Combining Community Approaches and Government Policy to Prevent HIV Infection in the Dominican Republic

Published by personnel from Horizons/Population Council, Johns Hopkins University, Centro de Orientación e Investigación Integral, Centro de Promoción y Solidaridad Humana, and International Center for Research on Women, this 55-page report shares findings from a study that assessed the impact and cost-effectiveness of two "environmental-structural" interventions in reducing HIV-related risk among female sex workers in the Dominican Republic. In contrast to health communication programmes that seek to prevent HIV/AIDS by reaching members of vulnerable groups as individuals, the two models at issue in this research address the physical, social, and political contexts in which individual behaviour takes place.

Developed by both non-government organisations (NGOs) and government agencies after what the authors describe as "extensive formative research and consultation with sex worker peer leaders", the models were implemented in 68 sex establishments in two Dominican cities. In Santo Domingo, a community-based solidarity approach to 100% condom use was implemented, while in Puerto Plata, a smaller coastal city where tourism is prevalent, solidarity was combined with government policy and regulation.

The communication strategy being tested in this research involves an environmental-structural approach that focuses on solidarity-building among female sex workers and those with whom they are in communication. Activities in both cities included workshops and meetings with sex workers, sex establishment owners and managers, and other employees (such as doormen and deejays) to strengthen collective commitment to HIV/sexually transmitted infection (STI) prevention, particularly in supporting sex workers to use condoms with partners. The aim was to involve community members as full partners in the conceptualisation, implementation, and evaluation of policy-based initiatives to ensure both their effectiveness as well as their acceptability and appropriateness to the intended "audience" (sex workers).

Interpersonal, face-to-face communication was used to engage the women themselves, and those who might support their adoption of healthier, risk-reducing behaviours; the sharing of information was fostered by entertaining modes of communicating. For instance, "During the workshops, interactive games helped the women describe and define the different types of relationships they had with their sexual partners and together identify the HIV/STI risks for each kind of relationship. As a group, the women brainstormed how they could be more critical and objective in establishing relationships of trust and participated in role plays to develop communication and negotiation techniques they could use to ensure safer sex with different partner types. Specific educational messages and materials were developed for these purposes." The gatherings also focused on exploring issues of trust and intimacy in condom use negotiation between sex workers and regular paying and non-paying partners.

Sex establishment owners were also engaged as potential allies. To enhance a collective commitment to prevention, each owner was encouraged to ensure that 100% condom use posters and other awareness-raising materials, as well as glass bowls filled with condoms, were in place within each establishment. Other cues to support condom use included deejay messages about safer sex, information booths at establishment entrances, and participatory theatre with male clients. In Puerto Plata, the same solidarity-building model was used but included a government-sponsored policy that required condom use between sex workers and all clients. To support this policy, owners were thought to be key motivators; they were told that they, not the sex workers, were responsible for ensuring compliance with the policy and with programme activities. For those not in compliance, government officials imposed a graduated series of warnings, fines, and other sanctions, including closure of the establishment.

To test the effectiveness of this strategy, and to compare the impact of the two models, researchers used a pre-/post-test evaluation design. Structured surveys and non-routine STI testing were conducted among a random, cross-sectional sample of approximately 200 female sex workers, age 18 years and older, from the study establishments; data were collected at baseline and at the end of the 12-month intervention period. In brief, both of the adapted 100% condom models had a positive impact on specific HIV-related outcomes. For instance, rates of STIs decreased almost 40% in both cities from pre- to post-intervention. However, findings suggest that an integrated model involving both a community-based solidarity strategy and a government-sponsored policy and regulation strategy - that is, the Puerto Plata model - led to further increases in HIV-related protective behaviour as well as reductions in STI among female sex workers. For example, the percent of sex workers who rejected having sex without a condom after hearing four reasons that a client might use to justify not using a condom increased significantly from 50-79%. In Santo Domingo, rejection of unsafe sex also increased from 64-72% percent, but the difference was not statistically significant.

The research also highlighted the importance of involving men as a strategy in future communication-based interventions that might be undertaken to reach this population, either in the Dominican Republic or elsewhere. "Participating sex workers from the current study who tested positive for STIs at both pre- and post-test were asked, in a brief open-ended questionnaire as part of post-test counseling, how the intervention could help support them to avoid reinfection. Almost unanimously the women stated that future intervention efforts must increase the reach and scope of work with male clients. Additionally, most women articulated the importance of special efforts to involve both regular paying and non-paying partners of female sex workers, by whom many of the women felt they had been infected. Currently, formative ethnographic research is under way in the Dominican Republic to understand how to engage male clients and mobilize their potential to prevent HIV."