaica (PIOJ) which has a goal of a healthy and stable population: Our vision is for a country with a health care system that is affordable, provides services in locations that everyone can reach, has facilities that are well-equipped, and is fully staffed with highly trained personnel. We will increase our ability to fight diseases that we can get from others (infectious diseases) as well as those that we develop because of how we live (lifestyle diseases). Our life expectancy (the age to which we are expected to live) will increase from 72 years to 76 years. The size of the population will be stable, increasing slowly over time in a balanced way to support our development.38 The MOHNSP for 2006-2010 has five thematic areas. These are: population health, individual health, quality management, disaster management, and leadership and management. The themes and objectives are outlined in the table on the following page. HIV/AIDS is related only to the outcomes of the individual health objective.

Planning Institute of Jamaica 2010

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Table 1. Theme Objectives of National Health Plan of 2006-2010 Themes Objective Population Health

Individual Health Quality Management Disaster Management Leadership and Management

To promote wellness and protect the health of the Jamaican population thereby reducing the incidence and severity of preventable illness, injury and disability To improve individuals’ health outcome by ensuring access to effective, affordable and equitable health care services To improve the quality of health care provided to the nation To improve the Ministry of Health’s ability to prepare for and respond to health threats from manmade/natural disasters To strengthen the leadership and management of the Ministry of Health to achieve organizational objectives

Focus on HIV No

Yes No No No

Source: Planning Institute of Jamaica

There is also a National HIV Strategic Plan for 2007-2012 (NSP) and a complementary National Monitoring and Evaluation Plan (NEMP). The National HIV Strategic Plan has four main priority areas: prevention, treatment and care, enabling environment and empowerment, and governance. The table below indicates the priority areas and corresponding strategic objectives which focus on MARPs. The NSP recognizes that stigma and discrimination is an issue is it relates to MARPs and HIV. In recognition of the fact that the NHP recognizes the vulnerability of MARPS, the priority areas of the NSP focus on issues related to this sub-population.39

Table 2. Priority Areas of National HIV Strategic Plan and its associated challenges & strategic objectives which focus on MARPS Priority Areas Strategic Objectives that focus on MARPs Challenges that affect MARPs Prevention Research based prevention efforts Drug Abuse Vulnerable Populations Gender and Social Vulnerability Treatment and Care HIV Testing Enabling Environment Identification and support for MSM Stigma and champions for change for other law Discrimination reform and advocacy, which protect the rights of all Jamaicans including the vulnerable and the marginalized. Empowerment and Governance

National HIV/STI Programme 2007

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The National Strategic Plan guides and directs the National HIV Program. In its aim to stem and mitigate the impact of HIV transmissions in Jamaica, strategies have been designed under the prevention priority. A behavior change communication strategy with emphasis on MSM and SW has been developed by the Prevention unit at the NHP. The strategy also has sub strategies such as Positive Prevention and Out of School Youth (OSY) for other vulnerable sub groups. The strategies for the MSM prevention programs include men’s health training, encouraging voluntary counseling and testing (VCT) and medical checks. The methods which will be used include peer support using influential people in the community while building life skills and empowering the men. The SW objectives are to: 1) promote condom use; 2) promote health seeking behavior; and 3) promote less drug use. The stigma and discrimination which afflicts the MSM and SW communities, as well as the high rates of HIV prevalence among MSM and SW, is related to laws of Jamaica which deem that sex work and sex between two males to be illegal. These are found as sections in the Offences Against the Persons Act. As a consequence of these laws, these groups are driven underground and become much harder to reach. The inverse is seen when there is no legislation against these acts, such as in the Bahamas and the Dominican Republic where HIV prevalence rates are lower. However it should be noted that there is a National HIV Policy (as well as several sector policies) which has been endorsed by the Jamaica Cabinet regarding the management of HIV and AIDS. A Green Paper has been tabled in the House of Representatives with respect to HIV and AIDS Workplace Policy. This policy speaks of mitigating HIV stigma and discrimination in the workplace. Although these policies are not MARPs specific they indicate the support of the government and politicians in mitigating the HIV epidemic and the issues around it. Legislation also allows the National HIV Program, which is currently a project under the Health Protection Unit at the Ministry of Health, to implement HIV programs and activities. Under the Public Health Act, the Minister of Health has the right to order an investigation into any disease of public health concern, as well as to implement any measure necessary to arrest the spread of that disease. If necessary, boards and committees may be set up to assist in the mitigation and prevention of the public health illness. To this end, the NHP is able to direct activities to assist in the mitigation of HIV in Jamaica. Funding When compared with most countries in Latin America and the Caribbean (LAC), a greater portion of Jamaica’s Total Health Expenditure (THE) comes from the local budget and not international donors. Jamaica’s THE in 2006 was 5.1% of the Gross Domestic Product (GDP) and of this, only 1.3% was received from international development partners.40 Compared to other countries in LAC and other Upper Middle Income (UMI) countries this percentage of the GDP on THE is low, as those countries spent 6.6% and 6.3% respectively in 2006. A low percentage of GDP spent on health services indicates that there are inadequate health services and technology and thus a less effective health system with low coverage.41 A large percentage of the funding for the National HIV Strategic Plan comes from international development partners, such as the World Bank (WB) and the Global Fund against AIDS Tuberculosis and 40 41

Health Systems Report:Jamaica. Health Systems 20/20 Project, Abt Associates Inc, 2010. Ibid

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Malaria (GFATM). However, even with this international aid there is still a 67.3 % shortfall in the funding for this plan. Currently the NSP is expected to cost USD 201.2 million to implement; however only USD 65.7 million is available, with USD 14.2 million being provided by the Government of Jamaica and USD 51.5 million being provided by international donors.42 Further to this, HIV only accounts for JMD 1.2 billion (USD 14.2 million) of the MOH’s JMD 31 billion (USD 366.2 million) annual budget, indicating that it is not a large part of the health budget and that the sector has other priority areas. Agreements with the international development partners require that local governments fund 80% of the administrative costs. However, this percentage may actually be higher, as the value of time and resources in the public health system which are used to render HIV services, such as laboratory testing and treatment of opportunistic infections, have never been quantified. Between 2007 and 2009 the majority of the HIV budget was spent on treatment, care and prevention. In 2009 JMD 390.69 million (36% of total HIV budget) was budgeted towards treatment and care with JMD 555.54 million actually being spent. This saw 42% more in actual spending than was expected. Similarly in 2009 prevention was budgeted at 29% of the HIV budget at JMD 314.07 million; however JMD 325.15 million, 3% more than was budgeted, was actually spent. The actual HIV spending for 2009 exceeded the estimated budget by 12%. Of note is that in the years 2007 and 2008, all components in the HIV budget were under spent; in 2009 all other components, except for treatment and care, prevention and capacity building, were under spent. Under budgeting in the areas of prevention, treatment and care in year 2009 could be a result of the world economic situation where prices increased dramatically for good, services and commodities. Further to this, the NHP is aligned to the government of Jamaica’s fiscal year which is between April-March, thus expenditure is indicative of the actual financial year expenditure but not the calendar year. Another issue which affects under spending could possibly be the procurement process which results in protracted implementation of activities. As HIV funding may be decreasing, plans are now a foot to integrate the National HIV Programme with National Family Planning Board in Jamaica in an attempt to sustain the HIV program. Such an integration will combine components of FP/RH and HIV services that are currently separate, with the goal of maximizing coverage and health outcomes for the client and optimizing the wise use of scarce resources.43 Targets The NEMP has set targets to be achieved by 2012. These targets will be the result of the implementation of activities related to the four priority areas of the NSP. The targets for the various sub-groups are based upon international development partner indicators, global indicators such as those from UNGASS, and local indicators set by the NHP. The indicators are categorized as impact, outcome and output. The baseline prevalence rates and numbers of some targets for the vulnerable populations, such as the MSM community, are not known. This makes it difficult to determine how severe the problem is currently, as well as if any real impact will be made by the programs implemented under the NSP. For example, an UNGASS indicator to be determined is the percentage of men reporting using a condom the last time they had anal sex with a male partner; the baseline value for this indicator has yet to be decided with the baseline year being 2003. However, there is a target of an increase of 10% and 20% over the baseline for 2010 and 2012 respectively. 42 43

Planning Institute of Jamaica 2009 NFPBNAP Integration, Ministry of Health 2010.

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Targets are not specific to geographical regions; however, they are specific to sub-populations and age groups. The baseline years vary depending on the target and the source of the data to inform target indicators. As a result, the timeframe for attaining targets may differ from two to three years and/or may have more than one target year during the strategic period. If the previous UNGASS indicator is to be used as an example an overall 20% increase from the baseline number is expected at the end of the strategic period, however an initial 10% increase is expected within the first 2 years. There are also general population targets, which would inevitably incorporate the vulnerable and most at risk populations. By 2011 the NHP would like at least 80% of males and 75% of females to report using a condom the last time they had sex with a non-regular partner. This target includes the entire population and can be disaggregated by vulnerable groups, sex and age. Table 6. Selected targets and indicators for the HIV strategic period 2007-201244 Indicator Source UNGASS

UNGASS

Indicator Percentage of men and women ages 1524 that are HIV infected Percentage of SW who are HIV infected

UNGASS

Percentage of MSM who are infected

USAID

Number of individuals reached through prevention activities, disaggregated by vulnerable groups (e.g., youth, MSM, SW, prisoners) Percentage of SW reporting using condom at last sex act with client Percentage of men reporting using condom the last time they had anal sex with a male partner Percentage of people by sex, age and at risk group who received HIV testing in the last 12 months and who know the results

UNGASS

Frequency

Base Line Value 1.2% 1.5%

Year 2002 2005

2005 and every 2 years 2006 and every 2 years monthly

2005

7% <7%

2010 2012

Prevention

25%-30%

2007 estimate

<25%

2011

Prevention

SW-8500 MSM-6600 STI Clinic225,000 Inmates 3000 (all cumulative)

2012

Prevention

2005 and every 2-3 yrs

75% 92%

2003 2005

>90%

2011

Prevention

2006 and every 2-3 year

TBD

2003

10% increase

2010

Prevention

20% over baseline

2012

SW 50%

2012

Annually

Every 2 years

SW -3480 MSM- 4800 STI Clinic Attendee40,000 InmatesTBD

SW-43% MSM- TBD

2005

Target Value â&#x2030;¤1.5%

Priority Area Year 2009 2011

Prevention

Treatment and Care

Jamaica National HIV/STI Programme Monitoring and Evaluation System 2007-2012 (2007)

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Jamaicaâ&#x20AC;&#x2122;s vision 2030, its MOHNSP and the NSP have all identified health and, in turn, HIV as areas to be addressed for the country to reach its full potential and be classified as a developed nation. With only approximately 5% of its GDP being spent on health, however, this target may be difficult to achieve. This is even more difficult as at the end of 2008 there was almost a 70% gap in funding the NSP. To this end, it is imperative that health expenditure and more so HIV expenditure are effectively spent to have the greatest impact, thus contributing to the broader development of Jamaica.

Epidemiology of Jamaica Rates The adult prevalence rate for HIV/AIDS in Jamaica is 1.7%. There has been a slight increase from 1.5% over the past decade. This increase is due in part to the fact that more people are living longer with the illness due to greater access to anti-retrovirals (ARVs). Although the epidemic is generalized, it is also concentrated among some sub-populations. These include MSM at 31.8% prevalence and sex workers at 5% prevalence rate.45 Other vulnerable populations include crack cocaine users at 5% and incarcerated persons at 3.3%.46 The number of new HIV cases has increased over the past 10 years from 1,436 in 1999 to 1,738 in 2009. This increase is due to several factors: new HIV infections, increased surveillance, increased access to HIV testing, increased awareness by health care workers, and increased awareness by the general population. Figure 1. Jamaica HIV Transmission by Category 1982-2009

Source: Harvey 2010

It should be noted that the numbers given for sex workers do not include those involved in informal sex work (the intimate entertainment industry) and so the real number of those involved in sex work could be a lot higher. The MSM prevalence is based on one study conducted in 2007 of just over 200 MSM and so may not be statistically significant/accurate. 46 UNAIDS 2009.

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Eighty (80) % of HIV infections are believed to be transmitted through multiple sex partners. About 20% of persons who have been infected with HIV/AIDS since the recording of HIV data in 1982 until 2009 have a history of sex with sex workers. Although this information has been recorded, not much is known about this group of persons and no targeted interventions have been developed for them. Approximately 90% of all HIV infections are attributed to heterosexual contact. However, there are approximately 43% of men who were diagnosed with HIV whose sexual orientation was unknown. Of those whose sexual orientation was known, 4% identified as bi-sexual and another 3.4% as homosexual. Twenty-four out of every 1,000 STI clinic attendees was HIV positive in 2009. As stated above, the reported prevalence of HIV/AIDS has increased slightly which is indicative of several factors. For example, increasing the access to voluntary counseling and testing (VCT) by the population increases the known number of people living with HIV, while a reduction in mortality increases the actual number of those living with HIV. In the case of access to VCT, there was an increase in the percentage of persons who had taken an HIV test in the last twelve months and received their results. A greater increase was seen by women as well as by the age group 24-49. There was a 14.7 % increase in the use of VCT by women from the year 2004 to the year 2008, while with men there was an increase of 11.4% (Hope Enterprises 2008).47 With respect to mortality, a total of 7,772 have died from AIDS since 1982, which is approximately 50% of the total who have reported AIDS. However, the rate of mortality is on the decline. In 2004 a total of 665 persons succumbed to AIDS related illnesses; however in 2009, only 378 persons died due to AIDS, indicating a 43% decline in the number of people who died from AIDS related illnesses. This decline can be attributed to increased access to anti-retroviral treatment, increase capabilities in laboratory services such as CD 4 counts and viral load, as well as increased earlier diagnosis and opportunistic treatment because of scaling up of the national VCT programs.48 Risk factors HIV risk factors have remained constant over the last 10 years, indicating that although some mitigation with transmission of the virus has taken place, societal behaviors have remained the same and in order to stunt the epidemic all programs need to address these constant risk issues. The main risk factors are listed in the table below. Table 7. Reported risk behaviors among adults with HIV (1982 â&#x20AC;&#x201C; Dec 2009 cumulative) N= 18,130 Risk No of persons (%) Sex with sex workers 3,581 (19.7) Crack, cocaine use 1,138 (6.3) STI history 8,137 (44.9) IV drug user 139 (0.8) Multiple sexual partners >80% No high risk behavior 5,135 (28.3 ) Source: Ministry of Health, National HIV/STI Programme, Jamaica AIDS Report 2009

47 48

Hope Enterprises 2008 National HIV/STI Programme 2010

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The most urbanized areas account for the highest prevalence of HIV, with 66% of HIV/AIDS cases being found there. The areas include Kingston & St. Andrew, St. Ann, St. Catherine and St. James. St. James has the highest cumulative prevalence rate of 1,854 per 100,000 persons. This is followed by Kingston & St. Andrew and St. Ann, with 1,432 and 1,038 per 100,000 persons respectively. The economies of St. James and St. Ann are driven by tourism, therefore making the tourism sector vulnerable to the transmission and impact of HIV/AIDS. Age also seems to factor highly in HIV transmission and AIDS prevalence. Seventy-nine (79) % of the persons with HIV are in the age group 20-49. This is a 10% increase from 2008.49 However, it is similar to the cumulative rate for 1982-2009, which is 74%. This slight increase can be attributed to new infections, as well as to antiretroviral treatment, which results in persons living longer with the virus. The ratio of male to female HIV/AIDS prevalence cumulatively from 1982-2009 is 1.35:1; however the ratio for male to female for 2009 is even closer at 1.2:1.50

Figure 9. Jamaica, HIV by Age and Gender

Source: National HIV/STI Programme 2010

49 50

National HIV/STI Programme 2010 Ibid

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The KAPB 2008 study highlighted that 27% of persons had not used condoms in their last 10 sex acts. This data is important as the majority of persons who are HIV positive do not know their status, thus increasing the chance of transmitting HIV. Non condom use is related to age and multiple partners. Most persons with multiple partners in the age group 15-24 were more likely to use condoms. This is partly due to the fact that many of these persons were not in committed relationships and lack of condom use is related to trust within relationships, as well as cultural beliefs and norms. Males stated discomfort or unnatural feeling with the use of condoms. Interestingly there has been a slight decrease in persons reporting sex with a sex worker between 2004 and 2008; however condom use by clients of sex workers in the age groups 1524 and 25-49 has also decreased. In 2004 the percentage condom use at the last interaction with a SW worker was 75.5 % and 80% respectively in the 15-24 and 25-49 age cohorts, as compared to 69.2% and 60% respectively in 2008.51

Behavior changes noted by KAPB 2008 study: Increase by 14.7% of females and 11.4% of males in knowledge of HIV status Up to 20% decrease in condom use with SW Percentage decrease in persons reporting sex with a SW 27 % of persons did not use a condom in their last sex act

Transactional sex was reported by at least one third of the respondents interviewed in the 2008 KAPB survey. Transactional sex denotes sex in exchange for cash or goods and is defined as both giving and/or receiving gifts. This activity inherently reduces condom negotiation power and strength, as the person receiving the cash or goods is willing to do anything requested of them in order to attain financial and material gain. The percentage of men who engaged in transactional sex was twice that of the women. Persons reporting transactional sex engaged in sexual activity more often than those who were not engaging in transactional sex. Risk characteristics which affect HIV transmission: Low condom use Age Urban areas/tourism areas Transactional Sex Coercive Sex Gender Most HIV+ donâ&#x20AC;&#x2122;t know their status

51 52

Coercive sex, which is sex by force, also affects the use of condoms. Over 20% of the SW who were part of the 2008 sex worker interview had been raped. Approximately 18.8 % of the HIV positive MSM who took part in the 2007 survey were also victims of rape.52

Hope Enterprises, 2008. National HIV/STI Programme 2010

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Characteristics of MARPs Evidence over the years has indicated that the burden of HIV transmissions and prevalence lies in what are considered the most vulnerable and most-at-risk populations. Both the Caribbean Strategic Framework 2008-2012 (CRSF) and the NSP have strategic objectives under their priority areas which focus on MARPs. The President’s Emergency Fund for AIDS Relief (PEPFAR) also focuses on MARPs. PEPFAR started a new five year cycle in 2009 partnering with twelve Caribbean islands, including Jamaica. The goals and objectives of the PEPFAR II Framework are closely linked to the five priority areas of the Caribbean Strategic Framework 2008-2012 (CRSF). Under its partnership with Jamaica, the PEPFAR II general objective states that, “The primary, shared goal of PEPFAR ... is to support the Government of Jamaica’s efforts to reduce the transmission of HIV over the next five years, with a focus on most-at-risk populations (MARP) and other vulnerable populations.” Undoubtedly all strategic plans and partnerships are focused on the reduction of HIV transmission in the MARPs, as they have been recognized locally and globally to carry the burden of the illness. UNAIDS considers MARPs to be: sex workers (SW), clients of sex workers, people who inject drugs (PWIDs) and men who have sex with men (MSM). In Jamaica, however, MARPs are considered to be MSM and SW, crack cocaine users, prison inmates, STI clinic attendees and out of school youth. PWIDs are not considered MARPs in Jamaica as their number is extremely small. Table 1. MARP Groups as classified by UNAIDS and the NHP UNAIDS MARPs Sub-groups NHP MARPs Sub-groups MSM MSM SW SW Clients of Sex Workers Crack Cocaine Users PWID Prison inmates STI Clinic attendees Out of School Youth Source: UNAIDS, the NHP

National HIV/STI Programme 2010

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what the route of transmission of HIV for crack users is. An inference can possibly be drawn that some of the HIV positive drug users may be SW and MSM or both. Similarly, while prevalence rates for prison inmates are high at 3.4%, this has been based on limited data that did not determine where transmission occurred – either before entering the prison system or while incarcerated. It is also difficult to determine the route of transmission, as this data was not collected. Therefore it is hard to draw any conclusions about what exactly is the important factor to address when designing prevention interventions for this population. STI clinic attendees also have a high prevalence rate of 3.4%, but again, there has been little disaggregating of the data to fully understand what sub populations and routes of transmission are most significant. However, high numbers of both sex workers and MSM are treated for STIs indicating that this is a risk factor for these populations. In this report we will be focusing on the characteristics of two of the most at risk populations. These are MSMs, with 31.8% prevalence and SW (including intimate entertainment workers) with 5% prevalence. The rationale for this is that crack cocaine use, STI’s and incarceration are risk factors that increase sex workers and MSM’s vulnerability to HIV, and are not direct routes of transmission. An estimate of the size and prevalence for each MARP group is given in the table below: Table 2. MARPS Size and Prevalence Estimate Population Estimated Number Sex workers 7,000 – 18,000 MSM 9,000 – 27,000 Crack cocaine users 4,000 Prison inmates 5,000 STI clinic attendees 45,000 Out of school youth unknown

HIV Prevalence 5% 32% 5% 3.5% 3.4% unknown

Source: Harvey 2010

Men who have sex with men The population of MSM is estimated to be between 9,000 and 27,000.54 A 2007 survey of 201 MSM found that the HIV prevalence was 31.8%. Condom use among this population was fairly low and inconsistent. Approximately 30% reported always using condoms with regular partners within the last 3 months. This group, like the general population, has a fairly high number of multiple sex partners. Over a quarter of the MSM had two or more male partners in the four weeks prior to the survey. Thirty-three (33) % reported having sex with more than one female in the last 12 months.55 This statistic is also indicative of the intersecting of MSM and the general heterosexual population. 54 55

Risk behaviors and characteristics of MSM: Assuming female gender roles Role of being receiver Coercive sex Physical abuse Stigma and discrimination Inconsistent condom use Multiple sex partners Transactional Sex Untreated STI

Harvey 2010 National HIV/STI Programme 2008

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Of the MSM who were HIV positive, almost 19% of them had been raped and 21.9% had been physically abused. These statistics possibly support the MSM behaviors espoused in a 2010 qualitative research study by Dr. Moji Anderson which identified that many MSM take on the submissive roles of females. Thus they become vulnerable and have less control in relationships and are comfortable with being abused by the more dominant partner. Physical abuse and coercive sex also fuel the lack of condom use or inconsistent condom use among this community. Another symptom of taking on the female role is that the ‘feminine’ partner wants to feel the ‘baby sperms’ inside of them which also increases the lack of condom use.56 MSM can also be categorized by their biological characteristics. That is to say an MSM who is a “bottom” or receiver is at greater risk of being HIV positive. The study estimated that 73.4 % of the men who were HIV positive Categories of MSM: were receivers as compared to 64.1% who were givers or Sex workers “tops.” On the other hand, men who both give and receive Transgender had 57.8% prevalence. These results speak to the fact that Sweepstakers receivers are more at risk from a biological and physiological Professional standpoint. Another biological risk for MSM is a history of School Boys STI. Of the men in the 1007 study, 8.5% had Chlamydia and Gay for Pay (Gigolo) 5.5 % had syphilis. This is an indication that there is a link Battyman between HIV and a history of STIs. It should be noted that Middle Class approximately 39% of the participants who reported an STI Bi-sexual or genital or anal discharge did not seek treatment for it, Upper Class which also increases one’s risk for HIV. The correlation Street Based between HIV and a history of STI is also validated by Homeless information collected from HIV/STI clinics which indicate Down Low that in 2009, 24 out of 1,000 persons with an STI was infected with HIV. The 2010 study shows that socio-economic issues also impact the behaviors and HIV risk of MSM, with 23.4% of the HIV positive MSMs were homeless.57 The 2009 NHP Annual report states that it is easier to access MSM of lower classes than the middle to upper classes who prefer to be anonymous and who may not perceive themselves to be at risk. The 2010 study by Dr. Anderson showed that many middle to upper class men and professional men are either down low homosexual or only have relationships and interactions internationally and not in Jamaica. An interesting culture of the MSM community is the parties they attend. Some argue that these parties are where the clandestine interactions between the upper/middle class and the lower class MSM take place. In speaking to some experts in the field, it is believed that “sweepstakers” are the missing link between the upper class/middle class men and the lower class men. These men have the financial means to fit into the middle to upper class circles; however they maintain a base and relationships with lower class men. These parties are places to meet new sex partners and engage in sexual activities. Although condoms may be available condom use is affected because of impaired judgment due to the 56 57

Anderson 2010 Ibid

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consumption of alcohol. Additionally, these parties have inter-socioeconomic class mixing; to this end the males of the lower socio-economic class tend not to have as much power in the use of condoms in this situation. There are also reports of sexual interaction with more than one partner at these parties. The internet plays a significant role in the lives of MSMs, as it is a place to meet new and potential partners.58 It is not certain what percentage of MSM in Jamaica uses these websites and what role the internet has in HIV transmission. A part of the MSM culture in Jamaica is the phenomenon of “gay for pay” men.59 These men only sleep with men for financial gain and are not gay but heterosexual. This MSM group is one which engages in sexual activity with women. Condom use with male partners by MSMs who have sex with females is higher than their male counterparts who don’t engage in sex with females. It should be noted though that this does not translate into condom use with the females. Many MSM and transgender persons engage in sex work. It was also noted that some of the transgendered men have sex with heterosexual men; from anecdotal comments sometimes without the knowledge of the heterosexual male. Stigma and discrimination affect the behavior of MSM. This is why some MSM are down low and choose to have clandestine relationships with other males including male sex workers. Stigma and discrimination also increase the social vulnerabilities of the group. This is supported by the 2008 MSM survey which found that more than 50% of the recipients had been verbally abused at one time or another because of their sexuality. Further to this more than 20% of the MSM who were HIV positive had spent a night in jail and a similar percentage had been physically abused. Table 8. Percentage of HIV positive males displaying certain risk characteristics from MSM survey 2008 Characteristic/Behavior Percentage of HIV positive MSM Homeless 23.4 Biological “bottom” 73.4 Coercive Sex 18.8 Physical Abuse 21.9 Spent night in jail 23.4 Source: National HIV/STI Programme 2008

Among the MSM population, just like the general population, there are intergenerational relationships. In the case of MSM, school boys are known to have sex with older men for financial support and/or to explore their sexuality in a ‘safe place.’ This, however, leaves the naive school boy at risk as they have no condom negotiating power in these relationships. Various types of MSM and their characteristics can be identified; however there is no information as it relates to percentages of the population who belong to each category of MSM. Additionally there is not much information on the HIV prevalence in each group of MSM and there is no hard data on how the interaction takes place between the varying groups. However, it is safe to say that MSM have multiple partners and have low condom usage and this pattern of behavior is similar to the general population. An added risk to MSM is the type of anal sex they partake in, i.e., if they are a receiver they are more at

58 59

Anderson 2010 Ibid

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risk. It is also safe to say that violence, whether within or out of sexual relationships, affects the HIV status of an MSM, as well as their socioeconomic standards. Sex Workers It is estimated that there are 7,000-18,000 sex workers in Jamaica.60 The HIV prevalence within this group is approximately 5%. Sex work in this context is defined by persons who receive cash, in kind or food in exchange for sex. Further to this, sex workers can be put in categories of hidden or overt. Overt includes SW who work on the streets, while hidden includes those who work in bars, massage parlors and exotic clubs.61 A high percentage of the sex workers were from urban areas, that is to say Kingston & St. Andrew, St. Ann and St. James. As with the general population, tourism areas are vulnerable to the impact of HIV and AIDS due to the risk population. The SW population is very mobile. From the survey a great number of sex workers worked in more than two parishes in the last six months. The SWs who are non street workers tend to be more mobile than street workers. In the 2008 study, the percentage of sex workers who were interviewed in the tourism parishes of St. Ann, St. James, Hanover and Westmoreland was greater than the percentage of the total SW population in those areas in 2001. This indicates a trend for sex workers to move toward tourism areas where they are able to work for higher rates. There was a decline in the percentage of sex workers in Kingston.62 It should be noted that HIV prevention programs and interventions are implemented throughout the island especially in the urban areas mentioned above as they carry the burden of the disease. As with MSM, coercive sex is a risk behavior of sex workers. Among SWs aged 25 or younger, 21.4% of have been raped, while the same percentage has slept outdoors at one time or another. However, it is unclear how many of these SWs are HIV positive. Many of the sex workers have used some form of drugs within the last six months, including ecstasy, alcohol, crack cocaine and marijuana. More than 70% report using marijuana in the last six months and about 50% report consuming alcohol on a daily basis. Drug use impairs judgment, thus increasing the risk of HIV as condom negotiating skills are compromised.

Risk Characteristics of Sex Workers Multiple sex partners Inconsistent condom use with main sex partners Drug use History of STIs Working in the Tourism Belt Coercive Sex Slept outdoors Age Mobility Low education Low socio-economic class Urban in specific urban areas

Older sex workers seem to be more vulnerable to HIV and other STIs than younger ones. Among the 5% of SWs who had HIV, 3.7% were in the over 25 age group, while more than 53% of the persons presenting with an STI were also in the over 25 age group. It has also been observed that those who are HIV positive tend to have less earning power and lower education and tend to be street based.63 60

Harvey 2010 Weir 2009 62 Ibid 63 National HIV Programme 2009 61

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The sex worker survey also revealed that condom use with regular partners was low among sex workers in both the below 25 age group and the over 25 age group. In the under 25 age group, the percentage condom use was 30.8%. In the over 25 age group, 27.7 % used a condom with their regular partners. However, there was virtually 100% condom use with new clients. This percentage decreased to about 90% with younger sex workers who were more likely not to use a condom with regular clients and main partners. This behavior puts the younger SW at risk, albeit the risk may be a little less than that of older sex workers considering other socio-economic factors such as education and not being street based. The issue of multiple sex partners is once again highlighted among this group. Not only do more than 70% of the SW have main partners, but at least 53% of these main partners have other partners. This is exacerbated by the fact that there is less than 40% condom use with main partners.64 Of the SWs interviewed, 48.5% were male sex workers. Approximately 25% of all SW twenty-five and under had both male and female sex clients.65 This indicates how the virus is transmitted in the general population. It may be difficult to map the interaction of SWs with each other and the general population; however research shows that older SWs are more vulnerable than younger sex workers to HIV because of their education status, their higher rate of STIs and the fact that they are street based. Being street based means that they are easier to target for HIV interventions, as most of the street based SWs are less mobile than the ones who operate out of bars and clubs. This does not mean that younger sex workers are not vulnerable. They have a higher percentage of inconsistent condom use and, as the KAPB 2008 study has implied, although fewer men are engaging with SW, there is a decline in the use of condoms. Transmission routes from MARPs to the non-MARP population As indicated above, there are high HIV prevalence rates in MSM and FSW and that almost all new infections are a result of unsafe sex. There are two general directions of transmission Routes of HIV transmission from MARPs to nonfrom the MARP to the non-MARP population. MARPs One is from HIV+ MSM to identified MSM, then from identified MSM to general men (nonSex drives incident cases in MARPs and identified). The other is from FSW into the non MARPs general population of men and from men to The highest risk is in older men who have their other sexual partners. Men, in particular sex with SW and then with young women older men with multiple sex partners and those Even though MSM prevalence is high who visit FSW, are the source of infection in transmission it is mostly within the MSM young women who are engaged in community nontraditional sex work (they don’t identify as sex workers but are offering sex in exchange for cash or in kind). The issue for FSW is that many of them have a regular (non client) partner with whom they are less likely to use a condom. These men also have other (regular) partners that don’t use condoms. Street based workers are already being reached by programs. However, the SWs who are not being reached are the massage workers/informal sex workers, who in Jamaica are known as “intimate entertainment workers.” In other words, informal sex workers drive new cases in non-MARPS populations.

64 65

Weir 2009 Ibid

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In terms of total volume of cases and the risk of spreading HIV outside the MARPs community, it is the relationship between identified/non identified MSM and the relationship between SWs, their primary partner and their clients that will drive future cases. Figure 10, below, shows another illustration of the routes of transmission between MARPs and non-MARPs. Figure 10. Routes of transmission from MARP to non-MARP population

Risk factors As detailed above the risk factors for these groups includes their history of STIs, having multiple sex partners, having sex with FSW and MSW, poor use of condoms, alcohol and drug consumption, lower education level and being homeless. Young unemployed MSM and informal sex workers seem to be at highest risk. These risk factors are illustrated in figure 2, on the following page.

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Figure 2. Routes of transmission and risk factors

Geography New cases of HIV cluster in population and place. Most new infections are in MSM, FSW and young women involved in nontraditional sex work. Most new infections occur in urban areas with 70% of prevalent cases in the metropolitan area of Kingston/St Andrew. Figure 11. Jamaicaâ&#x20AC;&#x2122;s population by parish

Sixty-six (66) % of prevalent HIV cases are in 5 parishes and most of those cases are in the urban areas of those parishes. Three urban areas (Montego Bay (St James Parish), Ochos Rios (St Ann Parish) and Kingston & St. Andrew) account for the bulk of urban prevalent cases.

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Figure 12. Jamaicaâ&#x20AC;&#x2122;s AIDS prevalence by parish

These same urban areas have the majority of MARPs populations and the highest transmission rates between MARPs and non- MARPs populations. Thus any prevention program should target these three urban areas and specifically the places in these urban areas where MARPs (particularly MSM) congregate and where SWs have sex with clients. Figure 13 below shows the general routes of transmission by geographic area.

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Figure 13. Geographic routes of transmission

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APPENDIX II Causal Pathway Analysis Guidelines

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INTRODUCTION Many things are needed to address the HIV/AIDS epidemic. First, we need to identify and treat all those who are HIV positive thereby reducing their infectivity and also reducing mortality. This effort is ongoing and has received the greatest attention and resources to date. Second, expanded HIV prevention can only be achieved with a thorough analysis of the epidemic’s dynamics and drivers in the context of each country, identifying the people at risk, where they practice unsafe behavior how many there are. Third, we need to be able to target cost effective intervention interventions and approaches to the people most at risk and in the course of this, engaging many state and non state actors. Finally, the ultimate effectiveness of any prevention program s depends on the degree to which effective interventions reach people at high risk of getting or transmitting HIV.i This requires in almost all circumstances strengthening the health systems of countries in very specific ways. According to the U.S. Government’s 2010 Global Health Initiative Consultation Document: “Building functioning systems will, in some cases, require a new way of thinking about health investments, with increased attention to the appropriate deployment of health professionals, improved distribution of medical supplies and improved functioning of information and logistics systems – all while maintaining a focus on delivering results. In the end, success will be measured not by the robustness of the health system itself, but by a country’s ability to meet the needs of key populations and improve health conditions.” The following guidelines are a resource to assist teams to understand how to link health goals with interventions with health system strengthening actions designed to achieve those goals. Causal pathway analysis is an analytic approach which focuses on designing projects to achieve maximum attributable health outcomes within limited resources. It starts with an understanding of the epidemiology of HIV transmission and then helps planners identify the most effective interventions, the system requirements for scaled up delivery and the health system strengthening actions needed to improve system performance. Its application in project design helps managers make appropriate choices among competing technical interventions, programmatic approaches and inputs. It also helps managers focus on the most important health system bottlenecks that impede success and focus on those system strengthening efforts that will result in the greatest improvement in system performance.

PRINCIPLES Causal pathway analysis is based on the following four principles: 1. Country specific. The choice of interventions, programmatic approaches and health system strengthening actions should be specific to the setting where they will be implemented and driven by an analysis of the epidemiology, specific causes and risk factors and characteristics of the people and systems that exist in that setting. 2. Evidence-based. Within each technical strategy, project or program, the choice of program inputs, processes, outputs, and health system strengthening actions, must be rooted in evidence. Managers should use data and evidence as the basis for decision making. They must be able to clearly articulate why a choice in one direction is better than alternatives and understand how each choice is a move in the right direction.

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3. Causation. Project activities should be logically and systematically constructed along a causal chain of programmatic action so that relative contribution of each intervention and program activity can be located along that causal chain from input, to process, output, outcome and impact. 4. Principle of the “vital few.” Given finite resources, managers need to focus first on the vital few problems and causes, population groups, interventions and program approaches that are most effective at making progress towards the goal. As capacity and resources allow they can extend efforts to other things. Not all risk factors cause most of the problems. Some problems are worse than others. Not all interventions are equally effective and not all health system bottlenecks are equally important. Not all health system strengthening actions result in equal changes in system performance all other things equal.

CONDUCTING A CAUSAL PATHWAY ANALYSIS The objective is to construct a tailored program, focusing on the most important things and build specifically to address the situation in the location/country of interest. Causal pathway analysis will result in a specific causal pathway linking measurable health impact to key programmatic inputs. Developing this causal chain requires us to deconstruct our project, working “backward,” starting by defining a measurable health goal and prompting a critical thought process about the linkages between the causes of poor health, populations affected, effective interventions, and systems strengthening actions. Tracing the causal pathway to health impact requires a 5-step process: 1. 2. 3. 4.

defining the problems, causes and risk factors driving new HIV cases identifying and understanding characteristics of the population(s) most at risk and why identifying the most cost effective, evidence based interventions determining the health system requirements for the scaled up delivery of those vital interventions 5. identifying the health system strengthening actions needed to improve health system performance in specific areas and carrying out health system strengthening actions for system improvement.

Step 1: Identify the problems to be overcome and the causes of those problems The goal of reducing HIV incidence and prevalence and ultimately mortality from AIDS can only be tackled with a thorough understanding of the direct and underlying causes of transmission. Epidemiological analysis is the key to understanding this epidemic and countries can be quite varied in terms of mode of transmission and populations at risk. Interventions have to be focused on the specific drivers of HIV transmission. Without an understanding of the main drivers it is impossible to make a choice between interventions. Interventions can be focused on either the direct or indirect (underlying) causes of transmission. For example, a direct cause of transmission is unprotected sexual intercourse. An indirect cause is inaccessibility to condoms.

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Questions to be answered Problems (proximal & distal) What are the epidemiologic problems to be addressed, e.g., what are the major causes of HIV transmission? What is the relative contribution of each of the causes to the overall problem? What are the risk factors that impact the problem most? When does the problem manifest itself? Who is being affected? How are the problems distributed in time and place? Causes What are the major causes of the most important problems? What are the direct and indirect causes of each of the major problems? Which direct and indirect causes contribute most to the major problems? How much of the problem is the result of which cause?

Step 2: Determining the characteristics of the population(s) at risk Not all populations are at equal risk. Those that are at highest risk exhibit particular characteristics, exhibit risky practices in specific times and places, are of certain socioeconomic classes, and so on. In order to have programs focus on the most important target groups, managers need to know who makes up these populations, where they live and what influences their beliefs, preferences and practices. Questions to be answered In Step 2 we analyze the determinants of health which include: The social and economic environment The physical environment The population groupsâ&#x20AC;&#x2122; individual characteristics and behaviors It is important to consider all determinants of health but determining the population groupsâ&#x20AC;&#x2122; individual characteristics and behaviors is especially important. Identify the population groups that have the problems (step 2) and that are exposed to the direct and indirect causes of those problems (step 3). This includes examining whether these population groups have the risk factors associated with the direct or indirect causes of the problems to be overcome including their socioeconomic status, education, location, health status, and other factors that characterize these high risk groups. Who is dying and from what and who is getting sick from what? Who are at greatest risk of the problem and what are their characteristics? Why is this population at risk? Who are the people that have the greatest influence on the people who are at greatest risk? Who do they listen to? What shapes their behavior? How is the population exposed to the risk factors?

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Is geographic location a cause? Gender? Age? Education? Does socioeconomic status play a role? What’s the trend in these causes? What are their perceptions? What are their preferences? Where (geographically) are deaths occurring and where are the risk factors most prevalent? Who are the people who are most exposed to the risk factors (who don’t yet have the problem)? Is the problem addressed at the facility or home? What percentage of population seeks care in facility vs. home? What is included in facility care that isn’t in home or community care? What are the risk factors at the community level? Are those who access health facilities most at risk? What are their characteristics? Are they wealth/poor, uneducated/educated, older/younger? When is a population at greatest risk? Are there any trends in care seeking behavior?

Step 3: Selecting the vital few evidence based interventions Not all interventions are equal in terms of effectiveness or in their ability to address problems, causes and risk factors that are driving the HIV epidemic. Based on the epidemiologic drivers of the epidemic and the characteristics of the populations at risk which are the most vital interventions? It is critical to identify the range of interventions and select those that can be delivered. Technical as well as programmatic interventions should be examined. Questions to be answered Technical interventions What are the interventions that focus on the direct and indirect risk factors which must be overcome to address the problems, e.g., inconsistent use of condoms by commercial sex workers? Which interventions are most cost effective? Which are acceptable to our target populations? What are the baseline coverage levels of these evidence based interventions in particular? What coverage levels are needed for the goal to be achieved with an emphasis on coverage levels in the highest risk population groups? If more than one intervention is needed what is the best combination? If only packages of interventions are available which elements of the package are actually the “active ingredient” and the most effective? Provide the cost and effectiveness for the interventions, where available. How much of the problem can be solved by each intervention given baseline coverage levels? How much in combination? Programmatic interventions What is the standard package for the intervention? How has the intervention been adapted in the country context? When is the most critical time during the programmatic intervention? What are the interventions for each problem and what is the known effectiveness of each? What are the baseline coverage levels? Under what conditions are they most effective? Why is there a belief that a focus on certain interventions will overcome the problem and achieve the goal?

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Step 4: Health system requirements and system bottlenecks Health systems will have to function in very specific ways to scale up the delivery of chosen interventions if they are to reach target populations at coverage levels that would reduce the problems. What are those specific health system requirements for the vital few chosen interventions? What would be the ideal state of the health system? While there are requirements for each heath system building block, it is the combined functioning of the building blocks that would allow for scaled up delivery of the interventions. For simplicity and clarity the building blocks have been separated here. This section answers the question â&#x20AC;&#x153;Health system strengthening for what?â&#x20AC;? The answer is to overcome bottlenecks. Questions to be answered Governance/policy/legal What policies, rules and regulations are needed to address the intervention? Do policies encourage provision of services where they are needed at the right time through the public or private sectors Stewardship: who are the stakeholders in which part of the public, NGO, and private sectors who need to be champions for this success? What is the best way to align donors with supporting the most critical interventions and more critical system improvements to make the greatest impact? What are the major policy, legal, regulatory, governance, leadership bottlenecks? Delivery What are the characteristics of the delivery system needed to deliver those interventions? What kind of demand needs to be created for these interventions for the high risk population groups? What is the best combination package of interventions? What is the best service mix? What kind of service delivery system is needed to get the interventions to the right people and right place? What would be the demand that needs to be created? What is the best way to get to the right providers at the right time and right place? Where is the most effective place to deliver the services? What are the major delivery bottlenecks? Financing How much funding is required for the interventions? How should the funding be allocated? What are the major financing bottlenecks? Information What kind of information is needed to be able to track people who are at risk and the services they receive (relevant for the interventions)? Where does that information need to be collected? How often does that information need to be collected? How will the information be used, by whom, for what, and does it align directly with the achievement of the health goal? What are the greatest information gaps and bottlenecks?

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Human resources How many staff are needed? Or what kind and of what skills? Where would they need to be distributed? What support do the staff need to succeed? What are the most important human resource bottlenecks? Medicines/supplies/logistics What kind of supply system is needed? What kind of guidelines/protocols are needed? What kinds of medicines needed to be procured? Where do they need to be distributed to? What kind of treatment protocols are necessary? What does the essential medicine list need to look like? Who are the users and what do the need to look ensure rational and effective use? What are the most important bottlenecks in the procurement, distribution and use of medicines, commodities and technology?

Step 5: Health system strengthening actions Overcoming the most critical health system bottlenecks is the objective of health system strengthening. HSS can focus on one specific bottleneck or combination of bottlenecks. In reality, to have a scaled up response to HIV will require simultaneous work across more than one, and perhaps all, system building blocks plus demand. This examination will specifically focus on the reason for poor health system performance relative to the system requirements identified in step 3 above. The outcome will be to identify the sequence of actions needed to implement health system strengthening in order to scale up the delivery of the vital few interventions. Questions to be answered What factors in each of the six building blocks serve as constraints to effective health system performance? What are causes of these bottlenecks? What changes are needed so the building block functions well (i.e., what are the causes of underperformance?). Determine key leverage points for system strengthening across the six health system building blocks.

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APPENDIX III Potential Applications of Performance-Based Financing to Improve the Performance of the HIV/AIDS Program in Jamaica

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A solution looking for a problem? Performance based financing (PBF) is the flavor of the month yet it is not very well defined in many peoples’ minds. At times it is being recommended as the panacea for all problems yet the evidence based in still growing on what problems it can address, under what conditions different types of PBF work best and how to implement them. This annex explains why PB is a good option for some things, defines PBF, examines the different options for Jamaica and makes recommendations on where PBF could be applied to address some of the health system problems facing Jamaica’s national HIV program. This paper provides a summary of system bottlenecks faced by Jamaica’s HIV/AIDS program, defines the range of PBF options, and then recommends how PBF could be applied in Jamaica to overcome some of the most important health system bottlenecks. A. Why PBF? Donors, multilateral agencies, global initiatives are all working to find ways to encourage better performance and the range of performance related payment methods has been lumped under the umbrella term “Performance based financing” or PBF. The more traditional input-focused approach has not lead to the degree of performance needed to achieve HIV goals so alternatives are needed. PBF approaches offer one such alternative, focusing more on outcome and impact and using the power of financial incentives to encourage specific improvements in health system performance. In all performance based financing methods, the common thread is that predefined performance levels must be achieved as a condition for the release of funding, whether of national or local budget, insurance payments, incentives, or cash to providers and households. Performance based financing (PBF) has been around for some time and has been applied under many circumstances. The World Bank formally advocated for it as early as 1993 in its World Development Report “Investing in Health”. Contracting has been applied for years on the private sector even in Africa and conditional cash transfers have been used for decades in Latin American countries for poverty. USAID applied macro performance based financing (USAID called it “non project assistance”) in the 1980s and the private sector has used financial incentives to improve managerial and staff performance for decades. More recently, GAVI was created with performance based financing as its foundational approach. So what’s new about this approach? PBF essentially arose in response to the inability of traditional (project) financing to yield significant improvements in service coverage and quality of care needed especially by poor and disadvantaged populations. It has only recently gained favor in the development sector. There have been some large scale and some small scale successes. All successful recent approaches have involved improved resource flows, changing the way marginal investments have been made (e.g., paying for performance on the margin rather than for inputs) and tracking and holding to account those who receive performance based funding. Funding is provided only upon achievement of agreed upon performance benchmarks. Oscar Picazo, in collaboration with colleagues at Management Sciences for Health has conducted a review of PBF approaches and discussion options and conditions for success. He writes that performance based financing essentially involves a change in paradigm, and this can be better

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understood if its key characteristics are ranged against traditional (project) financing, as shown in Table 1 ii PBF must be seen as opposing the principles and approaches of traditional financing by tackling and correcting previous approaches’ major weaknesses. Under traditional financing, the incentives are mainly to cover costs and spend allocated budgets rather than to prevent illness, manage and control chronic illness, and to cure acute illness. Health workers are paid salaries which provide little incentive to maximize performance unless they are self motivated to do so. Licensing and accreditation bodies normally focus on what the health facility has (structural aspects of care) rather than what it does (care processes) or what it accomplishes (service coverage or performance outcomes). And since many of these health facilities do not have autonomy or revenue retention powers, they tend to be subject to “command and control” of far-away central authorities such as central ministries of health. This is particularly relevant given the structure of fiscal decentralization arrangements between central government and local governments (provinces and large municipalities) where the bulk of HIV transmission occurs and the most effect response should take place. Differences between PBF approaches and more traditional financing approaches can be summed up as follows. PBF approaches more us: From a focus on inputs to focus on outputs and outcomes From grants to sub national units of government to conditional grants predicated on performance From command and control to contracting out type arrangement providing incentives to change performance From a rigid focus on processes to a flexible focus leaving services to providers From focusing on standards, ratios and norms to improvements in enabling environment From poorly defined catchment populations to well defined populations and service targets From a focus on cost efficiency to cost effectiveness B. Classification and Typology of PBF Approaches Picazo arrived at a classification scheme for different PBF approaches demonstrating that, while similar in underlying principle, PBF comes in many stripes and colors. PBF encompasses an array of public/private partnerships (PPP), health service contracting (HSC), output-based aid (OBA), and paying for performance (P4P). While these are not identical, they do come from the same motivation, i.e., changing the ways services and providers are financed in order to achieve better results. Vouchers are becoming popular and have been tried in many HIV/AIDS programs globally. For a bibliography on the use of vouchers in HIV/AIDS programs see page 59. Table 1 on the following page provides one way of classifying PBF schemes based on relevant level of concern (macro/sectoral, institutional, and service delivery) and aspect of financing (demand or supply side) that is supported. Examples in this table are those potentially relevant to Jamaica.

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Table 1. Types of PBF Schemes Arrayed by Level and Their Location by Chapter in This Report Focus Examples of PBF methods potentially appropriate for Jamaica Agreement between Donor funding for Jamaica could be released based on certain HIV/AIDS donors performance requirements and agreed upon performance benchmarks. and countries and PEPFAR funding released based on certain performance by the National the Jamaica Program. government agencies Agreement between Conditional transfers from national government to local authorities or central government autonomous hospitals based on agreed upon performance targets. and provinces or Conditional grants under the National Program to specific high risk municipalities geographies dependent on those geographies allocating an agreed upon (intergovernmental portion of their own resources to cost effective HIV/AIDS prevention for fiscal transfers) high risk populations. Conditional transfers from provinces/municipalities to districts for agreed upon results related to prevention and treatment for MARPS. Agreement between Supply-side Demand-side two parties or * Health service contracts * Vouchers for health services or institutions such as between government or donor commodities such as condoms to reduce between the and NGOs or mission facilities financial barriers to access Ministry of Health * Outsourcing of services such and suppliers of as testing in private clinics to condoms or extend the ability of municipal health government clinics to reach authorities and a MARPS non government * Social franchising (clinics and organization. drugstores) to enhance access by MARPS to specific interventions and services. * Health insurance accreditation * Health insurance financial protection for and payment to NGO and members reducing the risk of illness to private providers encouraging certain populations. them to provide certain services and cover certain populations. 66 Individual focus Supply-side Demand-side Agreement between * Provider incentives for specific * Conditional cash transfer (CCT) programs payers- providers services in specific geographies for increasing demand for certain services (supply side) and to specific populations. such as testing for MSM payers-patients * Targeted demand subsidies such as (demand side) coverage of certain interventions through health insurance and vouchers * Patient or treatment incentives to encourage consumption of certain services or to reduce user charges. 66

While the focus here may be individual, most of the supply-side P4P programs in developing countries are actually managed at the institutional level (clinic or hospital) where staff decide among themselves how to divide the bonuses they earn.

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The common thread across all PBF methods is that predefined performance must be achieved as a condition for the release of funding, whether of national or local budget, insurance payments, incentives, or cash to households. C. Potential PBF options for Jamaicaiii Based on the epidemiology and the health system bottlenecks in our analysis there are a number of performance based financing options Jamaica and its donors may want to consider Cash on Delivery (COD) Aid - The basic concept is that a donor, e.g., PEPFAR enters into an agreement with the government of Jamaica (a “contract”) in which the donor agrees to provide resources to Jamaica if it achieves a certain development outcome. Outcomes could be a shift more resources to prevention and increase coverage of MARPS with targeted interventions or greater allocations to high risk geographic areas or a greater amount of spending on programs focusing on MARPS. This would pay Jamaica only on the basis of measured results. The COD payment does not substitute for traditional input-based foreign assistance which would continue. The COD payment would be an additional incentive for improved performance. In this example, this COD approach would improve the effectiveness of other aid modalities by motivating national leaders and local actors to focus on the HIV prevention which is in everyone’s interest. Because the COD approach does not prescribe how Jamaica would achieve these prevention results or that any reduction in incidence be attributed to a specific intervention, it leaves the recipient free to develop an integrated approach that the government feels is most appropriate for Jamaica. The cash-on-delivery approach is crucially dependent on being able to determine whether HIV transmission has been reduced, and in a fair and timely way.iv Conditional Budget Transfers (or Conditional Budget Grants) – As outlined in the financing section of this report, health-related fiscal transfers from the state to the parishes do not dictate how those funds are to be used. Spending is based on locally determined priorities. Applying a PBF lens, the National Target Program could transfer funds to parishes conditional that they achieve certain targets, e.g., reduced HIV transmission through improved use of condoms by MARPS, or based on changes in policies which inhibit demand, e.g., policies encouraging community level providers to distribute condoms and monitor compliance with ARV regimes by PLHIV. Conditional Cash Transfer (CCT) and vouchers– A form of pay for performance and social protection where the government or nongovernment agency (funder) provides cash (instead of goods) to targeted poor and vulnerable households. One purpose is to make the cash payment conditional upon their meeting well-accepted social goals (e.g., getting tested for HIV complying with treatment schedules). In the short term, a CCT program eases the poverty problem of the household that receives the cash at regular intervals; in the long term, it also allows HIV+ to continue to be a productive member of society. This is particularly important for poor MARPS who cannot pay user fees, can’t afford needed commodities (e.g., needles and condoms) and whose health benefits the country more generally. Another application is to reduce the cost of accessing some services (e.g., treatment or condoms) where demand exists but where cost is an impediment. In this case they increase consumer purchasing power, letting the market control prices. Services are generally provided by accredited providers to assure quality. These providers then compete for clients and turn over their collected vouchers to the voucher agency for the payment of services they have rendered to the voucher-holders.

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Vouchers can address supply side bottlenecks. On the supply side, vouchers may reduce constraints to the production of goods and services. In general, vouchers allow the government or donor to limit its role as financier of social goods and services while allowing the private sector to be the providers of these same goods and services. In other countries, vouchers have effectively been used to encourage IDUs to purchase clean needles, for addicts to purchase methadone and for HIV+ people to purchase condoms and lubricants from both commercial and government providers. Output Based Aid (OBA) –This PBF method replaces user fee revenue with a targeted subsidy that is conditional on providing specific services to a specific target group. In this case, for example, a parish health department could contract with a private laboratory to provide free HIV tests in specific parts of a parish for hard to reach populations. The health department would pay for the user fees that would have been received plus potentially a bonus if certain conditions are met. The health department guarantees funding with some of the money up front and the remainder at the end once pre defined targets have been achieved.v The advantages are that it is transparent. Who pays, what is paid and who benefits is clearly laid out. Risk of financial loss to the provider when serving poor or hard to reach populations is shared but there remains an incentive for good performance. Performance Based Contracting (PBC) – Contracting is a common form of relationship between a funder and a provider. What is new in the health field is the incentive component. This normally involved an explicit agreement between a state funder and a private/NGO/CBO provider. Services, volume, quality and other issues are defined in advance and payment is made based on specific performance criteria. It involves monitoring of performance by the funder against agreed upon indicators and submission of performance records on a periodic basis by the provider. An example for Jamaica might be a contract to a non government community based MARPS group to identify HIV+ MARPS who are on treatment and to keep them complying with treatment regimes (e.g., ARVs) for the long term. Another example could be a performance contract between Montego Bay Parish Health Dept and a taxi cab company to maintain a continued supply of condoms in condom vending machines with zero stock outs in priority high risk and high transmission sites in the city. The city would buy the condoms which would be provided free of charge to the consumer and the taxi company would be paid for the logistic service it performs but only if they achieve zero stock outs. Social (Clinic) Franchising – In this case, a series of providers develop a brand of delivery sites that provide standardized, high quality services, such as lab testing, for a fixed, predetermined price. Different individuals could open up a franchise with the franchisor offering the use of the brand if conditions are met. A set menu of services would be offered for a predetermined fee which is generally lower than commercial outlets but of good quality and more accessible. This model could be used in Jamaica, for example, to promote condoms. This allows government to expand its services without having to hire more staff, build more clinics or develop difficult to implement outreach programs.

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D. What options have been tried before in HIV/AIDS programs? Based on the review of the literature the use of PBF for HIV/AIDS programming is not widespread with the exception of voucher programs. An extensive literature exists on the use of vouchers for improving performance of STI, HIV/AIDS programs and for improving demand for services. There has, however, been extensive use of these methods for other health outcomes and there is reason to believe that the adaptation of these methods for HIV/AIDS program outcomes would not be difficult. E. Criteria for choosing among competing PBF options for Jamaica Obviously not all PBF options would be appropriate for Jamaica. The criteria that may be appropriate would be: 1. They improve demand for critical services (e.g., testing, ARV treatment) and commodities (condoms) for the most difficult to reach MARPS populations, e.g., MSM, street based sex workers. 2. They improve service delivery and access to key commodities and services at community level for the most difficult to reach MARPS.. 3. They encourage changes in laws, policies or regulations that lead to stigma and discrimination. 4. They encourage more cost effective provision of already cost effective services and interventions. F. Recommendations Recommendations are ranked in order of ease of implementation with the easiest to implement ranked first, descending to the most difficult. All of these options are potentially useful for Jamaica. Testing these ideas would be part of a learning agenda for PEPFAR and USAID and if successful, initial trials could be expanded. All could be tailored to encourage both prevention and treatment. Option 1: Vouchers for key commodities and conditional cash transfers for certain behavior changes and to facilitate access to privately provided HIV/AIDS services There are six scenarios in which vouchers might make sense. For targeting subsidies more accurately, for stimulating demand for under-consumed services, for simplifying the administration of demand side subsidies, for reducing provider induced demand and for providing services package of fixed or predictable costs and finally, to improve consumer satisfaction.vi Good candidates for vouchers would include groups that operate outside the law, such as, sex workers or MSM in Jamaica. A second group would be those who ostracized, stigmatized or discriminated against such as PLHIV. The third group would be poor if they can be accurately identified. The idea would be to distribute vouchers to the highest risk MARPS groups who are poor or lack financial access to subsidized commodities and critical services. This includes condoms and lubricant distributed through private providers (e.g., pharmacies) that agree on a set voucher price for those commodities. Also included would be HIV testing by private providers to avoid the discrimination periodically received in public facilities. The vouchers could be distributed by community level organizations which are franchised (see social franchising below) or through contracted providers (see performance contracting below).

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We also recommend trying a program on conditional cash transfers to specific MARPS groups in order to keep them HIV negative. The cash transfer would be conditional on a negative HIV test administered at defined intervals. In order to remain HIV- they must adopt certain behaviors and use certain precautions. Their reward would be a cash transfer. Option 2: Performance contracting with private providers, NGOs and CBOs Performance based contracts could be provided to both public and private sector providers to deliver HIV counseling and testing, distribution and control of vouchers, and in referral of MARPS for testing and treatment. The contract could require performance in certain key areas such as testing a certain percent of MARPS in certain locations, provision of so many HIV tests to MARPS, and so on. If there are a number of private providers in a given location contracts could be let on a competitive basis and then monitored by municipalities or national government. The highest risk MARPS groups in Jamaica are also the hardest to reach, the most likely to fall off treatment once diagnosed, those most difficult to counsel and the least likely to be served in public facilities. Civil society groups and community level NGOs, including organized groups of MARPS themselves, could provide surveillance and identification of high risk groups, encourage testing, counsel HIV+ MARPS, referral services to appropriate providers. These groups could also (with policy changes allowing it) provide a continued supply of ARVs, monitor compliance and follow up with HIV+ people to assure continued compliance. Standards for operation, staffing and staff qualifications would be issued by donors and government and funding could be provided by donor and government budgets. As AIDS slowly becomes a chronic disease these groups can provide services more cheaply than government and be more accessible to the target populations. This would decongest government facilities. Option 3: Conditional grants/budget transfers to municipalities through the NTP Currently, central government resources are distributed to parishes on an unconditional block grant basis depending on population size with coefficients. In the future, USAID and PEPFAR could assist the National Program to distribute its funding to parishes on a conditional basis with agreed upon benchmarks and results to be reported periodically. Option 4: Cash on delivery aid for agreed upon policy change PEPFAR may consider making future PEPFAR support to Jamaica conditional on changes in certain legal or policy changes. For example changes to the laws governing same sex behavior. Conditions could also include and increased budget allocation for procuring ARVs and subsidizing and distributing free of charge condoms and other commodities to high risk MARPS groups. Once the stipulated conditions are met PEPFAR funds could flow to Jamaica and be used in any way the government wishes. PEPFAR could also make conditional the disbursement of funds provided HIV funding to the municipalities place performance requirements on municipalities for the use of those funds.

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Bibliography on use of vouchers in STI and HIV/AIDS programs Educational Material / General Information Competitive Vouchers 

Gorter AC and Bellows BW, Do competitive voucher schemes improve the provision of health care to underserved and/or vulnerable population groups? Experiences from Nicaragua, India and Africa. Invited Seminar, Department of Social Medicine, University of Bristol, April 24, 2008.

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Sandiford P, Gorter A, Rojas Z, Salvetto M. A guide to competitive vouchers in health. Published by the Private Sector Advisory Unit of the World Bank, Summer, 2005. ISBN: 0-82135855-3.

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Gorter A, Sandiford P, Rojas Z, Salvetto M. Competitive Voucher Schemes for Health. Background Paper. Developed for the Private Sector Advisory Unit of the World Bank as part of a toolkit on competitive voucher schemes for health, Summer, 2003.

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Sandiford P, Gorter A and Salvetto M. Vouchers for Health, Using Voucher Schemes for OutputBased Aid. The World Bank Group. Public Policy for the Private Sector, Viewpoint 2002; 243, 14. (Note available at http://rru.worldbank.org/Documents/PublicPolicyJournal/243Sandi042302.pdf )

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"Sobre Todo: Salud", Folleto educativo desarrollado en 2002 por el programa en conjunto con la fundacion SOA de Holanda, diseñado y validado para las trabajadoras sexuales beneficiarias del programa.

Publications cervical cancer prevention voucher scheme: 

Micol Salvetto and Vivian Alvarado, A voucher scheme approach to screening for cercical cancer: the Nicaraguan experience, Cancer Research Journal 2008, 2 (2/3): 137-158.

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Roberto Pérez Solís, Invitan a marcha contra el cáncer, La Prensa 3 de Octubre 2007.

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Vivian Alvarado, Programa Integral de Prevención y Detección Precoz del Cáncer Cervical, ICAS, 2007.

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Vivian Alvarado, Informe Final del Programa Integral de Prevención de Cáncer Cervical colaboración ICAS y Embajada del Reino de los Países Bajos, Managua, Nicaragua, 2005.

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Howe SL, Vargas DE, Granada D, Smith JK, Cervical cancer prevention in remote rural Nicaragua: A program evaluation. Gynecologic Oncology, 2005; 99: S232 – S235.

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Salvetto M and Sandiford P, External Quality Assurance for cervical cytology in developing countries, Acta Cytologica, 2004 Jan-Feb;48(1):23-31.

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Heather Lindsey, Researchers aiming to improve cervical cancer screening in developing countries, Oncology Times, Part1 in Volume XXVI, No 9:page 22 and 27, 2004 and Part2 in Volume XXVI, No 10:page 42-4, 2004.

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Edgardo Platero, Evaluación Final del Proyecto, prevencion del cancer cervico-uterino en mujeres pobres del area rural de los departamentos de Cuscatlan, La Paz y Morazan (UNFPA, DfID), El Salvador, 2004.

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ICAS, Esquema de Garantía de Calidad Externa (GCE) para la Citología Cervical en Nicaragua. Managua, Marzo 2003.

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Sandiford P, Gorter A and Salvetto M. Use of voucher schemes for the output-based aid in the health sector in Nicaragua: three case studies. Invited presentation at the World Bank workshop on Output-Based Aid (OBA), Frankfurt, Germany, January 24-26, 2002

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Salvetto M. Manual la prueba del PAP: Teoría y práctica. Sencillo método para diagnosticas el cáncer del cuello del útero, ICAS, Managua, Nicaragua, 2000.

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Salvetto M. Guía del Esquema de Garantía de Calidad Externa (GCE): Citología Cervical en el Perú. ICAS, Managua, Nicaragua, 2000.

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Salvetto M, Cáncer Cervical: El precio de la mala calidad, Boletín Salud con Calidad N° 8 Diciembre 1998 - Febrero 1999.

Publications adolescent voucher scheme: 

Gorter AC, McKay J, Meuwissen L, Segura Z, Medina J and Bellows B, Targeting vouchers to underserved populations in Nicaragua, accepted for presentation in panel: “Output financed healthcare: Ensuring quality health care for the poor”, The Global Health Council’s 36th Annual International Conference on Global Health, May 26-30, 2009, Washington, DC.

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Medina J, Segura Z, Medina G, Rodriguez O, Resultados del diagnostico a Maestros de 40 colegios de 7 municipio de Matagalpa, un municipio de la RAAS y un municipio de la RAAN, sobre los conocimientos en aspectos relacionados a la prevencion de las ITS/VIH/SIDA, Febrero Marzo 2007.

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Meuwissen LE, Gorter AC, Segura Z, Kester ADM and Knottnerus JA. Uncovering and responding to needs for sexual and reproductive health care among poor urban female adolescents in Nicaragua. Tropical Medicine and International Health 2006, 11(12), 1858-1867.

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Meuwissen LE, Gorter AC, Kester ADM and Knottnereus A. Does a competitive voucher program for adolescents improve the quality of reproductive health care? A simulated patient study in Latin America. BMC Public Health 2006, 6:204. Published online August 7 doi:10.1186/14712458-6-204.

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Meuwissen LE, Gorter AC, Kester ADM and Knottnerus JA. Can a comprehensive voucher program prompt changes in doctors’ knowledge, attitudes, and practices related to sexual and reproductive health care for adolescents? A case study from Latin America. Tropical Medicine and International Health 2006;11(6):889–898. (translated in Spanish)

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Meuwissen LE, Gorter AC, Knottnereus A. Impact of accessible sexual and reproductive health care on poor and underserved adolescents in Managua, Nicaragua: A quasi-experimental

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intervention study. Journal of Adolescent Health, 2006;38(1):56. (translated in Spanish) http://www.sciencedirect.com/science/article/B6T80-4HXBN0YC/2/105255f574347a2a006d7b37141d504a 

Meuwissen LE, Gorter AC, Knottnereus A. Perceived quality of reproductive care for girls in a competitive voucher programme. A quasi-experimental intervention study, Managua, Nicaragua. International Journal for Quality in Health Care, 2006;18(1):35-42 (Epub 2006 Jan 18). (translated in Spanish)

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Segura ZE, Medina JA, Donaire TE, Blanco OS, Gorter AC, Análisis de los Resultados del Programa de Salud Sexual y Reproductiva para Adolescentes, Managua y Chinandega. 2002 – 2005, ICAS, Managua, Nicaragua, October 2005.

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Medina JA, Salud Sexual y Reproductiva para Adolescentes, presentation “Clausura y Presentación de Resultados de los Programas de Adolescentes y ITS-VIH-SIDA”, ICAS in collaboration with the Dutch Embassy, Centro de Convenciones Crown Plaza, Managua, Nicaragua, September 29, 2005.

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Medina JA, Donaire TE, Meuwissen LE, Informe Linea de Base, proyecto educacion y atencion en salud reproductiva para jovenes, ICAS in colaboration with NicaSalud, Managua Nicaragua, June 2005.

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Meuwissen LE , El impacto de servicios de salud sexual y reproductiva accesible en el comportamiento de adolescentes, presentation in conference El Impacto de Programas de Salud Preventiva en la Sociedad Nicaragüense organised by ICAS in colaboration with Ministry of Health of Nicaragua, Hotel Seminole, Managua, Nicaragua, November 26, 2004.

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Meuwissen LE, Donaire TE, Medina JA, Segura ZE and Gorter AC. Nicaragua: Introducing a voucher scheme for disadvantaged adolescents' access to services in three districts. Sexual Health Exchange, 2004, 3&4 (translated in Spanish). http://www.kit.nl/ils/exchange_content/html/20043_4_nicaragua__introducing.asp

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Meuwissen L, Barriers to accede reproductive health services successfully removed. Presentation at Youth and Health: Generation on the Edge, Global Health Council’s 31st Annual Conference, Washington, DC, USA, 1-4 June 2004.

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Gorter A, Segura Z, González P and Meuwissen L, A voucher scheme for adolescents of Managua: an innovative programme to improve the uptake and quality of sexual health care, Seminar – Adolescent Sexual Health Care at the London School of Hygiene and Tropical Medicine, London, June 4, 2001.

Publications STI/HIV/AIDS voucher scheme for vulnerable populations: 

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Gorter AC, Segura ZE, Medina JA, Rodriguez OG, Medina GM, Peralta WJ and Rovin K, Providing STI/HIV/AIDS services to glue-sniffing young people in Nicaragua: needs, relevance and feasibility, Poster at the XVII International Conference on AIDS, 3-8 August 2008, Mexico City.

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Gorter AC and McKay J, Competitive voucher schemes to increase access to and quality of sexual and reproductive health care for marginalized and/or vulnerable populations, invited presentation at the British Society for Population Studies meeting “Reproductive health in Latin America: costs, outcomes and policies”, London School of Economics and Political Sciences, September 20, 2007, London, UK.

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Gorter AC and McKay J, Competitive Voucher Schemes for Health, Oral presentation at panel “How Can Private Providers be Engaged in Serving the Poor?”, 6th World Congress on Health Economics (iHEA), July 8-11, 2007, Copenhagen.

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Segura Z, Medina J, Medina G, Rodriguez O, Informe de Estudio sobre los aspectos generales del perfil epidemiologico y de salud, asi como de las capacidades de las instituciones para la prevencion, atencion y tratamiento de las ITS/VIH/SIDA y los conocimientos, aptitudes y practicas de las poblaciones de la zona de la estacion de paso de Peñas Blancas, Nicaragua, mayo 2007.

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Gorter AC, Segura ZE, Savelkoul PHM, Morré SA, Chlamydia trachomatis infections in Nicaragua: Preliminary results from a competitive voucher scheme to prevent and treat sexually transmitted infections and HIV/AIDS among sex workers, Drugs of Today 2006, 42 (Suppl. A): 4754.

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McKay JE, Campbell DJ, Gorter AC. Lessons for management of STI treatment programs as part of HIV/AIDS prevention strategies. American Journal of Public Health 2006; 96:7-9.

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Gorter AC, Segura ZE, Medina JA, McKay JE. Effectiveness and impact of a long running competitive voucher program providing quality STI/HIV care to groups most at risk of HIV in Nicaragua. Poster XVI International Conference on AIDS, Toronto, Canada, 13-18 August 2006.

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Gorter AC, Segura ZE, Medina JA, McKay JE. Adolescent and young sex workers in Managua, Nicaragua compared to their older peers: STI/HIV prevalence and evaluation of the effectiveness of a competitive voucher program disaggregated by age. Poster XVI International Conference on AIDS, Toronto, Canada, 13-18 August 2006.

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McKay JE, Campbell DJ and Gorter AC, Can targeted, high-cost STI treatment contribute to costeffective HIV prevention in developing countries? Evidence from a 10-year program in Nicaragua? Oral presentation IAEN Pre-Conference Meeting, Toronto 11-12 August 2006 (International AIDS Economics Network).

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McKay J, Campbell D, Gorter AC, Segura ZE. Can targeted STI treatment be a cost-effective contributor to HIV/AIDS prevention in developing countries despite its high unit cost? An applied study based on a long running voucher program in Nicaragua using simulation modelling to track program impacts, determine cost-effectiveness and identify cost effective program modifications. Poster XVI International Conference on AIDS, Toronto, Canada, 13-18 August 2006.

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Gorter AC, Segura ZE, Savelkoul PHM, Peña AS, Morré SA, Chlamydia trachomatis infections in Nicaragua: Preliminary results from a competitive voucher scheme to prevent and treat sexually transmitted infections and HIV/AIDS among sex workers. Poster presentation at the Eleventh International Symposium on Human Chlamydial Infections, Ontario, Canada, 18-23 June 2006.

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Gorter AC, Chlamydia trachomatis in Nicaragua, Invited presentation Second Mini Symposium Chlamydia trachomatis infections, VU University, Amsterdam, the Netherlands, March 28, 2006.

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Borghi J, Gorter A, Sandiford P and Segura Z, Counting the cost of a competitive voucher scheme for STI treatment in Nicaragua, ID21 Research Highlight: 18 January 2006. http://www.id21.org/id21ext/h6jb2g3.html

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Segura ZE, Prevención de las ITS- VIH – SIDA, presentation “Clausura y Presentación de Resultados de los Programas de Adolescentes y ITS-VIH-SIDA, 2002-2005”, ICAS in collaboration with the Dutch Embassy, Centro de Convenciones Crown Plaza, Managua, Nicaragua, September 29, 2005.

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Gorter AC, Segura ZE, Hermans MHA, Savelkoul PHM, Morré SA, Prevalence of sexually transmitted infections among different ‘high-risk’ populations of Managua, targeted by a HIV prevention programme using a competitive voucher scheme. Poster at 16th Biennial meeting of the ISSTDR, Amsterdam, 10-13 July 2005.

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Borghi J, Gorter A, Sandiford P and Segura Z. The Cost-Effectiveness of a Voucher Scheme to Reduce Sexually Transmitted Infections in High Risk Groups: the case of Managua, Nicaragua. Health Policy & Planning, 2005; 20(4): 222-31.

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Institute for Health Sector Development (IHSD-HLSP), UK, Private Sector Participation in Health. This resource reviews a number of demand- and supply-side mechanisms for engaging with the private sector. Four case studies - from Cambodia, Nicaragua (the Nicaraguan voucher scheme), Pakistan and Tanzania - illustrate some of the mechanisms reviewed, HLSP website, 2005. http://www.hlspinstitute.org/files/project/15043/D-PSPCaseStudiespdf.pdf

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Karl L. Dehne, Gabriele Riedner, Sexually transmitted infections among adolescents: the need for adequate health services, GTZ and WHO, Geneva, Switzerland, 2005. The Nicaraguan voucher scheme serves as one of the examples of innovative approaches to increase use of STI services by adolescents. ISBN 92 4 156288 9. http://www.who.int/child-adolescent-health

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WHO, Protecting young people from HIV and AIDS, the role of health services, in collaboration with UNAIDS, UNFPA, UNODC and Youthnet, Geneva, Switzerland, December 2004. The sex worker voucher scheme serves as one of the examples of innovative approaches to increase service use by young people. ISBN 92 4 159247 8. http://www.who.int/child-adolescent-health

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WHO, Achieving the global goals: access to services, Global consultation on the health services response to the prevention and care of HIV/AIDS among young people, Technical Report of a WHO Consultation in collaboration with UNAIDS, UNFPA and Youthnet, Montreux, 17-21 March

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2003. Published in 2004, Geneva, Switzerland. A chapter describes how a competitive voucher scheme works and its pros and cons. ISBN 92 4 159132 3. http://www.who.int/child-adolescent-health 

Chiaki Yamamoto, Output-based aid in health: Reaching the poor through public private partnership. The sex worker voucher scheme is described in this paper as one of the examples of Output Based AID in health. Paper Prepared for Technical Consultation on Health Sector Reform and Reproductive Health: Developing the Evidence Base Geneva, WHO, 30th November2nd December 2004.

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McKay, Resultados de un estudio de costo-beneficio en programas preventivos de VIH, presentation in conference El Impacto de Programas de Salud Preventiva en la Sociedad Nicaragüense organised by ICAS in colaboration with Ministry of Health of Nicaragua, Hotel Seminole, Managua, Nicaragua, November 26, 2004.

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McKay J, Campbell D, ¿Produce beneficios invertir en prevención del VIH/SIDA atendiendo a grupos con prácticas de alto riesgo?: Resultados de un estudio de costo-beneficio en Managua, Versión en español de tesis de grado de la Maestría en Salud Publica Internacional de la Universidad de Sydney, Australia. Managua, Nicaragua, Octubre 2004

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Gorter A, Segura Z, Zuñiga E and Medina J, Scaling up a successful research project to reach vulnerable populations with STI/HIV care through a competitive voucher scheme in Nicaragua. Poster at the 15th International AIDS Conference, Bangkok, 11-16th July 2004.

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Segura Z, Gorter A, Voucher scheme for sexual and reproductive health services, Nicaragua. In UNAIDS and the Royal Tropical Institute (2004), Techniques and practices for Local Responses to HIV/AIDS, part 2, KIT Publishers, Amsterdam, The Netherlands. Published at website KIT (Dutch Royal Tropical Institute)

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KfW, Case study of the Nicaragua voucher scheme for sex workers in Private Sector Participation in Health Sector Cooperation – Options and Experiences, Report February 2004, edited by Private Sector Participation, KfW Bankengruppe, Frankfurt am Main, Germany.

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Julienne McKay, An Economic Evaluation of a Voucher Scheme Amongst Commercial Sex Workers and Their Clients in Nicaragua Operated since 1996 by ICAS, University of Sydney, Australia. May 2004.

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Borghi J, Gorter A, Sandiford P & Segura Z, The Cost-Effectiveness of a Voucher Scheme to Reduce Sexually Transmitted Infections in Sex Workers and their Clients: the case of Managua, Nicaragua. Oral presentation at the 4th World Congress of the International Health Economics Association, San Francisco, USA, June 15-18, 2003.

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Segura Z, Gorter A, Zúñiga E, Torrentes R, Reducción de sífilis y factores de riesgo en trabajadoras sexuales de Managua, análisis de datos del Programa de bonos. Poster presentation II Foro en VIH/SIDA/ITS de América Latina y el Caribe, La Habana – Cuba, 7-12 April 2003.

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Gorter A, Review paper on evidence for using competitive voucher schemes and related methods for ensuring young people have access to health service interventions designed to prevent or provide care for HIV/AIDS, background paper prepared for the “Consultation on the health services response to the prevention and care of HIV/AIDS among young people” organized by WHO with UNICEF, UNFPA, UNAIDS and YouthNet, Montreux, Switzerland, March 2003.

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Sandiford P, Competitive voucher schemes, Can they improve healthcare for the poor? ID21 Insights Health Issue #3, March 2003 at: http://www.id21.org/insights/insights-h03/index.html

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Sandiford P, Gorter A, Salvetto M. Bonos para una mejor salud sexual. Programa basado en la compra del servicio completo en lugar de financiar insumos. El Observador 24:4-5, 19 December 2002.

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Gorter A, Segura Z, Sandiford P, Competitive Voucher Schemes for Better Health for Vulnerable Populations and Poor. Invited presentation and clinic at the Discussion Forum on Private Provision of Health Services in Developing Countries of the World Bank, Washington DC, US, November 7, 2002.

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Gorter A, Segura Z, Zuñiga E, Torrentes R, Risk factors for syphilis within a female sex worker population in Managua, analysing data from a voucher program. Oral presentation at 18th Congress of Sexually Transmitted Infections, Vienna, September 12-14, 2002

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Gorter A, Segura Z, Zuñiga E, Torrentes R, The potential of voucher schemes for the prevention and treatment of sexually transmitted infections amongst clients of sex workers. Poster presentation XIV International AIDS Conference, Barcelona, Spain, July 2002.

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Segura Z, Gorter A, Zuñiga E, Torrentes R, A voucher scheme to reach young sex workers (including glue-sniffing girls), to treat sexually transmitted infections and to prevent HIV transmission. Poster XIV International AIDS Conference 2002, Barcelona, Spain, July 2002.

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Segura Z, Gorter A, Zuñiga E, Torrentes R, Programa de “bonos” del ICAS para combatir el VIHSIDA. Invited presentation at the regional workshop of the Novib Aids Platform in Latin America, Salvador, Brazil, 23-25 January 2002.

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Gorter A, Segura Z, Zuñiga E, Torrentes R, The ICAS voucher scheme to combat HIV/AIDS, Nicaragua. Invited presentation at the DfID Safe Passages to Adulthood & WHO Expert Meeting, Brighton, UK, December 2001. Published in the DfID/WHO Safe Passage to Adulthood series: Preventing HIV/AIDS, promoting sexual health, among especially vulnerable young

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people, July 2002 (series on best practices ISBN 0-85432-783-5). http://www.socstats.soton.ac.uk/cshr/pdfs/evypframework.pdf 

Segura Z, Gorter A, Zuñiga E, Torrentes R, Un programa de 'Bonos' reduce las ITS en inhalantes de pega en Managua. Oral presentation II Congreso Centroamericano de ITS/VIH/SIDA, Guatemala, November 2001.

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Report of the Technical Appraisal Mission of the Ministry of Health of Honduras of the voucher project in Managua: Sept 5-8, 2001.

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Segura Z, Gorter A, Zúñiga E, Torrentes R, Un programa de bonos atrae no solo a trabajadoras sexuales sino también a sus clientes, invited presentation at the UNAIDS Workshop on the development of projects on HIV/AIDS in Central America and Mexico, San Pedro Sula, Honduras, 2-3 August 2001.

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Gorter A, Segura Z, Zuñiga E, Torrentes R and Sandiford P, Voucher programs can effectively reduce sexual transmitted infections in groups with high rates, the case of Managua, Poster International Congress of Sexually Transmitted Infections Berlin, June 24 – 27, 2001.

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Pearson M, Demand side financing for health care, Discussion paper for DfID on voucher schemes, Health Systems Resource Centre, UK, April 2001.

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Gorter A and Sandiford P, Vouching for health: HIV prevention for sex workers in Nicaragua, ID21 News, March 2001. http://www.id21.org/id21ext/h6ps1g1.html

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Josephine Borghi, The Cost-Effectiveness of a voucher programme for sex workers and their clients, The case of Managua-Nicaragua. Economical Report Prepared for the Instituto Centro Americano del Salud. In collaboration with Anna Gorter, Zoyla Segura, Esteban Zuniga, Roger Torrentes, March 2001.

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Segura Z, Gorter A, Torrentes R, Zuniga E, Un programa de bonos atrae efectivamente no solo a las trabajadoras sexuales sino que también a sus parejas y/o clientes, enfocando en la prevención, detección y tratamiento de las ETS, oral presentation in “I Foro y II Conferencia de Cooperación Técnica Horizontal de América Latina y del Caribe en VIH y SIDA y ETS”, Rio de Janeiro, Brasil, Nov 6-11, 2000.

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Gorter A, Segura Z, Zuniga E, Torrentes R and Sandiford P, A voucher programme can efficiently target groups with high need for sexual health services, the case of Managua, Oral Presentation 13th World Aids Conference, Durban, June 2000. The programme received a special mention at the last day rapporteur session of the conference.

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Segura Z, Gorter A, Torrentes R, Zuniga E, Sandiford P, Un programa de prevención del VIH/SIDA en Managua; detección, tratamiento y prevención de ETS en grupos de alto riesgo a través de un innovador programa de bonos, Paper at I Congreso Centroamericano de Enfermedades de Transmisión Sexual y VIH/SIDA, San Pedro Sula, Honduras Nov. 7-10, 1999.

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Gorter A, Segura Z, Sandiford P, Zuñiga E, Torrentes R, Ådahl S. “You should not tell us to use condoms, but our clients!” An extended voucher programme in. Research for Sex Work Newsletter 3, July 2000, Amsterdam. http://www.nswp.org/pdf/R4SW-03.PDF

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Sandiford P, Segura Z and Gorter A, Voucher schemes and Magnetic Resonance, DfID workshop on "Making the Most of the Private Sector", London. May 2000.

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Sandiford P, Salvetto M, Segura Z, Gorter A. Clinics for sex workers in Managua. In Harper M (ed.) 'Public services through private enterprise; micro-privatisation for improved delivery', IT Publications, London, and Oxford IBH Publishers New Delhi, 2000.

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Gorter A, Sandiford P, Segura Z and Villabella C. Improved health care for sex workers. A voucher programme for female sex workers in Nicaragua. Research for Sex Work Newsletter 2, August 1999, Amsterdam. http://www.nswp.org/pdf/R4SW-02.PDF

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Sandiford P, Coldham C and Gorter A, Should publicly-funded health services be distributed by vouchers?: A review of experience in other sectors. Unpublished paper. ICAS, Nicaragua, 1998.

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A voucher scheme improves female sex workers’ access to quality health care. International Health Matters, No. 4, June 1999. London. (Newsletter of DfID).

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Sandiford P, Gorter A, Salvetto M, Segura Z, A voucher scheme for female sex workers. Invited presentation at the IHSD seminar, May 1999. London.

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Segura Guevara Z, Novedoso programa mejora calidad de servicios de control de ETS para trabajadoras sexuales, Boletin Salud con Calidad, No.9, 1999, ICAS, San Jose, Costa Rica.

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Gorter AC, Sandiford P and Villabella C, A voucher scheme to improve access to health services for female sex workers reduces sexually transmitted diseases, abstract 12th World Aids Conference, Geneva, June 28-July 3 1998.

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“Better Medical care for prostitutes: Action programme in Central America seeks to improve health and ward off the threat of AIDS”. This article describes the voucher scheme and was written up as one of the Department for International Development ‘success stories’ of UK development assistance. The scheme was mentioned by Minister Claire Short of DFID in her speech to mark World AIDS day 1997.

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Villabella C, Gorter A, Sandiford P and Monge R, Ensayo de un sistema de bonos para mejorar la calidad, eficiencia y equidad de los servicios de salud y el control de las enfermedades de transmission sexual en trabajadoras sexuales, Paper at V Conferencia Latinoamericano de SIDA, Lima, Peru, Dec. 3-6, 1997.

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Villabella C, Gorter A and Sandiford P, Programa de Bonos para control de Enfermedades de Transmisión Sexual en Trabajadoras Sexuales, Paper at XXI Congreso Centroamericano de Ginecología, Managua, Nicaragua, Nov.17-21 1997.

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Visit of a delegation of the Ministry of Health of Peru (26-30 October 1997) to learn the details of the voucher project and consider replication in Lima. (David Lewis, DFID Health Officer based in Lima and two officials of the Ministry of Health Lorena Vargas and Patricia Segura).

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Gorter A, Sandiford P, Villabella C, Monge R, and Standing H, Female sex workers: more than a core. Paper at Pre-conference workshop on health needs for FSWs, International STD congress, Sevilla, Spain, 19-22 October 1997.

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Villabella C y Roman J. Infecciones por Chlamidias, XII Congreso de Estudiantes de Medicina de Centroamérica, Managua, Nicaragua, 19-21 August 1997.

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Sandiford P, Trial of a voucher system for female sex-workers. Invited presentation at the working group of the European Commission’s Task Force on AIDS, Brussels, 21 March 1997.

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Standing H, Gorter A, Sandiford P, Monge R, Palmen M and Pauw J, The management of health related occupational risks among female sex workers in Managua. Was submitted to Social Science and Medicine and translated to Spanish and distributed in Managua.

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Sandiford P and Gorter A. Enfermedades de Transmisión Sexual / SIDA, Prevención y Consecuencias en la Salud de Hombres y Mujeres. Invited Presentation II Curso Internacional “Salud Reproductiva y Sociedad”, 3-7 March 1997, “Cayetano Heredia” University in Lima, Peru.

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A report on the project was produced for the BBC World Service and broadcast on November 18, 1996.

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Sandiford P, Gorter AC, and Braddock M. Are Voucher Systems the Way to Organize Health Care in the 21st Century? Paper presented at the 6th International Conference on System Science in Health Care, Barcelona, Spain, September 16-20, 1996.

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Sandiford P, Gorter A and Torres MC. Sexually transmitted disease in developing countries [letter]. Transactions of the Royal Society of Tropical Medicine and Hygiene, 90:587; 1996. A letter in response to a lead article on STDs in developing countries by David Mabey.

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Gorter A, Sandiford P, seminar “Voucher scheme for sex workers in Managua” at the Liverpool School of Tropical Medicine, Liverpool, UK, February 1996.

Other publications on voucher schemes 

Bhatia MR and Gorter AC. Improving access to Reproductive and Child Health services in developing countries: are competitive voucher schemes an option? Journal of International Development; 2007; 19(7): 975-981 (16 March 2007, DOI: 10.1002/jid.1361). Summary published in id21 Research Highlight: 18 December 2007.

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Bhatia MR, Yesudian CAK, Gorter AC and Thankappan KR. Demand side financing for Reproductive and Child Health (RCH) services in India. Economic and Political Weekly, January 2006, India.

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Piot, Peer, et. al., Coming to terms with complexity: a call to action for HIV prevention The Lancet; 372: 845-59; and Bertozzi, Stegan M, et. al., Making HIV prevention programmes work The Lancet 2008; 372: 831-44 ii Picazo, Oscar Performance Based Financing of Health Services: Basic Concepts and Illustrative Cases Management Sciences for Health 2010 iii “Pay for performance” (a.k.a. P4P), a catch all phrase incorporating multiple supply and demand side payments on condition that certain performance is achieve, will not be highlighted here but individual types of P4P will be outlined. A number of these kinds of options are outlined below and include conditional grants, conditional cash transfers, and performance contract and so on. iv A good reference to this approach was written by Timothy B. Hallett and Over, Mead How to Pay “Cash-onDelivery” for HIV Infections Averted: Two Measurement Approaches and Ten Payout Functions Center for Global Development Working Paper 2010, April 2010 v Yogita Mumssen, Geeta Kumar and Lars Johannes, Targeting Subsidies Through Output-Based Aid Output Based Aid Approaches, Note Number 22, October 2008 vi Peter Berman Take a Walk on the Demand Side Conference on Vouchers for Health: Increasing Access, Equity and Quality. April 12-13, Gurgaon, India

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