EVALUATION OF THE USAID AIDS HELP PROJECT
Submitted by:
The Synergy Project
TvT Associates, Inc.
And
University of Washington
King K. Holmes, M.D., Ph.D.
Connie Celum, M.D., M.P.H.
Annette E. Ghee, M.P.H.
Submitted to:
The United States Agency for International Development/Peru
Under Contract No. HRN-C-00-99-00005-00
EVALUATION OF THE USAID AIDS HELP PROJECT
Project Number 527–0378
Submitted by:
The Synergy Project
TvT Associates, Inc.
and
University of Washington
King K. Holmes, M.D., Ph.D.
Connie Celum, M.D., M.P.H.
Annette E. Ghee, M.P.H.
Submitted to:
The United States Agency for International Development/Peru
Under Contract No. HRN-C-00-99-00005-00
June 2000
 ACRONYMS AND FOREIGN TERMS
ART Antiretroviral therapy
BCC Behavior change communication
BCI Behavior change intervention
CDC Centers for Disease Control and Prevention
CEPESJU Centro de Estudios de Problemas Económicas y Sociales de la Juventud
CERETS Centro de Referencia de Enfermedades Transmisión Sexual
COPRECOS Comité de Prevención Contra el SIDA de las Fuerzas Armadas del Peru
ENDES National Demographic, Education and Health Survey (Encuesta Nacional de
Demografía, Educación y Salud)
FSW Female sex worker
GAM Self-help group (grupo de ayuda mutua)
HIV/AIDS Human immunodeficiency virus/acquired immune deficiency syndrome
HPN Office of Health, Population and Nutrition
IEC Information, education and communication
INPPARES Instituto Peruano de Paternidad Responsable
JERECIAS Unit of PROMUDEH
MCH Maternal and child health
MHOL Movimiento Homosexual de Lima
MOH Ministry of Health
MSF Médecins sans Frontières (Doctors without Borders)
MSM Males who have sex with males
NGO Nongovernmental organization
OGE Oficina General de Epidemiología
PAHO Pan American Health Organization
PEP Peer educator (promotor de educación en pares)
PHC Primary health care
PLWHA Persons living with HIV/AIDS
PROCETSS National Program for the Control of STDs and AIDS (Programa de Control de
Enfermedades de Transmisión Sexual y SIDA)
PROMUDEH Ministry of Women’s Advancement and Human Development
PROSA Programa de Soporte a la Autoayuda
RCS Red SIDA Perú (Peruvian AIDS Network)
RPR Rapid plasma reagin
STD/STI Sexually transmitted disease/sexually transmitted infection
UAMPS Unidad de Atención Medica Periódica
ULE Urine leukocyte esterase
UNAIDS Joint United Nations Programme on HIV/AIDS
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
UNSCHO United Nations Day in the Schools
UPCH Universidad Peruana Cayetano Heredia
USAID U. S. Agency for International Development
USNAMRID U.S. Naval Medical Research Institute Detachment, Lima, Peru
WHO World Health Organization
CONTENTS
Page
EXECUTIVE SUMMARY............................................................................................. i
I. BACKGROUND ....................................................................................................... 1
Program and Institutional Sustainability ...................................................................... 4
II. EVALUATION PURPOSE AND METHODOLOGY............................................. 5
III.SUMMARY OF FINDINGS AND SPECIFIC RECOMMENDATIONS............... 6
Recommendations....................................................................................................... 8
Regionalization ........................................................................................................... 8
CERETS, UAMPS, and MCH Clinics: STDs and HIV Services.................................. 9
Persons Living with HIV/AIDS and Self-Help Groups................................................ 11
High-Risk Target Populations...................................................................................... 11
Surveillance and Monitoring Systems.......................................................................... 16
Use of the RAPID Model to Disseminate Findings and Affect Policy .......................... 17
Performance of USAID ............................................................................................... 18
Interinstitutional and Crossprogrammatic Coordination ............................................... 18
Institutionalization of Technically Sound Behavior Change Communication (BCC)
Approaches............................................................................................................ 19
NGO Strengthening Activities..................................................................................... 22
Collaboration with Business and Industry.................................................................... 26
Improved Information Dissemination via Publications, Conferences/Workshops,
and a Documentation Center.................................................................................. 27
Recommendations for Ensuring Sustainability of HIV/AIDS/STD Prevention and
Care Activities....................................................................................................... 29
Recommendation Concerning Transfer of HIV/AIDS/STD Prevention and Care
Activities to VIGIA ............................................................................................... 32
Additional Crosscutting Recommendations ................................................................. 33
TABLES
1: Funding for PROCETSS from the Government of Peru/Ministry of Health and from
USAID, 1997–2000..................................................................................................... 6
2: Distribution of Audience Members Attending PROCETSS “Impact of the HIV/AIDS
Epidemic” Presentations.............................................................................................. 18
3: Summary of AIDS Help–funded NGO Activities ........................................................ 23
APPENDICES
A: Scope of Work
B: Summary of Evaluation Activities
C: Documents Reviewed
D: PROCETSS Organizational Chart
i
EXECUTIVE SUMMARY
SCOPE OF WORK
The scope of work (appendix A) for this final evaluation of the AIDS Help project
included four objectives:
1. Assess progress toward achievement of described results and assess the
performance of the Ministry of Health (MOH)/Programa de Control de ETS y
SIDA (PROCETSS) as the implementing entity and of the U.S. Agency for
International Development (USAID) as the funding agency;
2. Determine the status of the project, potential information, education and
communication (IEC) and nongovernmental organization (NGO) health care
network activities;
3. Evaluate financial, institutional, and social sustainability of the project; and,
4. Determine the impact of transferring project activities to the VIGIA project.
The AIDS Help project was supported by USAID (total three-year budget: $1,000,000)
and was implemented by the MOH/PROCETSS between January 1, 1997, and December
31, 1999. The evaluation in Peru took place from January 12, 2000, through January 23,
2000, in Lima, Callao, Iquitos, Trujillo, Chimbote, and Chiclayo (appendix B).
Evaluation activities included meetings and presentations from representatives of the
following institutions: USAID; MOH/Peru, including the PROCETSS team and VIGIA
project director and the Oficina General de Epidemiología (OGE); the military Comité
de Prevención Contra el SIDA de las Fuerzas Armadas del Peru (COPRECOS); United
Nations organizations, including the Joint United Nations Programme on HIV/AIDS
(UNAIDS), the United Nations Population Fund (UNFPA), the United Nations
Children’s Fund (UNICEF), the United Nations Day in the Schools (UNSCHO); NGOs
and community members from high-risk populations, including males who have sex with
males (MSM) and female sex workers (FSWs); Instituto Materno Perinatal, Universidad
Peruana Cayetano Heredia (UPCH), San Marcos University, and Hospital Carrion in
Lima and Callao; interinstitutional (or intersectoral) roundtable discussions concerning
human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS); and
PROCETSS operational units in each of the cities visited; and, review of the many
documents provided by USAID, PROCETSS, VIGIA, and others (see appendix C),
including the AIDS Help Activity Design and the final project report prepared by
PROCETSS.
ii
FINDINGS
Epidemiology of HIV/AIDS in Peru
The Peruvian HIV epidemic remains largely concentrated in high-risk populations, with
the highest prevalence among MSM, ranging from 14 percent prevalence in Lima to an
average of 4.7 percent in seven cities other than Lima. In Lima, the observed annual HIV
incidence has been 3.3 percent in a cohort of MSM (the ALASKA cohort), which is 2–3
times higher than the average annual incidence of 1.6 percent among comparable groups
of MSM from six U.S. cities for the years 1995–97. The HIV prevalence among FSWs
in Lima has ranged from approximately 1 percent to 3 percent, and the prevalence among
pregnant women throughout Peru has ranged from 0.3 percent to 0.5 percent. Interviews
of HIV–infected pregnant women in Lima and of their male partners indicate that the
majority of such women appear to have been infected by male partners who either had
sex with other males or with FSWs.
The proportion of reported AIDS cases involving women has been gradually increasing
in Peru (for 1998, approximately 25 percent were female) as has the proportion of cases
among men attributed to reported heterosexual activity (for 1998, 55 percent of men
reported with AIDS were heterosexual, while 45 percent were homosexual or bisexual).
A substantial minority (approximately 20 percent) of both HIV–positive and HIV–
negative MSM in Peru report bisexual behavior and represent a potential bridge for
transmitting HIV and STDs to heterosexual populations. Similarly, a large proportion of
young Peruvian men report sex with FSWs (35 percent within the past year) and
represent a large bridge population for transmission of HIV from high- to low-risk
women.
PROGRESS TOWARD DESIRED RESULTS AND
CURRENT STATUS OF PROJECT
Overview of the PROCETSS Program
During the past three years, PROCETSS has been developing a sexually transmitted
disease (STD)/HIV–prevention program that represents a model for the Andean region.1
For example, Peru was among the first three countries in Latin America (with Brazil and
Bolivia) to adopt syndromic management of STDs and to begin zidovudine prophylaxis
to prevent perinatal HIV transmission in 1996. The program strategy is guided by
epidemiological data; interventions are evidence based and are being scaled up to cover
most medium-sized cities throughout the country by the end of the year 2000. The
program uses peer educators (PEPs) working with MSM and FSWs, and in Lima, Callao,
and Iquitos, with youth to promote condom use and prompt use of strengthened STD/HIV
 
1 Holmes, K.K. and Prada, G. “Prevention of STD/HIV in the Andean region: models for other regions?”
Symposium presented at the 9th International Congress on Infectious Diseases, Buenos Aires, Argentina,
April 10–13, 2000. Abstracts 29.001–29.004.
iii
prevention services. The behavior change communication (BCC) materials produced are
of high quality, accessible, acceptable, and widely used, including by the large work
force of PEPs who have face-to-face contact with high-risk populations. Visits to several
regions outside Lima allowed direct assessment of the strength of the regional offices of
PROCETSS. These were observed to be dynamic, well managed, and coordinating very
active programs in Iquitos, Chiclayo, and Trujillo, but were acknowledged by
PROCETSS staff to be weaker in selected regions not visited.
Behavior Change Interventions (BCI)
Interventions have focused on motivating changes in sexual risk behavior promoting
condom use and encouraging appropriate use of STD services among highly sexually
active persons. These interventions have been developed in a technically sound manner
and have included a range of approaches, most notably the use of printed media
(brochures and fliers) and videotapes coupled with an impressive capacity to deliver face￾to-face education/motivation and condoms by both peers and trained counselors.
Surveillance and ongoing epidemiological research suggest that this approach has
improved condom use behavior and lowered STD rates in high-risk groups, but analyses
of these data are incomplete. PROCETSS has made efforts to explain the potential
impact of the epidemic in demographic and economic terms to stimulate a favorable
policy-making environment, and this is thought to have helped with increasing budgetary
support by the MOH, but there is little evidence that these efforts have reached other key
policy makers at the highest level of government or influential individuals in the business
community.
Nongovernmental Organizations (NGOs)
The most effective NGOs working with HIV/AIDS prevention are either based in Lima
or have focused their activities there, but there is recognition both by the government and
by these NGOs of the importance of building community-based programs in other cities
of the country. During the AIDS Help project period, several operational research
activities were funded by PROCETSS, undertaken by NGOs, and used by PROCETSS
primarily in the development of BCC materials for high-risk behavior groups. NGO staff
collaborated with PROCETSS to train peer educators and STD counselors and were
included in PROCETSS’ training activities to a limited extent. Process indicators suggest
that these activities had a positive impact on NGO capability and the sustainability of
NGO efforts, but this was not systematically assessed.
The System of HIV/STD Service Delivery
This system appropriately focuses on primary prevention of transmission, and on
secondary prevention of opportunistic infections among those with known HIV infection.
Funds from the social security and military systems provide antiretroviral treatment for
limited numbers of persons with AIDS (e.g., approximately 300 persons). The potential
cost of antiretroviral drugs for treating 1,000 individuals with AIDS in Peru probably
ranges from at least $7 to 10 million per year for drugs alone, depending on the type of
iv
triple combination antiretroviral therapy used (this calculation excludes laboratory,
personnel, and other health care infrastructure costs). The current system of syndromic
management of STDs can be modified by eliminating treatment for cervical infection
from the vaginal discharge algorithm, with considerable cost savings.
SUSTAINABILITY OF THE PROJECT
Financial and institutional sustainability is evidenced by the commitment from the
government of Peru, which has steadily increased the budget for PROCETSS from
7,500,000 soles in 1997 to 18,500,000 soles in 2000, with considerable regional and local
support leveraged by these funds. For example, based on interviews in Iquitos, it was
estimated that for one position funded by PROCETSS, there were 35.5 positions fully or
largely committed to HIV/AIDS/STD care and prevention that were funded by local and
regional MOH sources.
The Centro de Referencia de Enfermedades Transmisión (CERETS)/Unidad de Atención
Medicas Periódica (UAMPS) services are provided at no charge to FSWs and MSM who
voluntarily seek care in Peru. The Peru program emphasizes civil liberties but not cost
recovery. The World Bank has emphasized the “negative externalities” of STD and HIV
infection, resulting in the failure of market forces to ensure delivery of services to those
who should receive them. The public good resulting in rendering an infected person less
infectious warrants and dictates the use of public funds for STD treatment throughout the
world.2,3
IMPACT OF TRANSFERRING USAID SUPPORT ACTIVITIES FROM AIDS
HELP TO THE VIGIA PROJECT
The VIGIA project mission, goal and purpose, policy underpinnings, linkages, and
activity interventions (surveillance, applied research, prevention and control, and
strengthening laboratory resources) are sufficiently broad and inclusive to encompass a
range of important HIV/AIDS/STD prevention activities. PROCETSS is the
governmental agency within the MOH responsible for HIV/AIDS/STD prevention and
care in Peru. Under AIDS Help, the USAID AIDS Help project coordinator related
directly to PROCETSS. The current channeling of USAID support for HIV/AIDS/STD
activities via the VIGIA project (Addressing Threats of Emerging and Re-Emerging
Infectious Diseases) shifts the locus of control dynamics for USAID support for
HIV/AIDS/STD. VIGIA interacts closely with OGE and the National Institute of Health,
as well as with PROCETSS. The need for development of overall consensus between
USAID, VIGIA, and PROCETSS on mutual goals and objectives, as well as criteria and
processes for selecting specific activity priorities, are discussed below. In addition,
 
2 Ainsworth, M. and Over, M. Confronting AIDS: Public Priorities in a Global Epidemic. A World Bank
policy research report, Oxford University Press, 1997.
3 Ainsworth, M., Franzen, L., and Over, M. Confronting AIDS: Evidence from the Developing World. The
European Commission, Brussels, Belgium, and the World Bank, Washington, D.C.: Office for Official
Publications of the European Communities ISBN 92-828-4991-0, L-2985 Luxembourg, 1998. Catalogue
number (10 15 05) CF-17-98-572-EN-C.
v
mechanisms are needed for encouraging and coordinating other USAID program
activities (e.g., in policy, human rights, youth, women’s health, and reproductive health)
involving HIV/AIDS/STD prevention and care.
RECOMMENDATIONS
The following overarching recommendations address future priorities for
HIV/AIDS/STD prevention and care in Peru, many of which could represent potential
new lines of USAID support.
1. Establish a multisectoral national AIDS advisory council of the government of
Peru. The council could formally adopt and validate a national five-year strategic
plan for AIDS, establish a favorable policy-making environment in Peru, involve key
decision-makers within public and private sectors, and further engage the NGO
community and persons living with HIV/AIDS (PLWHAs) in planning and
implementing STD– and HIV–prevention programs.
2. Consolidate community-based, regional HIV/AIDS/STD prevention activities at
the peripheral level. Consider slowing the scale up and expansion of the ambitious
PROCETSS program development to consolidate and stabilize all that has been
achieved to date. Use year 2000 sentinel surveillance data from cities outside Lima to
target interventions for MSM and FSWs to highest morbidity regions, and increase
emphasis on training, supervision, ongoing monitoring of PEPs and CERETS;
implement an improved informatics system; update IEC materials; and, evaluate the
impact of the PEP and CERETS/UAMPS programs.
3. Promote a balance appropriate to the stage of the epidemic and the evolving
science of HIV/AIDS prevention and care between a vertical HIV/AIDS/STD
system serving high-risk target populations and horizontal integration of
HIV/AIDS/STD prevention and care services. Vertical programs are important
when HIV is concentrated in core groups, as those populations historically have been
marginalized, stigmatized, and generally unreachable when HIV services were
provided primarily through family planning and primary health care (PHC) programs.
At the same time, it is important to continue to improve the quality of HIV prevention
and the technical level of STD services offered to the general population through
programs that see sexually active teens and young adults (e.g., family planning,
antenatal, PHC programs, and pharmacies).
4. Support the continuation and expansion of HIV/AIDS/STD prevention and
reproductive health services for youth, including out-of-school youth. This would
include strengthened and expanded health services specifically intended for high-risk
youth that encounter considerable barriers to presenting reproductive health concerns
to health care providers. It is appropriate to support the development of a network of
health care services appealing to youth both within public and private sectors. Such a
network also should address the present legal barriers (e.g., need for parental consent)
vi
to adolescent access to reproductive health care services. Recently developed BCC
programs to better motivate behavior change and awareness of STD prevention issues
among youth (particularly out-of-school youth) require close supervision, monitoring,
and strengthening to increase their effectiveness and needs over time.
5. Maximize the effectiveness of investment in HIV/AIDS/STD prevention in Peru
by the national government and donors by supporting epidemiologic,
operational, and health services research. Specifically, support inclusion of the
1996 STD and Sexual Behavior Survey Set in the year 2000 National Demographic,
Education and Health Survey (ENDES). In particular, expand the questions for
assessing trends in risk behavior and disease morbidity to help evaluate the impact of
HIV/AIDS/STD prevention programs over time. Evaluate the cost-effectiveness of
the PEP and CERETS programs for diagnosing and managing HIV and STDs,
condom promotion, and risk reduction. Assess the potential costs of providing
antiretroviral therapy for persons with advanced HIV infection (e. g., CD4 less than
200 or clinical AIDS).
6. UNAIDS should lead efforts to inform and mobilize other funding agencies, to
coordinate a donor group for HIV/AIDS/STD prevention and care, and to
strengthen advocacy efforts led by PROCETSS. USAID could play a lead role
among these funding agencies.
7. Consider the following technical changes in the current PROCETSS program:
ß Modify the algorithm used by PROCETSS and the reproductive health
program for managing vaginal discharge in light of recent data showing low
specificity of the vaginal discharge algorithm for cervical infection.
ß Develop a BCC program in diverse settings to motivate clients of FSWs to use
condoms and seek STD and HIV screening. Assess the feasibility and
applicability of the Thai programs that promote 100 percent condom use
among FSWs and that successfully modified sexual behavior among Thai
military recruits.
1
I. BACKGROUND
The global epidemic of human immunodeficiency virus (HIV) has resulted in 50 million
cases of HIV infection by the year 2000, with over 15,000 new HIV infections occurring
per day in 2000, 95 percent of which occur in developing countries. A recent intelligence
report in the United States concluded that emerging infectious diseases—particularly HIV
and acquired immune deficiency syndrome (AIDS)—represent a security threat that
warrants intensified prevention efforts.
The U.S. Agency for International Development’s (USAID’s) current Strategic Support
Objective is to “increase the use of improved, effective and sustainable responses to
reduce HIV transmission and to mitigate the impact of the HIV/AIDS pandemic.” This
was built on two overarching themes: the need for continued and expanded emphasis on
sustainable responses to prevent HIV transmission and a new emphasis on mitigating the
epidemic’s impact on people and communities while more closely studying its social
economic, and policy impacts.
USAID is using six approaches to achieve this Strategic Support Objective:
ß strategies to reduce the sexual transmission of HIV;
ß managing and preventing sexually transmitted infections (STIs);
ß eliminating barriers to providing HIV/AIDS services to youth, women,
persons living with HIV/AIDS (PLWHAs), and other vulnerable populations;
ß increasing the capacity of nongovernmental, community-based and
commercial organizations to respond to HIV/AIDS;
ß increasing the quality, availability, and use of evaluative and surveillance
information; and,
ß developing and promoting effective strategies for providing basic care and
support services for PLWHAs.
Few countries in Latin America have established effective sexually transmitted disease
(STD) diagnosis and treatment services for female sex workers (FSWs). In 1995–96,
Sanchez et al. found that the previously existing program for periodic examination of
FSWs in Lima was ineffective, and that the scope, quality, and efficacy of STD control
programs must be more technically appropriate, better managed, and adequately
financed.4
 Initial ethnographic research on health-seeking behavior and perceived needs
involving collaboration between the Programa de Control de Enfermedades de
 
4
 Sanchez, J., Gotuzzo, E., Escamilla, J., Carrillo, Carlos, Moreyra, L., Stamm, W., Ashley, R., Swenson,
P., and Holmes, K.K. “Sexually transmitted infections in female sex workers: reduced by condom use but
not by a limited periodic examination program.” STD 1998;25(2):82-89.
2
Transmisión Sexual y SIDA (PROCETSS) and several nongovernmental organizations
(NGOs) led to the following changes in the STD program in Lima and Callao:
ß modification of STD services configuration to meet perceived needs and to
reduce perceived barriers to STD services;
ß communication and counseling on risk reduction;
ß social support or easy access to related social services;
ß condom promotion and motivation of high-risk populations by peer educators
(promotor de educación en pares [PEPs]) to seek care for STD signs or
symptoms;
ß regular periodic examination for symptoms or signs of STD together with
screening for asymptomatic STD for the highest risk males who have sex with
males (MSM) and FSWs, and appropriate treatment;
ß monitoring of the prevalence and incidence of STD to guide the frequency of
testing;
ß extension of services to FSWs not traditionally served by existing programs
with the use of PEPs who are paid to promote the use of services and condoms
by other FSWs; and,
ß availability of anonymous and confidential HIV testing.5,6
The upgraded Lima and Callao programs for FSWs were associated with statistically
significant reduction in the prevalence of STDs and significant increases in condom use
over time. This successful program is now being scaled up to reach most of the cities in
Peru with populations greater than 50,000. A similar program has been undertaken with
USAID funding in Bolivia,7
 and the Peru–Bolivia program for STD prevention in FSWs
is becoming known as the “Andean approach,” and represents an interesting model for
STD/HIV prevention in the region. 8
In recognition of the alarming surveillance data and the weak national AIDS control
based on a World Health Organization (WHO)/Global Programme on AIDS review of the
 
5
 Sanchez, J., Campos, P., Courtois, B., Gutierrez, L., Carrillo, C., Alarcon, J., Gotuzzo, E., Hughes, J.,
Watts, D., Hillier, S.L., Buchanan, K., and Holmes, K.K. STD Prevention in Female Sex Workers:
Prospective Evaluation of Condom Promotion and Strengthened STD Services. Manuscript available upon
request.
6
 Sanchez, J. et al., 1998, op. cit.
7 Levine, W.C., Revollo, R., Kaune, V., Vega, J., Tinajeros, F., Garnica, M., Estenssoro, M., Lewis, J.S.,
Higueras, G., Zurita, R., Wright-De Aguero, L., Pareja, R., Miranda, P., Ransom, R.L., Zaidi, A.A.,
Melgar, M.L., and Kuritsky, J.N. “Decline in sexually transmitted disease prevalence in female Bolivian
sex workers: impact of an HIV prevention project.” AIDS 1998 Oct 1;12(14):1899–1906.
8
 Holmes, K.K. and Prada, G., 2000, op. cit.
3
Peru AIDS control program in 1995, USAID/Peru developed a specific program for HIV
prevention in 1996–97, Ayuda CONTRASIDA, or AIDS Help, with the goal of
strengthening existing institutions and building additional local capacity to conduct HIV
prevention. The three Intermediate Results of the AIDS Help program were that
ß the major stakeholders in HIV/AIDS were strengthened,
ß the overarching environment is more receptive and committed to HIV/AIDS
activities, and
ß activities in HIV/AIDS prevention, care, and support are more closely
coordinated among the stakeholders and within the overarching environment.
The timing of the AIDS Help project in 1996 coincided with the expansion of HIV–
prevention and surveillance activities by PROCETSS. The revised goals and strategies
employed by PROCETSS were described in a 1996 document, Doctrina, Normas y
Procedimientos para el control de la ETS y el SIDA en el Peru. PROCETSS leadership
played a key role in working with the Peruvian Congress in achieving passage of
Reglamento de Ley No. 26626, which addressed the human rights of persons with
HIV/AIDS in Peru. PROCETSS undertook four major programmatic foci from 1995–
2000:
ß Procedures to prevent, diagnose, and treat STDs and HIV/AIDS,
ß Interventions to reduce the risk of HIV acquisition in susceptible populations,
ß Strengthening of the institutions involved in these activities, and
ß Improvement of epidemiologic and surveillance activities to guide and
evaluate interventions.
One early indicator of success of these revised strategies by PROCETSS, funded in part
by the AIDS Help Project, was the increase in reported AIDS cases from 200 cases in
1994 (reported from 18 locales) to 2,447 cases in 1995 (reported from 82 locales).
Another indicator of success was increased governmental recognition of AIDS and
support of PROCETSS prevention activities, as manifested by President Fujimori’s
opening address to the Fifth Pan American Conference on AIDS in Lima in 1997.
PROCETSS was also recognized by Dr. Rafael Mazin of WHO in June 1998, as a
program that has “achieved a delay in the progression of the diseases” and had
“developed or implemented all of the United Nations’ recommended strategies,
transforming their approach into a model program applicable to other countries”;9
 In
addition in 2000, the Peru AIDS prevention program was cited by the Joint United
Nations Programme on HIV/AIDS (UNAIDS) as one of the best in the world.
 
9 Mazin, Rafael. Pan American Health Organization (PAHO), quoted in Diario el Sol. “Perú será
modelode acción de la lucha contra el SIDA.” June 17, 1998.
4
In summary, PROCETSS had established its prevention priorities and strategies (which
paralleled all six of the USAID approaches) when USAID began its support through
AIDS Help in 1996. AIDS Help funding was used by PROCETSS to support these
activities through surveillance and formative research—much of it carried out by
NGOs—to assist in program development, courses on prevention strategies and
evaluation for regional directors, condom distribution, development of IEC materials and
guidelines, and distribution of the newsletter, Contrasida.
PROGRAM AND INSTITUTIONAL SUSTAINABILITY
The definition of sustainability used in this document follows the definition provided in
the AIDS Help evaluation scope of work (appendix A). Financial sustainability is the
capacity to recover, obtain, or otherwise generate financial resources required for
continuity of activities without additional USAID support; institutional sustainability
refers to the capacity of MOH health authorities to plan, manage, administer, monitor,
and adjust project activities to ensure effectiveness and continuity. Social sustainability
connotes ownership by NGOs and other institutions of some project activities.
The longevity of the program in the absence of external support is affected by several
features. The first most clear cut feature is the program’s cost-effectiveness, or the cost
to deliver an intervention that has a measurable impact on health. The many ways to
show cost-effectiveness include cost per HIV infection averted, cost per condom
distributed per STI or cured, cost per transmission-related contact averted, or cost per
daily-adjusted life year saved. Several cost-effectiveness studies have been undertaken in
developing country settings, yielding a general picture of the relative cost benefit of
different prevention approaches. Although targeted interventions such as condom
promotions and STD treatment are ranked among the most cost-effective of health
interventions,10 recent World Bank analyses have concluded that prominent “negative
externalities” make HIV/AIDS prevention relatively nonresponsive to market-driven
forces of supply and demand, and therefore unusually dependent on long-term public
subsidies.11
To assess sustainability, one can augment a cost-effectiveness analysis by considering the
acceptability to users and policy makers of systems put in place to deliver programs.
Acceptability and effectiveness of the program are based in large measure on the level of
infrastructure and technology in place, and on how maintenance and upgrading of these
resources are anticipated. Acceptability and effectiveness also are tied to how well the
program has met the perceived need of priority target group members and to what degree
these constituencies support the program on a policy level. Furthermore, sustainability is
tied to the program’s support from key decision-makers in society.
 
10 Over, M. and Piot, P. “HIV infection and sexually transmitted diseases.” In Jamison, D.T. Disease
Control Priorities in Developing Countries. International Bank for Reconstruction and Development, The
World Bank, Oxford Medical Publication, 1993, pp. 455–527.
11 Ainsworth, M. and Over, M., 1997, op. cit.
5
II. EVALUATION PURPOSE AND METHODOLOGY
The USAID Mission and Synergy scope of work for the evaluation (appendix A) called
for the review of the AIDS Help project support to the national program (PROCETSS)
with the four objectives listed above. The team was asked to determine the progress
made towards the intermediate goals outlined in the original project document (Activity
Design) and summarized in detail in the final report submitted by PROCETSS, which
describe the key lessons learned from this project experience.
The team also was asked to summarize the financial and institutional capacity at the
conclusion of the project and make recommendations to help refine technical emphasis
and appropriate channels for future USAID support to the national program. The work
plan for the evaluation was drafted by the PROCETSS staff in consultation with
USAID/Peru. This plan was then revised by the evaluation team as required based on
additional indepth consultation with USAID/Peru and PROCETSS staff and as new
information needs emerged.
The data available and the constraints of the 2–week evaluation period limited collection
of data quantifying the impact of the PROCETSS AIDS Help project component on
STD/HIV transmission patterns in Peru. Emphasis was placed on the process-oriented
indicators listed in the original AIDS Help project document and summarized in the
PROCETSS final project report. In addition, the team used recommended approaches12
to assess the technical soundness, quality, and scope of the approaches used by the
PROCETSS program.
The evaluation team consisted of three individuals from the University of Washington, a
subcontractor to TvT Associates, Inc., under the Synergy project. Team expertise
included STD/HIV epidemiology and clinical care, BCC intervention design, and NGO
organizational development. After initial orientation from the USAID/Peru Office of
Health, Population, and Nutrition (HPN) director, as well as from the directors of the
AIDS HELP project and the USAID Quality and Coverage project, the team then
reviewed an extensive collection of project-related documentation, including the draft
national STD/HIV plan for the upcoming three-year period, existing PROCETSS plans
corresponding to key project strategies, national plans for other related health programs,
STD/HIV treatment guidelines, and IEC materials produced in the last four years,
including training modules, project monitoring tools, and surveillance data collection
protocols and forms. The team then conducted approximately 50 indepth interviews with
key informants (1–2 hours duration) including PROCETSS staff, the VIGIA director,
health services officials, clinic staff, and NGO representatives. Group interviews or
focus groups were held with approximately 300 peer educators (MSM, FSWs and youth),
sex workers, and clients. Appendix B presents the schedule of evaluation activities in six
cities jointly selected by PROCETSS and the evaluation team.
 
12 Rossi, P.H. and Freeman, H.E. Evaluation: A Systematic Approach. Newbury Park: Sage Publications,
CA, 1989.
6
III. SUMMARY OF FINDINGS AND SPECIFIC RECOMMENDATIONS
OBJECTIVE 1
ASSESS PROGRESS TOWARD ACHIEVEMENT OF
DESIRED RESULTS
The expenditures of PROCETSS by category and funding source (from the government
of Peru/Ministry of Health and from USAID Ayuda CONTRASIDA) are shown in table
1. The annual government of Peru contribution (not adjusted for inflation) has grown
steadily from approximately 7.5 million soles in 1997 to 18.6 million soles in 2000. The
USAID Ayuda CONTRASIDA support was 658,000 soles in 1997, 951,000 in 1998, and
1,377,000 in 1999, approximating 10 percent of the total PROCETSS budget. (See
appendix D for an organizational chart of PROCETSS.)
Table 1. Funding for PROCETSS from the Government of Peru/Ministry of Health and
from USAID, 1997–2000
AIDS Help initially supported a portion of the salaries for all key professional staff of
PROCETSS, until these positions became part of the core government of Peru budget for
PROCETSS.
BUDGET IN SOLES
MINISTRY OF HEALTH/PROCETSS
1997 1998 1999 2000
Period of Operations
Payroll 195,000 250,000 263,000 325,000
Follow Up of FSWs, MSM 468,000 1,545,000 2,922,780
Information, Education, and Comunication (IEC)
Printed Material 881,127 1,291,483 1,655,000
Medications (Treatments) 1,713,644 3,963,817 2,588,327 7,112,390
Laboratory Supplies 2,448,179 2,214,302 4,335,000 5,333,935
Condoms 1,402,050 2,120,698 1,685,147 2,876,495
Training 325,000 361,200 127,000
Development of Investigation 127,000 127,000
National Evaluation, Supervision 380,000 407,500 407,500
TOTAL 7,472,000 11,204,000 12,630,000 18,570,600
USAID PROJECT: AIDS HELP
1997 1998 1999 2000
Project Personnel 131,970 165,600 111,047
Technical Assistance 71,616 105,165 137,047
Investigation 133,420 172,021 54,580
IEC 72,875 218,093 219,429
Training 123,239 47,247 4,624
Coordination (MSM Follow Up) 62,275 122,421 717,855
Equipment 42,400 28,139 16,446
Travel (Conventions, Monitoring Visits) 20,701 91,894 115,586
TOTAL 658,496 950,580 1,376,614 0
7
These personnel supervised the development of STD/HIV/AIDS sentinel surveillance and
the development of the strategic plans and guidelines for clinical care of STDs and HIV,
counseling and outreach by peer educators (PEPs), and the information, education and
communication (IEC) materials produced by PROCETSS with AIDS Help assistance.
These products were of high quality, evidence based, and up-to-date. They have been
piloted among appropriate at-risk populations. Extensive training in use of these
guidelines may be altering patterns of prevention and care throughout Peru (based on
interviews with physicians in Lima, Callao, Iquitos, Trujillo, and Chiclayo). To quote the
United Nations Population Fund (UNFPA) director, “The PROCETSS program has
become very active and has done a lot since Dr. Sanchez has taken it over” (a period
encompassing the AIDS Help project). Evidence from sentinel surveillance and the
ALASKA cohort of MSM in Lima demonstrated a very high prevalence and incidence of
HIV infection and syphilis in MSM throughout Peru, and relatively high prevalence of all
STDs among FSWs. Epidemiologic studies in Lima have demonstrated the importance
of these high-risk groups in the transmission of HIV to the general population, through
very large bridge populations of bisexual men and clients of FSWs. In contrast, the
general population of women, such as those seen in antenatal and family planning clinics,
has few sexual partners (the median lifetime number of partners is 1); such women make
no contribution to the sexual transmission of STD/HIV.13,14
The evidence of effectiveness and impact of improved STD/HIV prevention services,
including peer outreach for BCC, promotion of condoms, and utilization of STD services
for FSWs in Lima and Callao15 has also been demonstrated in other countries (e.g.,
Bolivia, Thailand, Kenya, South Africa, and India). Similarly, the effectiveness of peer￾mediated outreach to MSM for risk reduction has been the basis for much of the HIV–
prevention effort throughout North America and Europe.16 The preliminary findings
concerning the impact of improved STD/HIV prevention services among FSWs in Lima17
has led in Peru to the development of a model system of CERETS and UAMPS and peer￾mediated outreach for high-risk men and women. This system is being scaled up to cover
all large- and medium-sized cities throughout Peru. This represents a remarkable
accomplishment for a developing country. Although the quality of the new CERETS
clinics visited varied, the quality observed was surprisingly good at five of six clinics
visited. Facilities varied from ample (Lima, Iquitos) to adequate (Chimbote, Trujillo, and
Juan Olaya clinic in Chiclayo) to poor (Mercedes Hospital, Chiclayo).
 
13 Sanchez, S.E., Koutsky, L.A., Sanchez, J., Fernandez, A., Casquero, J., Kreiss, J., Catlin, M., Xia, M.,
and Holmes, K.K. “Rapid and inexpensive approaches to managing abnormal vaginal discharge or lower
abdominal pain: An evaluation in women attending gynecology and family planning clinics in Peru.” Sex
Transm Infec, 74 (Suppl 1):S85–S94, 1998.
14 Sanchez, J., Gotuzzo, E., Escamilla, J., Carrillo, C., Phillips, I.A., Barrios, C., Stamm, W.E., Ashley,
R.L., Kreiss, J.K., and Holmes, K.K. “Gender differences in sexual practices and seroprevalence of
sexually transmitted infections.” Am J Public Health 1996;86:1098–1107.
15 Sanchez, J. and Campos, P. et al., op. cit.
16 Kelly, J. et al. “HIV risk behavior reduction following intervention with key opinion leaders of
population: An experimental analysis.” Am J Pub Health 1991;81:168–71.
17 Sanchez, J. and Campos, P. et al., op. cit.
8
The enthusiasm and growing impact of PEPs was evident in all six regions assessed.
Again this level of scale up is ambitious, and to quote the coordinator of Medecins du
Monde in Iquitos, “The PEPs are important and this program is definitely working.”
Indeed, the PEPs represent the hallmark of the PROCETSS program; their effectiveness
and enthusiasm depend on their continued training and ability to provide IEC, condoms,
and referrals for care. The PEPs program exemplifies a community-based prevention
program. The turnover in FSW PEPs has been fairly high, so ongoing training is
essential. They expressed a perceived need for new materials and new approaches to
counseling FSWs. A remaining need is for the development of an outreach program
involving BCC for clients of FSWs—a bridging group that represents the major source of
transmission of HIV and other STDs to the general population of women.
RECOMMENDATIONS
In the future, PROCETSS’ BCC activity should train PEPs and counselors in the
CERETS to deliver client-centered counseling, as this has been shown to be effective
in reducing the incidence of STDs in Project RESPECT.18
PROCETSS should design programs and strategies that focus on potential bridge
populations (i.e., male clients of FSWs and bisexual men).
REGIONALIZATION
The evaluation team visited Iquitos, Trujillo, Chimbote, and Chiclayo to assess the
impact of the efforts of PROCETSS to export lessons learned in Lima and Callao to other
regions in Peru. The extent of regionalization of prevention and care services achieved in
Peru is impressive, with strengthening of surveillance, clinical services, and peer outreach
for high-risk populations, together with programs implemented through maternal and
child health (MCH) clinics for preventing perinatal HIV transmission, congenital
syphilis, and counseling as high priorities. The quality of the programs observed was
considered good to excellent. Regionalization has moved extremely quickly in the past
three years, as is appropriate in an epidemic. However, the need exists now for
consolidation with closer supervision, feedback on monitoring activities, and continuing
training because personnel turnover is inevitable, and technical approaches continue to
evolve in the AIDS field. The behavior changes that the team was informed of first hand
from MSM, FSWs, and clients (e.g., decreasing unprotected exposure and an increase in
health care seeking) are likely having a major impact on reducing HIV transmission in
Peru.
 
18 Kamb, M.L., Fishbein, M., Douglas, J.M., Jr., Rhodes, F., Rogers, J., Bolan,G., Zenilman, J., Hoxworth,
T., Malotte, C.K., Iatesta, M., Kent, C., Lentz, A., Graziano, S., Byers, R.H., and Peterman, T.A. “Efficacy
of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a
randomized controlled trial.” Project RESPECT Study Group. JAMA 1998 Oct 7;280(13):1161–1167.
9
Regional outreach should be consolidated, with closer supervision of PEPs and STD
services in CERETS and UAMP as well as timely data analysis of monitoring
indicators and feedback, and evaluation of process indicators and impact.
CERETS, UAMPS, AND MCH CLINICS: STDS AND HIV SERVICES
PROCETSS has selected a health center (CERETS) in each of 18 regions that has been
strengthened to serve as a reference center for health services for high-risk persons,
specifically MSM and FSWs. The center goes through an accreditation system after
being trained in STD syndromic management. As an innovative approach, patient
advocates are identified, typically an MSM for the hours in which MSM are seen at the
health center and an FSW during hours when FSWs are referred for care. A reference
laboratory is established for HIV and rapid plasma reagin (RPR) ELISAs, gonorrhea
cultures, and in some cases, chlamydia ELISAs. The PROCETSS program provides
quality assurance for both the clinical and laboratory components of the CERETS.
Logistical problems were observed (e.g., supplies of condoms, access to CD4 tests, and
technological difficulties that occurred with one ELISA machine for chlamydia
diagnosis), but medication supplies were adequate.
PROCETSS has collaborated closely with MCH programs at regional hospital clinics to
establish prenatal syphilis testing (a high priority to prevent congenital syphilis), HIV
testing and counseling services, and prophylaxis for HIV–seropositive pregnant women
and their newborn infants to prevent prenatal HIV transmission.
PROCETSS is expanding the periodic STD and HIV screening program to all of the 18
districts described above, which were selected based on total population, large MSM and
FSW populations, and HIV prevalence in the 1998 sentinel surveillance program. The
STD screening includes RPR and HIV serologies, pharyngeal and rectal gonococcal
cultures, and urine leukocyte esterase (ULE) testing. A urethral swab is obtained for
gonorrheal culture and urine for chlamydia EIA if the ULE is positive. MSM are treated
with benzathine penicillin injections if the RPR is reactive, doxycline and ciprofloxacin
for signs of urethritis or a positive ULE, and ciprofloxacin if the gonorrhea culture is
positive. Up until the present time, women with vaginal discharge have been receiving
presumptive, syndromic treatment both for vaginal and cervical infection; however,
recent data from a number of publications have shown that treatment for cervical
infection is no longer indicated in the vaginal discharge algorithm.
Recommendations
PROCETSS should monitor the use of antibiotics for the syndromic management of
women with vaginal discharge and provide training to regional PROCETSS
directors, physicians in CERETS, and clinicians in primary care programs in Peru,
as to the rationale for the change in the vaginal discharge algorithm.
Ensure adequate access to CD4 counts for patients in AIDS clinics as a way to
optimize the clinical management and accurate surveillance of HIV/AIDS.
10
Donor agencies can do more to support AIDS care in developing countries.
The current emphasis on prevention of infection is very appropriate, and the additional
help with prevention and treatment of opportunistic infections is also appropriate.
Antiretroviral therapy (ART) continues to be too expensive for the poorest countries to
support. However, Argentina and Brazil provide public funding for antiretroviral
therapy. A UNAIDS plan to provide antiretroviral drugs on a discounted basis to four
countries in the world (including Chile in Latin America) has not been implemented.
Recently, however, five pharmaceutical companies have announced that they will heavily
discount the price of antiretroviral drugs for developing countries. Donor agencies in
Peru could at least fund operational research on the feasibility, cost, and impact of
delivery approaches to ART. This research clearly must address systems of care to ensure
adequate monitoring of side effects and compliance as well as medications. In view of
growing pressure to expand treatment to developing countries, PROCETSS should
analyze the potential costs and infrastructure needs for providing combination
antiretroviral therapy (ideally double nucleoside reverse transcriptase inhibitors with
either a nonnucleoside reverse transcriptase inhibitor or protease inhibitor) in selected
Centers of Excellence to persons with clinical AIDS and/or CD4 counts less than 200 in
Peru. Estimates should include not only the costs of antiretroviral drugs but also the costs
for laboratory, supplies and testing, personnel, training and monitoring of toxicity,
compliance, and efficacy. PROCETSS should engage PLWHAs in its assessment of the
feasibility and costs of providing antiretroviral drugs to selected patients to ensure input
on the ethics and implementation of such a program.
Recommendations
The government of Peru and pharmaceutical companies could negotiate lower costs
of antiretroviral drugs for bulk purchasing as well as drugs for other STDs.
PROCETSS could seek waivers of any government taxation on essential drugs
needed for the treatment of AIDS and other STDs (e.g., doxycycline, which is
grossly overpriced in Peru, as it is in most of Latin America).
PC–based informatics systems should be strengthened in major AIDS clinics and
CERETS to facilitate data analyses and the coordination of care between AIDS and
STD clinics, district health centers, obstetric/gynecology clinics, and tuberculosis
clinics.
Computerized clinical and pharmacy records would also enable AIDS clinics to monitor
compliance with opportunistic infection prophylaxis and antiretroviral drugs, the latter of
particular importance in HIV–positive pregnant women. At the local hospital level,
improved informatics systems can allow clinicians to gather and use data for monitoring
compliance with treatment or visits.
11
PERSONS LIVING WITH HIV/AIDS AND SELF-HELP GROUPS
Currently, there are 27 active self-help support groups (grupos de apoyo mutuo [GAMs])
in Lima with 20–30 active members each. GAMs provide social and psychological
support to persons living with HIV/AIDS (PLWHAs). They work with newly diagnosed
HIV–infected persons to understand and accept their diagnosis and to maintain a high
quality of life. An association of GAM networks in Lima tries to coordinate educational
and support activities. A few GAMs restrict membership and do not invite PLWHAs of
lower socioeconomic status, but this seems to be the exception. Generally, GAM
members see their role as a support group more than as a voice for public advocacy. The
exception includes Carrion GAM members who ask PROCETSS to support increased
public acceptance of PLWHAs by promoting a more positive image of HIV–infected
individuals leading productive lives, rather than the end-stage AIDS patients. The
exception also includes GAMs based within the Programa de Soporte y Autoauyda de
Personas Seropositivas (PROSA), an NGO that has had a high-profile presence, including
leading a public march to raise awareness of HIV–care issues. There is a growing
advocacy effort by several GAMs to obtain government support to provide antiretroviral
therapy for HIV–positive persons, although there is awareness of the considerable cost of
such therapy.
Recommendations
Further administrative and financial support that would be valued by GAMs could
provide Internet access to improve awareness of new developments in HIV/AIDS
and fund social activities, workshops on specific topics (such as nutrition),
newsletters, hospice services for PLWHAs, child care, and family support services
for women with HIV infection.
Continue to work on improving the quality of life of PLWHAs, specifically through
ongoing psychological and community-level support as well as clinical services.
The MOH should endorse and conduct media campaigns that promote a more
positive image of living with HIV/AIDS (e.g., by identifying popular figures who are
willing to promote HIV prevention or disclose their HIV–seropositivity).
The MOH should continue to discourage job and housing discrimination based on
HIV status.
HIGH-RISK TARGET POPULATIONS
Female Sex Worker Peer Educators (PEPs)
PROCETSS initiated pilot work with FSWs in Lima in 1997 to develop materials (e.g.,
brochures) and prevention messages. The objectives of the PROCETSS prevention
program for FSWs were to
12
ß implement peer education,
ß increase condom use and condom negotiation skills among FSWs,
ß promote diffusion of messages about prevention of STD and HIV among
FSWs,
ß increase the proportion of FSWs who have regular STD screening to 25
percent in intervention cities.
The program has existed the longest in Lima and continues to expand its coverage
throughout Peru; in 1998, 90 new sex work sites were identified, and in 1999, 372 new
sites were identified. The mapping exercise indicated that approximately 23 percent of
FSWs worked in bars, 19 percent on the streets, 19 percent in massage parlors (only in
Lima), 14 percent in discotheques, and 8 percent in brothels. During the initial mapping
phase, 3,652 FSWs were interviewed and 560 were invited to be peer educators, of whom
339 were trained and 140 were selected to be PEPs. As new FSW PEPs and their
replacements are recruited to join the group, one-on-one training is conducted and
refresher trainings are conducted intermittently (see discussion in BCC section). FSWs
were selected on the basis of their communication skills, participation in the training
sessions, acceptance by their peers, length of residency in that city, and interest in
collaborating with PROCETSS. Additionally, the duration of their sex work, educational
level, and social circumstances were considered to achieve a balance in the types of
women selected to be PEPs.
The specific targets for the PEPs are to attend ongoing training (two educational sessions
a month), provide 50 condoms to each FSW they contact, refer 10 FSWs to CERETS a
week, and assist with identifying new sex work sites and new potential PEPs. The
periodic examinations recommended for FSWs through PROCETSS at CERETS includes
monthly examinations for vaginal discharge and cervicitis, syphilis serologies every 3
months, and voluntary HIV testing every 6 months.
Impact of FSW PEP Program
In 1999, FSWs attended an average of 14 training sessions with an average of eight
women attending each session. PEPs each gave out an average of 40 CERETS referral
cards to other FSWs a week. Based on the numbers of FSWs who turned in referral cards
when they presented for STD screening at CERETS, 20 percent of those referred actually
came for STD screening. This probably underestimates the true proportion of PEP
referrals. The proportion of new FSWs who had referral cards when presenting for STD
screening was substantially higher (51 percent) and has increased since the program was
initiated. Another measure of the community and individual impact of the FSW PEP
program will be through data collected in the 2000 sentinel surveillance program. The
1998 sentinel surveillance provides baseline data at the beginning of the FSW
intervention, at which time 40 percent of FSWs could describe common STD symptoms
in women and approximately 35 percent could name the CERETS where they could
receive STD services.
13
MSM Peer Educators (PEPs)
PROCETSS has identified and trained a network of MSM PEPs who counsel MSM about
STD symptoms and services, refer to CERETS for STD services and HIV screening, and
distribute and promote condoms. The peer educator strategy evolved from the use of
outreach workers in the 1996 cross-sectional study of MSM in Lima, which recruited
MSM from venues where they met to socialize (e.g., discotheques, bars, volleyball
leagues, beauty salons) and meet partners (e.g., saunas, streets). These studies clearly
showed that surveillance studies and interventions in the MSM community need to
include the diverse subgroups of MSM, such as male sex workers, transvestites,
machismo men who are often insertive (buses), more effeminate men who are often
receptive (mujeres), men who are both insertive and receptive who are often more openly
gay (modernos), and bisexual men, who have different rates of HIV seropositivity and
different prevalences of specific sexual behaviors.
The PEP system for MSM, as for FSWs, is based on the principle that peers can best
reach high-risk individuals in the venues where they socialize, build trust, and
communicate prevention messages. In Lima, focus groups were held to develop
prevention materials (e.g., brochures, videotapes) and names of possible MSM leaders
were elicited. These MSM were then recruited to attend 4–day training workshops of
approximately 20 MSM each, from whom approximately half were selected as possible
PEPs for additional training. As the peer educator program for MSM has been expanded
to other regions, a monitor was selected who works with the PROCETSS coordinator in
each region, observes the individual PEPs weekly, and meets with the PEPs weekly to
review their activities, provide ongoing training, and solve problems concerning their
outreach (e.g., harassment, personal safety) and effectiveness in promoting condoms and
prevention. Areas and specific venues frequented by MSM are elicited from the key
informants and peer educators. The PEPs work in pairs three shifts a week, typically
during the night, with an average of 3–4 hours a shift and rotate venues so that they will
encounter different MSM. The PEPs wear identification with a photograph to identify
themselves as PROCETSS workers, wear a T–shirt and/or baseball cap with the
PROCETSS logo, and carry a briefcase with the PROCETSS and MOH logos, as well as
the logo of the MSM HIV–prevention campaign, “Tu si entiendes.”
The primary activities of the PEPs are to approach men in social venues, streets, and
parks, introduce themselves as working with the Ministry of Health and PROCETSS, and
engage men in a general discussion about HIV and STDs. After building trust, they ask
whether men have had sex with sex workers or men and then deliver a more specific
message about HIV and STD risks and the importance of condom use, early STD
diagnosis and treatment if symptomatic, and HIV testing. The PEPs use one of a number
of brochures that have been developed and piloted in Lima to target MSM that describe
why and how to use a condom as well as signs and symptoms of STDs. The brochures are
entitled, Ponte vida, ponte vivo, ponte condon; Utiliza todas sus armas; and, Lo que
querias saber de las ETS (see appendix C). During the months of the sentinel
surveillance program, MSM are referred to CERETS for HIV and STD screening.
14
During the other months, MSM are referred to CERETS if they have symptoms of STDs
for syndromic management. The PEPs provide the man with a referral card with the
address and hours of the CERETS, the PEP’s name, and a unique identifier that enables
tracking the yield of the contacts and each PEP’s productivity. They dispense condoms,
ranging from 1 per contact in Chiclayo to 25 per man for a month’s supply in Lima (50
condoms/month dispensed to male sex workers).
Recommendations Related to the Prevention of STD/HIV in FSWs and MSM
Ensure ongoing recruitment and adequate training and monitoring of peer
educators. It is important that PEPs remain focused on condom promotion and increase
their skills (especially those of FSWs) in helping clients with condom negotiation skills
in promoting condom use with regular partners and in overcoming resistance to HIV
testing due to fear of receiving a positive result and/or not having treatment options.
Consider additional training on theory-based counseling techniques which have
demonstrated efficacy (e.g., based upon the transtheoretical model, and motivational
interviewing) to aid CERETS counselors and PEPs in effectively intervening with FSWs
and MSM who are reluctant or refuse to come to CERETS for HIV and STD counseling
and testing. Evaluate the quality and content of prevention messages and counseling
provided by PEPs and counselors at the CERETS. The monitors should directly observe
PEPs conducting fieldwork to assess how PEPs engage MSM and FSWs and overcome
resistance to condoms or HIV/STD testing.
Ensure adequate attention to optimal data collection analysis and feedback on risk
behaviors and STD/HIV prevalence and to quality control of data in ongoing
monitoring and sentinel surveillance. The longer and more involved instrument to
collect risk behavior in the 2000 sentinel surveillance will require piloting as well as
training of PROCETSS regional and local staff to ensure that the staff who will
administer the questionnaires understand the importance, rationale, and procedures for
collecting the information.
Consider slowing the expansion of the FSW/MSM interventions to fewer cities. Use
the HIV and STD prevalence data from the 2000 sentinel surveillance to select a smaller
number of cities with higher HIV and syphilis prevalence among FSWs and MSM for the
periodic STD and HIV screening. It will be more difficult to evaluate the MSM
interventions in cities with smaller populations of MSM and lower HIV and STD
prevalence.
Evaluate the feasibility and acceptability of self-obtained swabs for diagnosis of
vaginitis and cervicitis among FSWs. Pilot the acceptability of self-obtained swabs,
and if FSWs find them acceptable, scale up to determine the impact on the proportion of
women who could be screened either at CERETS or in the field with self-obtained swabs
in a given locale.
15
Formative research (i.e., indepth interviews or focus groups, if possible) is needed to
determine ways to identify and engage male clients of FSWs as well as bisexual men
and reduce barriers to PEP work from establishment owners/managers and FSW
steady male partners. Bisexual men and male clients of FSWs represent important
bridging populations to women. A high proportion of clients report infrequent condom
use with their female partners. Therefore, bisexual men and clients of FSWs should be
targeted for outreach by PEPs. It is important not only to promote condom use, but also
to promote appropriate health care seeking among male clients of FSWs, to pilot test the
delivery of prevention materials by FSWs to clients as well as to establishment
owners/managers and FSW male partners. Similar efforts should be made to target
bisexual men by PEPs and to determine the most effective prevention messages for that
bridging population. Specific prevention messages should be developed about condom
use with their female partners, the higher risk of STD and HIV transmission from men to
women (than vice versa), and the importance of encouraging HIV–infected men to
disclose their HIV seropositivity to their female partners and refer them for HIV testing.
Counselors will need specific training and prevention materials to work with bisexual
men and clients of FSWs. The feasibility of HIV–infected bisexual men discussing their
HIV status and referring their female partners for HIV counseling and testing should be
assessed.
Continue to reinforce efforts to obtain police cooperation by working through the
multisectoral groups established by regional PROCETSS programs. Assess the
feasibility of developing specific trainings for police to be developed by PROCETSS and
implemented using training of trainer approaches. Clarify the target of such trainings,
develop appropriate training methodology, implement pilot activity, and evaluate.
Reinforce linkages between PEPs and NGOs. Assess existing NGO resources and
where appropriate, encourage PEP referrals to NGO–based social and legal services
(e.g., child care, housing, food assistance, and family law). Continue to expand
NGO participation in inservice PEP trainings.
HIV/AIDS/STD Prevention and Care Activities for Youth
Activities in Peru related to reproductive health in adolescents are hampered by a law
which requires parental/guardian consent for health services for youth 16–18 years of
age, requiring that a parent/guardian accompany children under 16 for health services.
This has evidently not hampered the delivery of family planning services to older
adolescents, but has hampered the development of BCC for adolescents, as well as the
delivery of care for STD/HIV/AIDS to adolescents. Promotion of policies to modify this
are important and are of interest to several health agencies working with adolescents,
such as UNFPA and the MOH. Family planning programs have focused on youth in
school.
The most recent survey showed that 29 percent of Peruvian children 13–17 years of age,
including 22 percent of those in Lima, no longer attend school. The 1996 Peruvian
ENDES survey found that 14 percent of adolescent females 15–19 years of age were
16
pregnant or had had children. To the extent that sexual risk taking is more common in
children no longer attending school (i.e., those who dropped out or finished school), they
represent a priority for HIV/AIDS/STD prevention and reproductive health promotion,
including BCC activities and health services. The Ministry of Women’s Advancement
and Human Development (PROMUDEH ) and its unit, JERECIAS, work with youth no
longer attending school. It is important for PROCETSS to coordinate activities with
existing programs for reproductive health. Furthermore, the experience and commitment
of those working with marginalized at-risk populations, using peer outreach workers, and
its recent experience (funded by UNAIDS) in working with PEPs and with IEC
development to reach adolescents at sites other than the classroom, create a strong
argument for the possibility of USAID investing in a similar long-term PROCETSS effort
to promote reproductive and HIV/AIDS/STD prevention in youth, particularly those not
in school.
Recommendation
Support the continuation and expansion of HIV/AIDS/STD prevention and
reproductive health services for youth, including out-of-school youth.
SURVEILLANCE AND MONITORING SYSTEMS
In 1996–97, PROCETSS markedly improved passive reporting of AIDS, although
reporting is still delayed and may underestimate AIDS cases outside of Lima due to the
unavailability of CD4 testing. PROCETSS funds and implements sentinel surveillance
for HIV throughout the country in MSM, FSWs, pregnant women, and (beginning in
1999) people deprived of freedom (prisoners). This may soon be extended to include
sentinel surveillance for several STDs among military registrants and young antenatal
women throughout the country in a Wellcome Trust–funded project, in collaboration with
the Universidad Peruana Cayetano Heredia (UPCH). Surveillance activities have now
been transferred from PROCETSS to the Oficina General de Epidemiología (OGE). In La
Libertad, the epidemiology unit’s close working relationship with PROCETSS on the use
of local data for program planning and evaluation was impressive. Surveillance could be
strengthened by adding CD4 counts for HIV seropositive persons in selected regions
($15,000 per year); by conducting routine HIV testing on persons with tuberculosis, by
expanded syphilis surveillance; by monitoring antimicrobial susceptibility of N.
gonorrhoeae; by improved informatics, training, and infrastructure; and, by behavioral
surveillance, which is beginning in the expanded 2000 sentinel surveillance
questionnaire. The forms and reporting system developed for monitoring and assisting
supervisors includes information about personnel; stocks of IEC materials, guidelines,
reagents, and medication; supervisory visits to the municipal intersectoral working group
meetings; reports of peer-outreach activities, IEC activities, clinical activities, case
reports, test results, activities of each individual PEP; and, MCH testing and counseling
training.
17
Recommendations for Surveillance and Monitoring
Develop the information management system and staff as needed for data analysis
and feedback, especially for monitoring and evaluation. The introduction of the
STD/HIV morbidity and prevention activity forms, with reporting from peripheral to
regional levels and regional to central levels, has sharply increased the reporting of STDs.
Improved diagnostic testing at CERETS and UAMPS provides for the first time in Latin
America national data on the numbers of tests and percent positive for HIV and various
other STDs among high-risk groups as well as for HIV and syphilis among pregnant
women. Improved informatics systems and training were requested by regional
coordinators and even by the PEP. PROCETSS remains responsible for analyzing data
collected in the monitoring of program activities. Because of planned health care reform,
the PROCETSS budget includes no funding for this type of monitoring and supervision
for 2000, and such funding is urgently needed.
HIV surveillance activities should routinely monitor and report on HIV prevalence
among persons with tuberculosis.
Include the 1996 STD and Sexual Behavior Survey Set in the 2000 ENDES, and in
subsequent versions of ENDES, to help evaluate the impact of HIV/AIDS/STD
prevention programs over time. Expand the questions needed to help assess trends
in risk-behavior and disease morbidity.
USE OF THE RAPID MODEL TO DISSEMINATE FINDINGS
AND AFFECT POLICY
In the area of advocacy, to stimulate a favorable policy-making environment,
PROCETSS undertook several specific communications activities. During the project
period, the RAPID model (AIDS impact model), summarizing the projected demographic
impact of AIDS and HIV/AIDS projections in Peru, was developed and presented to a
variety of decision-makers and key influential audiences during 1998 and 1999. Both the
frequency of these activities and the diversity of audiences reached are notable.
Newspaper coverage was provided to the evaluation team, indicating that the
epidemiologic data were being cited.
Assessment of Use of the RAPID Model
The focus on the use of the RAPID model in Peru was a projection of HIV and AIDS
morbidity in Peru. It is difficult to assess the specific impact of presentations of this
model (versus the impact of other presentations) on policy makers in Peru, but overall
budgetary increases for HIV/AIDS/STD prevention and care from the government of
Peru are consistent with the impact of such presentations.
18
Table 2. Distribution of Audience Members Attending PROCETSS
“Impact of the HIV/AIDS Epidemic” Presentations
TYPE OF AUDIENCE
1998
Number
(percent)
1999
Number
(percent)
Intersectoral working group 157 (40) 51 ( 4)
International public health professionals (including
UNAIDS) 110 (28) 0
Opinion leaders in public, private and armed forces
sectors 47 (12) 340** (30)
Medical professionals (national level) 55* (14) 750 (66)
Journalists 20 ( 5) 0
TOTAL 389 1141
* All working within the National Police force
** Included 300 National Police members
PERFORMANCE OF USAID
The best evidence for the satisfactory performance of USAID in the AIDS Help Project is
perhaps the remarkable success of the PROCETSS program itself in developing and
scaling up delivery of innovative but appropriate HIV/AIDS and STD prevention services
and care in Peru. USAID could play an important role in meeting those objectives of
AIDS Help not yet achieved but still potentially valuable. These original objectives
include:
ß Provide leadership in working with UNAIDS to develop a donor group,
ß Support strengthening of NGO infrastructure for AIDS–prevention services
advocacy outside Lima,
ß Promote creative approaches to involving the private sector and nonhealth
agencies of the government of Peru in STD/HIV prevention and care,
ß Support development of a national AIDS advisory council, and
ß Beyond the original objectives of AIDS Help, national HIV/AIDS/STD
prevention and care recommendations made throughout this document,
including those given priority in the executive summary, represent potential
areas of future involvement of USAID support.
INTERINSTITUTIONAL AND CROSSPROGRAMMATIC COORDINATION
Interinstitutional coordination under AIDS Help was successful in some cases and less so
in others. The national AIDS advisory council envisioned by the AIDS Help activity
plan was not formed by the government of Peru, but remains an important goal. This
19
apparently requires support from both the MOH and the office of the president.
However, intersectoral committees have played an important coordinating role at the
regional level. These committees have been particularly active in achieving cooperation
between health and police authorities. PROCETSS is working effectively with OGE, and
is beginning to plan HIV/STD screening and prevention programs with COPRECOS and
the Armed Forces. PROCETSS and the MOH MCH programs have very effectively
worked together to establish impressive, comprehensive programs for HIV/AIDS/STD
prevention in pregnant women. Coordination with family planning programs has been
limited to collaboration on guidelines for syndromic management of STDs and
reproductive tract infections (RTIs), but could and should become much more extensive
with extramural support and encouragement. Coordination of prevention programs
involving youth has begun with UNAIDS support; there remains a major future need for
a multicomponent program for prevention and care of HIV/AIDS/STD in youth that
should extend to the regional level. PROCETSS has collaborated closely with several
other institutions and professional groups in Peru (universities, medical institutions, U.S.
Naval Medical Research Institute Detachment [USNAMRID]) in carrying out training,
operational research, and development of clinical services.
Peru has already come far towards involving many institutions, even though not faced
with the galvanizing scope of an epidemic as large as the Thai epidemic. The formation
of a national AIDS advisory council and adoption of a multisectoral strategic and action
plan (probably based on the framework already prepared by PROCETSS) remains a
useful goal. This could lend legitimacy and guidance to the regional intersectoral
committees. USAID could continue to encourage this and further facilitate a concerted
programmatic attack on HIV/AIDS by internal planning and close coordination of
potential USAID HIV/AIDS/STD/RTI activities related to policy, youth, women, and
reproductive health and family planning, as well as emerging infectious diseases.
OBJECTIVE 2
ASSESS CURRENT STATUS OF THE PROJECT,
INCLUDING ACTIVITIES RELATED TO BCC, COLLABORATION
WITH NGOS, AND INFORMATION EXCHANGE NETWORKS
INSTITUTIONALIZATION OF TECHNICALLY SOUND BEHAVIOR CHANGE
COMMUNICATION (BCC) APPROACHES
PROCETSS has created an STD/HIV Behavior Change Intervention Unit (Unidad de
Intervenciones para el Cambio de Comportamiento STD/HIV) managed by an
experienced BCC specialist/psychologist and two junior psychologists responsible for the
counseling and youth programs, respectively. In 1999, the MOH restructured some of its
core support programs and consolidated BCC, supervision and monitoring, and training
into a centralized service shared by all technical programs. The current head of the
centralized BCC unit is the former manager of the PROCETSS BCC unit and, like her
successor, demonstrated clear technical capacity for BCC planning and intervention
20
design. Although currently the unit is capable of producing a wide variety of effective
BCC interventions rather quickly, it is possible that the future centralization of BCC
services in the MOH could initially impede PROCETSS ability to directly produce
updated and new materials.
A hallmark of the PROCETSS BCC program is its clear targeting of high-risk behavior
groups and its use of a diverse media mix. Communications campaigns involve multiple
and creative media (brochures, posters, comic books/fotonovelas, video spots, flip charts,
and identity materials for peer outreach workers). Careful attention has been paid to
formative research and validation frequently in collaboration with NGO partners with
financial support from the AIDS Help project, which ensured access to suitable audience
members (as described in the NGO section). Comments from peer educators confirmed
that the materials are acceptable and appropriate for their designated audiences. For
videotape production, PROCETSS has used professional services to ensure quality. Use
of radio for other than talk show formats (e.g., radio dramas, popular music) appears to
be limited but recent linkages with a popular Peruvian television actor who is HIV–
infected is likely to expand opportunities for using electronic media.
As part of the improvement of STD clinical care nationwide, counseling services have
been introduced as an indispensable part. The counseling service coverage is impressive
with a total of 1,379 PROCETSS trained counselors currently active and available for up
to 30–minute sessions. By all accounts, there has been considerable staff turnover, which
necessitates ongoing recruitment and training. Counseling sessions focus on increasing
knowledge of STD/HIV transmission and risks, a very general review of behavioral
targets and brief condom use demonstration, and on issues related to HIV testing (full
pre- and posttest counseling is now the standard of care in PROCETSS clinical services).
The design and content of the 3–day counselor training sessions, although appropriate for
counselors without prior experience with STD patients, does not allow for advanced
communications/counseling skills acquisition, such as client-centered counseling. This is
important because it has recently been shown that client-centered counseling intervention
can have a sustained impact on heterosexual STD/HIV risk behavior and reduced STD
acquisition rates.19, 20
 PROCETSS has upgraded STD counseling services by setting forth
clear, technically sound counseling guidelines and including counseling as part of
integrated STD/HIV care. The effect of these recently developed STD services requires
further evaluation. “STD/HIV knowledge” could be delivered by alternative methods,
such as clinic-based BCC materials (e.g., waiting room posters, fotonovelas or
videotapes), thus making more time available for client-centered counseling, such as
motivational interviewing.
The AIDS Help project has supported the establishment of extensive peer outreach
programs directed to MSM, FSWs and most recently, youth. Consistent with
PROCETSS overall strategy, these programs were initially developed and field tested in
 
19Nduati, R., John, G., Mbori-Ngacha, D., Richardson, B., Overbaugh, J., Mwatha, A., Ndinya-Achola, J.,
Bwayo, J., Onyango, F.E., Hughes, J., Kreiss, J. “Effect of breastfeeding and formula feeding on
transmission of HIV–1: a randomized clinical trial.” JAMA 2000 Mar 1;283(9):1167–1174.
20Kamb, M.L. et al., 1998, op.cit.
21
Lima, and in the case of MSM and FSWs, have been expanded to the regional level.
There currently are between 8 and 20 PEPs working in each city or community where the
intervention is active. The size of the PEP teams varies with estimated target population
size. The criteria for FSW and MSM peer selection are appropriate and many of these
programs have matured to the point where more experienced outreach workers serve as
mentors for newer ones. Although turnover of FSW and MSM peer outreach workers
remains a concern, between 30 percent and 50 percent of all those in a given site had
participated since the program’s inception, ensuring that more experienced individuals
were available. During all the site visits, monitors indicated that they had recent field
experience accompanying outreach workers. The inappropriate management of outreach
workers (e.g., strictly regulated performance standards and lack of solidarity within the
group) was rare. One concern is that criteria for youth peer selection had not yet focused
on those with ready access to youth no longer attending school. However, this pilot
program was launched only 5 months ago and it is too early to assess the final
composition, much less the acceptability and effectiveness of this group.
The initial 3–day training for PEPs involved 18 hours of didactic training about sexuality,
self-esteem, general health maintenance, STD and HIV risks and prevention, condom
negotiation and condom use skills negotiation, legal issues related to prostitution, and
testimonials by women already working as PEPs. Opportunities for refresher training
cover topics identified by PEPs. The process for training newly recruited peer outreach
workers was less clear and systematic. In one site, a new recruit had been given a brief
orientation by the monitor and immediately joined another peer outreach worker for
fieldwork the following day.
The communications materials provided to all PEPs include audience-appropriate flip
charts to use in the field (containing sections about self-esteem, STD signs and symptoms
in men and women, basic facts about HIV, health services available through PROCETSS,
and condom use skills). FSW and MSM PEPs are also provided T–shirts with the
PROCETSS and prevention campaign logo, identification cards with photographs, and
briefcases with the PROCETSS logo that they can use to carry condoms, brochures, and
referral cards in their fieldwork.
The performance of the PEP program based on process indicators, such as numbers of
new STD patients referred by clients, is impressive. In some centers, the numbers of new
patients seen in a given time period (per week or per month) have more than doubled.
The evaluation team observed moderately heavy clinic patient load and patients with
important STDs receiving treatment at the clinics. In terms of impact, enhanced STD
services for FSW in Lima and Callao have lowered STD prevalence among FSWs
(Sanchez) and PEP outreach is one of several elements of upgraded services.
Recommendations Related to IEC/BCC
Strengthen advocacy. A national advisory committee could play an active role in
designing an advocacy plan and participating in advocacy activities, including public
meetings and workshops. Continue partnerships with key media representatives who
22
have a demonstrated interest in HIV/STD or health issues. Identify training programs for
journalists and assess the feasibility of developing a training seminar to be implemented
with PROCETSS consultation.
Continue to strengthen counseling services. Develop clinic-based BCC materials with
particular emphasis on transferring much of the informational content currently included
in a counseling session to a passive learning tool (e.g., mini media, waiting room
videotape). Evaluate the quality of existing counseling services to understand the
specific content and counseling techniques being used. Institute ongoing supervision for
STD counselors as part of a quality assurance program. Prepare to introduce client￾centered counseling methods where services are established, staff is sufficiently
experienced, and ongoing quality assurance and close supervision are operational.
Develop BCC tailored to regional needs. Obtain regional level input into BCC
materials needs and development (especially clinic staff and PEPs). As part of the BCC
evaluation process, develop short BCC workshops (half-day) to include as part of the
agenda for previously programmed activities with regional-level participation (e.g., PEP
training, HIV surveillance meetings, national or subregional training, or supervisory
meetings). Assess and develop regional-level BCC materials’ production capacity.
Specify regional-level BCC needs and objectives (see point below) that may require
emphasis on particular approaches such as advocacy, counseling or campaigns using
mass or mini media. Careful consideration should be given to feasibility for
implementation at the regional level and to resources, particularly opportunities for
community-based NGO partnerships.
Evaluate intervention exposure, acceptability, and impact. Evaluate BCC materials to
assess which approaches are more effective with different target audiences. These
studies should seek to understand the key elements of those approaches that are effective
for different groups according to the integrated behavior change model.
NGO STRENGTHENING ACTIVITIES
Much of the progress towards building NGO capacity for launching an expanded
response to HIV/STD prevention and care is evidenced by the continuing growth and
maturity of a cadre of Lima-based NGOs. These organizations are motivated by a range
of perspectives, from an interest in delivering high-quality and highly acceptable medical
and/or social services to their constituencies, to advancing a human rights agenda on
behalf of disenfranchised groups, such as HIV–positive persons or MSM. These
organizations generally were using technically sound approaches, whether in
participatory training workshops with their constituencies, counseling and medical
services for specific target groups, operations research activities, or development and
validation of BCC materials. They also have well-developed management systems and
staffs with planning skills. One NGO, Via Libre, was represented at a 1999 2–week
course sponsored by the NIH–Fogarty International Center at the University of
Washington on Ethical Review of Human Research on AIDS.
23
Under the AIDS Help project, PROCETSS contracted with several NGOs to conduct
operations research activities. The findings from these projects were used to refine
PROCETSS activities (see table 3 below). Although the original intention was for
PROCETSS to let contracts to NGOs for specific projects based on their experience and
technical ability to execute these projects, government contracting regulations ultimately
precluded this type of collaboration. The process required competitive bidding with
awards made based solely on budget considerations. Thus, the original concept of a
flexible small grants program channeled through the government program was not
feasible. Despite these constraints on NGO–government collaboration, all informants
agreed that the working relationship between PROCETSS and NGOs has improved
steadily over the AIDS Help period. There are now open channels of communication and
opportunities for professional interaction between PROCETSS and NGOs.
Table 3. Summary of AIDS Help–funded NGO Activities
TITLE OF ACTIVITY IMPLEMENTING NGO
Evaluation of an STD clinical management protocol
in patients with vaginal discharge in a reproductive
health clinic
Instituto Peruano de Paternidad
Responsible (INPPARES)
Study of the sexual health in a peri-urban area of
Lima
PRISMA
Between combs and brushes Asociación Germinal
Reasons why MSM have unsafe sexual practices Movimiento Homosexual de Lima
(MHOL)
Routes of condom access among adolescents in
Lima, Cuzco, and Iquitos
Asociación Kallpa
It is important to differentiate between the group of mature Lima-based STD/AIDS–
focused NGOs and a group of established NGOs with a reproductive health or family
planning focus who also have STD/HIV prevention activities. The reproductive health/
family planning NGOs visited during this evaluation had international funding support,
established reproductive health clinical services and, in at least one case, INPPARES,
program affiliates at the provincial level. Because their typical users consisted of couples
who would potentially use contraceptives, they usually did not reach groups at elevated
risk for STD (i.e., MSM and FSWs). However, these NGOs have made considerable
efforts to reach youth at risk for adverse reproductive health outcomes. For example,
INPPARES has recently launched a peer outreach program targeting street children with
a program that emphasizes STD prevention in a broader reproductive health context. A
review of the communications aspects of this and other STD prevention programs at
INPPARES revealed an incomplete understanding of several key behavior change
messages such as STD symptom recognition. This observation highlighted future
24
opportunities for improved collaboration, both with STD/HIV–focused NGOs and with
PROCETSS.
During the AIDS Help project period, Lima-based NGOs also demonstrated a capacity to
provide complementary support to government activities by providing resource persons
for PEP training sessions or facilitating GAMs. Although participation of NGO
representatives in PROCETSS trainings appeared limited, this does not appear to have
impeded their professional development over the project period.
In recent years, it has become clear that the need for NGO collaboration and institutional
strengthening are greatest outside Lima, in those areas of the country identified by
surveillance activities as priority areas for STD/HIV prevention. Unfortunately, it was
not possible to review NGO capabilities at the provincial level. The team met with the
representative of only one French NGO, Medicins du Monde, based in Iquitos. This
international NGO had given considerable support to the regional program in the form of
a donation of STD drugs and transportation (a vehicle and boat). However, this
collaboration was not oriented toward catalyzing indigenous NGO capacity nor was
technology transfer a focus. Another example of international NGO collaboration is the
support given by Médecins sans Frontières (Doctors without Borders [MSF], Belgium) to
the FSW PEPs working in Lima Sur. Although the team was not able to meet directly
with MSF representatives, they are providing identity materials (vests) to this group of
PEPs.
The Red SIDA Perú (RCS, Peruvian AIDS Network) was established in 1997 and is
currently comprised of seven member NGOs: Asociación Germinal, Asociación
KALLPA, Asociación PRISMA, Asociación Via Libre, Centro de Estudios de Problemas
Económicos y Sociales de la Joventud (CEPESJU), Movimiento Homosexual de Lima
(MHOL), and Programa de Soporte a Autoayuda de Personas Seropositivas (PROSA).
All of these NGOs are mature Lima-based organizations with extensive experience and
generally high-level capabilities in the STD/HIV prevention and care field. In the AIDS
Help project design, the original intent of catalyzing the formation of an NGO network
was to support an expanded response to STD/HIV that would be community-based and
complementary to the government program. From the perspective of the RCS leadership,
however, the organization was set up with a more modest focus—to ensure the long-term
existence of the network and support its members in their work. Early on, RCS
leadership established the network with legal obligations requiring member organizations
to be government registered. Implicit in the registration process, member NGOs must
demonstrate a fairly high level of administrative and managerial sophistication. In
addition, RCS required member NGOs to demonstrate several years of experience
working in the STD/HIV field. This structure was adopted in the interest of the long￾term stability of the network and to improve the likelihood that member NGOs would be
able to fulfill shared contractual obligations when collaborative projects were awarded to
the network. The end result is that the RCS currently falls short of contributing to an
expanded national response. When RCS leadership was posed, the question of how the
organization could contribute to building NGO capability at the regional level, it
25
enthusiastically offered to help strengthen NGOs based in the regions to improve its
capacity for project management and implementation.
The project experience of RCS has been limited principally due to the slow process of
setting up the organization. However, its recent experience implementing a pilot youth￾focused behavioral intervention in Callao (with UNAIDS support) has catalyzed
PROCETSS youth activities. Similarly with UNAIDS support, RCS has recently
developed and published a technical update document for journalists.
In the larger NGO context, PROCETSS has a fruitful history of collaboration with the
academic community, most notably the Universidad Peruana Cayetano Heredia,
Universidad Mayor San Marcos, and the U.S. Naval Medical Research Institute
Detachment in Lima. These collaborations include joint applied research projects and
support to PROCETSS training activities. The collaborations are facilitated by pre￾existing university affiliations of some PROCETSS staff.
The long-term sustainability of the NGO community working in the STD/AIDS field is
based on two fundamental elements: accountability and autonomy.21 Accountability
itself has several dimensions, including accountability to constituencies, to donors and to
having an impact in their area of strategic emphasis. In these terms, the Lima-based
NGOs appear to have achieved a level of accountability in all areas although measurable
indicators of this were beyond the scope of the evaluation. NGO autonomy can also be
examined along a number of dimensions, including a clearly articulated commitment to
maintaining independence in decision-making. This naturally leads to some level of
separation between government and NGO programming and is evident among Lima￾based NGOs. Another concern related to autonomy is the financial independence of an
NGO. Most mature NGOs are experienced at obtaining independent funding and some
have long-standing financial and technical linkages with international NGOs and donors.
Another feature related to the autonomy of NGOs is their grassroots base and capacity for
social activism. Some of the Lima-based NGOs reviewed for this evaluation evidenced
considerable grassroots support, particularly those organizations focused on providing
support to seropositive individuals and those with a primary mission focused on human
rights for disenfranchised populations. Finally, technical and managerial expertise is an
aspect of autonomy and as previously described, this dimension appeared to be well
developed within all NGOs contacted during the evaluation. In summary, there is
evidence that the involvement of Lima-based NGOs in HIV/AIDS advocacy, prevention,
and care is likely to be sustainable. However, the same cannot be said for regional-based
NGOs (excluding Lima-based NGOs with regional offices) with which the evaluation
team had limited contact.
Recommendations for Strengthening NGOs
The two major recommendations for continued strengthening of the involvement of
NGOs in HIV/AIDS advocacy, prevention, and care in Peru are to develop regional NGO
 
21 Fisher, J. NGOs and the Political Development of the Third World. West Hartford: Kumarian Press,
1998.
26
capacity and to consider expansion of the scope of NGO involvement in AIDS prevention
and care.
Develop and strengthen the capacity of NGOs at the regional level. This might be
accomplished by using the Lima-based Red SIDA Perú NGOs to develop collaborative or
satellite linkages with regional NGOs. It will be necessary to assess the needs and
capacities for regional NGOs, develop a management and technology transfer scheme,
and encourage innovative programs (e.g., NGO training and supervision of PEPs,
providing child care services in the STD/AIDS service delivery setting). A small grant
fund administered centrally for regional-based NGOs could call for submission of project
proposals that both fit within their organizational mission and complement PROCETSS
objectives and focus on priority populations for AIDS/STD prevention. Ideally, the grant
process would allow sufficient flexibility to favor innovative community-based projects.
The grant preparation process would ideally be incorporated into the training and
technology transfer efforts.
Develop a shared or complementary long-term policy agenda with PROCETSS,
NGO leadership, and intersectoral working groups. The PROCETSS/MOH
infrastructure carries the burden of HIV/AIDS prevention and care in Peru, especially
outside Lima. Continued strengthening of NGO capacity in HIV/AIDS prevention and
care, as well as in advocacy, will complement the ambitious MOH efforts.
COLLABORATION WITH BUSINESS AND INDUSTRY
The Peruvian economy has been in a recession for most of the last decade. The
PROCETSS leadership reports that the business community has shown low levels of
interest in AIDS/STD health issues. Although the evaluation team did not meet formally
with business community representatives to verify this barrier from their perspective, it
seems understandable. There appears to be no workplace HIV/STD prevention programs
in place. However, there is evidence that the private sector representatives, in their role
as community leaders, are participating in their capacity as members of some regional￾level, intersectoral working groups, and informal conversations with businessmen
suggested potential interest where self-interest and altruism overlap.
Recommendations for Business and Industry
Solicit private sector participation in a national AIDS advisory council. The
involvement of private sector community leaders with links to key national business
associations in a national AIDS advisory council would help build interest in potential
workplace HIV/AIDS prevention programs and help expand the national response to
include the private sector. Model programs in Africa include interventions among truck
drivers in Mombassa, Kenya,22 and among factory workers in Zimbabwe (D. Katzenstein,
unpublished data). It would be useful to coordinate trips for private sector representatives
 
22 Rakwar, J., Lavreys, L., Thompson, M.L., Jackson, D., Bwayo, J., Hassanali, S., Mandaliya, K., Ndinya￾Achola, J., and Kreiss, J. “Cofactors for the acquisition of HIV–1 among heterosexual men: prospective
cohort study of trucking company workers in Kenya.” AIDS 1999 Apr 1;13(5):607–614.
27
to the national advisory council to visit model workplace programs, preferably in the
region. Such trips would ideally be coordinated by PROCETSS, with financial support
from the private sector.
Establish an external affairs unit within PROCETSS, linked to the similar unit in
the MOH. This unit could promote active private sector outreach as a first step
towards fostering development of workplace HIV/STD prevention programs.
USAID may want to consider active support to PROCETSS as it develops a policy
strategy (see BCC section) and professional capacity to address this area. Potential
linkages with the USAID democracy program could provide access to an audience of key
private sector decision-makers with an interest in HIV/AIDS prevention programs.
International experience has shown that multinational corporations frequently are among
the first to put innovative approaches to workplace prevention in place.
Solicit grant proposals for innovative workplace-based HIV/AIDS/STD prevention
programs.
IMPROVED INFORMATION DISSEMINATION VIA PUBLICATIONS,
CONFERENCES/WORKSHOPS, AND A DOCUMENTATION CENTER
PROCETSS produces two major publications on a monthly basis. Contrasida Informe is
a publication directed to a general audience of professionals working in the AIDS/STD
prevention field (see BCC section) and has somewhat of an advocacy focus.
Diseminación Inferati va sobre las Enfermedades de Transmisión Sexual y VIH/SIDA is
distributed predominantly to health care providers currently offering HIV and STD care.
Its content centers around a collection of recent articles translated from the peer-reviewed
scientific literature. The effectiveness of the publication would be enhanced by the
inclusion of a summary article that focuses on interpreting the various scientific articles it
reviewed. This summary could include key points from each article of interest to health
care providers and planners and, when appropriate, highlight how the findings from the
current article change or update current scientific approaches to patient management or
health service delivery problems in Peru. In general, this publication would benefit
addressing barriers to adoption of new standards of care by health care providers.
The AIDS Help project supported the establishment of a documentation center housed at
Via Libre, a Lima-based NGO. According to the center’s librarian, university students
are the leading users of the center. The user population is somewhat more heterogeneous
and included journalists in the weeks prior to December 1, World AIDS Day. The
somewhat limited user population of the center is of concern, particularly since one of the
intended objectives was to continuously inform and teach sensitivity to key opinion
leaders. The center’s infrastructure is adequate given current demand and includes
Internet access, although the two available terminals are only accessible to documentation
center staff who conduct searches based on a user’s request. The center is staffed by a
trained librarian and an information specialist primarily responsible for conducting
Internet searches. The continued expansion and updating of the center’s document
collection has been hampered by lack of funds. It also is unclear how this documentation
28
center fits in with other resources, such as university libraries. It seems important to
revisit a strategic plan for this service, particularly given recently explosive growth in
Internet-based information exchange.
In the last five to seven years, PROCETSS has sponsored a wide range of national and
international meetings and training workshops. The training activities directly related to
clinical management and STD/HIV service delivery are described in the BCC section of
this document. PROCETSS has considerable capacity to design and coordinate effective
scientific meetings. These activities have brought leading representatives of the
scientific, health policy-making and NGO communities together on a regular basis to
exchange information and update their respective approaches. These activities are seen
as quite valuable for building capacity among the health care and NGO sector and
expanding the national response to AIDS/STD prevention and care.
Recommendations
Continue to invite donor support for national and international meetings and
training workshops. These have been supported by USAID and are viewed as having
been very successful.
PROCETSS could provide support for abstracting data appropriate for Peru and
make this available with commentary to interest groups in Peru. Increasingly, even
developing countries are moving toward use of the Internet for updating scientific
information on HIV/AIDS.
Enhance the advocacy agenda of publications (as described in the BCC section of this
evaluation).
OBJECTIVE 3
FINANCIAL, INSTITUTIONAL AND SOCIAL SUSTAINABILITY
Increased understanding and commitment by the government of Peru to increase AIDS
prevention, care, and support is evidenced by the fact that national funding to
PROCETSS for STD/HIV/AIDS prevention has increased from about 7,500,000 soles in
1997, to 11,204,000 in 1998, to 12,630,000 in 1999 to 18,500,000 soles in 2000 (more
than a 150 percent increase in soles since 1997). Additional support from AIDS Help
represents about 10 percent of the annual budget from 1997–99. Additional external
support from a World Bank loan and UNAIDS totaled 360,000 in 1999. Regional and
local support leveraged by this national program is hard to assess but undoubtedly it
considerably exceeds the support from PROCETSS. For example, in Iquitos,
PROCETSS funded one position (the regional PROCETSS coordinator) in the health
services system, while the regional government supported 35.5 positions involved in
HIV/AIDS/STD prevention or care, several of whom (in larger health centers and the
29
CERETS) worked full time on HIV/AIDS/STD as coordinators, counselors, clinicians, or
laboratory technicians responsible for HIV testing, RPR tests, etc. The regional health
department paid for 25 percent of ELISA tests for HIV (but thought PROCETSS should
have paid for all ELISA tests). Mèdicin du Mond provided further support for personnel
and supplies. On the other hand, PROCETSS fully funded the peer outreach network,
laboratory supplies, and medications for CERETS and UAMPS. The government of Peru
is now scaling up a PROCETSS/MCH collaborative system for antenatal screening for
HIV and syphilis, and is providing prophylactic antiretroviral therapy and syphilis
treatment for pregnant women throughout the country. The government of Peru fully
funds testing and treatment, and provides 3 months of formula feeding for infants of
HIV–infected women. The numbers of cases of congenital syphilis averted are
impressive. The government of Peru also provides CD4 testing for HIV–infected persons
in Lima. PROCETSS has developed guidelines for prevention and management of
opportunistic infections and provides medications for this. The government of Peru does
not provide antiretroviral treatment for HIV infections, except for perinatal prophylaxis.
As discussed above, the HIV/AIDS–prevention activities developed by PROCETSS in
Peru represent a model program for Latin America. Although the community-based
work of PROCETSS with high-risk populations is evidence based and epidemiologically
sound, donor agencies and their affiliated MOH programs have seldom worked with
these high-risk groups. It is by working with such marginalized populations that
PROCETSS activities complement those that work with the general population of
women, such as MCH and family planning, who probably do not contribute in a major
way to HIV transmission at the present time in Peru.
The fact that the national government of Peru currently funds virtually all of the
community-based peer outreach effort, even at the regional level, represents a strong,
sound commitment of the government of Peru to HIV/AIDS/STD prevention. This
financial support is all the more impressive against the backdrop of overall recession,
leading to several programmatic reforms within the Ministry of Health. However, this
sole dependence on a single source of funding—national government of Peru— also
represents a potential vulnerability in the sense that potential change has often led to
substantial decrements in governmental funding and commitment for AIDS in some
countries, perhaps because of variable enthusiasm for work with stigmatized groups and
behaviors. It is less risky to work on malaria and child survival than to work on AIDS.
Multiple sources of funding and multiple implementing agencies can buffer temporary
funding setbacks. A donor agency would be wise to sustain direct support for a fledgling,
promising program in a country like Peru, with a still concentrated AIDS epidemic but
with patterns of sexual behavior that make it vulnerable to a more generalized epidemic.
RECOMMENDATIONS FOR ENSURING SUSTAINABILITY
OF HIV/AIDS/STD PREVENTION AND CARE ACTIVITIES
Financial sustainability may be improved in the intermediate term by consolidating
rather than expanding prevention activities. Institutional sustainability can be
improved by continued public and external support at least at current levels, for the
30
foreseeable future, and by encouraging stable leadership and administrative structure and
processes within national HIV/AIDS/STD prevention and care efforts. Social
sustainability may perhaps be improved by nurturing further development of NGO
involvement, especially at the peripheral level.
Current interventions appear sustainable, but now require careful supervision,
monitoring and evaluation, behavioral and biologic measures (e.g., STD prevalence and
ideally, HIV incidence in Lima and perhaps Iquitos) as well as process measures (e.g.,
number of condoms distributed and contacts made by PEPs). PROCETSS has developed
systems to collect data on these process indicators.
The costs of maintaining high-quality, periodic STD and HIV screening programs
targeting FSWs, MSM, and youth in all large cities in Peru will be substantial. An
alternative to expanding HIV and STD prevention activities among FSWs and MSM that
warrants consideration is to more slowly develop the peer education, network, and
clinical services phasing in new cities based on analysis of the 2000 sentinel surveillance
data, while assessing the impact in communities added in a stepwise manner. FSWs and
MSM in the intervention communities could then be compared with those in other
communities regarding condom use with casual and regular partners, number of partners,
and prevalence of gonorrhea, early syphilis, and HIV as ascertained in the annual sentinel
surveillance. HIV incidence may not be high enough outside Lima to detect difference
attributable to the intervention in a short period. Nonetheless, HIV incidence, as well as
incidence of other STDs, should be compared in the intervention communities and
nonintervention communities, using the detuned ELISA on the HIV reactive sera in the
sentinel surveillance. Consolidation through ongoing supervision, continued training,
monitoring, establishing informatic systems and communication networks across regions,
coupled with intensified evaluation and demonstration of impact in regions where
interventions are working well—all could facilitate the next phase of program expansion.
Program sustainability should be further strengthened by renewed efforts to build a
national network of NGOs, perhaps coordinated by the existing NGO network in
Lima, and to proceed with policy development as addressed in the
recommendations.
OBJECTIVE 4
DETERMINE IMPACT OF TRANSFERRING PROJECT ACTIVITIES
TO THE VIGIA PROJECT
The VIGIA project has de facto assumed USAID responsibilities for some USAID–
funded AIDS prevention activities in Peru. AIDS and STDs were listed as the first two
examples of seven emerging diseases in Peru in the VIGIA activity description provided
to the evaluation team. Funding for HIV/AIDS prevention during the first three years of
the VIGIA project totaled $70,000. VIGIA provided $300,000 to PROCETSS in 1999,
31
coinciding with the end of AIDS Help. These VIGIA funds were used by PROCETSS to
pay for condom distribution, BCC, and referrals by PEPs for STD and HIV screening.
The ALASKA project was funded in part by USNAMRID and the University of
Washington, and by PROCETSS, with separate objectives of operational research to
define the incidence and risk factors fof HIV infection and other STDs among MSM in
Lima and developing and evaluating the use of PEPs for HIV/AIDS/STD intervention
activities for MSM. These seem to have been appropriate and complementary objectives
that have been met, providing useful epidemiologic data and a model of peer-based
intervention for MSM in Peru and indeed for the region. Comparable efforts have been
relatively rare elsewhere in Latin America.
Several issues of transferring of AIDS Help activities to VIGIA were observed:
ß Initial differences in priorities of HIV/AIDS/STD prevention activities as
well as approach by the PROCETSS and VIGIA programs: Whereas
PROCETSS adopted a focus on high-risk populations with the highest HIV
and STD prevalence, VIGIA favored mass-media campaigns and community￾based activities for the general population and youth.
ß Vertical versus horizontal programs: VIGIA initially preferred a
horizontally integrated program for HIV/STD prevention. This may be most
appropriate for STD/HIV prevention and early diagnosis in sexually active
women who sometimes receive services from MCH or family planning, but
not for marginalized populations, such as MSM, FSWs, or out-of-school
youth. However, horizontal integration of epidemiologic and surveillance
activities into OGE, which is supported by VIGIA, appears to be appropriate
and is proceeding well.
ß Advisability of joint planning: PROCETSS developed its prevention
strategies for 1996–2000 before USAID provided AIDS Help and VIGIA
support. It would be advisable for PROCETSS to include VIGIA project staff
in discussions related to planning its program priorities for 2000–2005 to
ensure buy in by VIGIA and optimal use and coordination of MOH and
VIGIA funds.
ß VIGIA now funds sentinel surveillance involving the collection of unlinked
HIV and syphilis prevalence data from antenatal populations and prisoners
(FSWs and MSM). PROCETSS obtains and analyzes additional
epidemiologic data from voluntary HIV and STD screening in the course of
monitoring CERETS and UAMPS activities. Ongoing collaboration between
OGE and PROCETSS in surveillance will be important.
ß PROCETSS and VIGIA could collaborate on the analysis of cost￾effectiveness of selected components of current PROCETSS programs.
32
ß Laboratory equipment is needed at CERETS both for the rapid diagnosis of
syphilis and HIV for diagnosis and care, as well as for surveillance (which
does not require rapid testing). It seems appropriate for VIGIA to assist in
funding for both types of equipment.
A national advisory council on AIDS was not convened by the MOH and is not available
for consultation by VIGIA. However, the VIGIA team has consulted with PROCETSS in
developing the work funded in the current budget. One impact of transferring HIV/AIDS
prevention funding from AIDS Help to VIGIA appears to have been that initially, VIGIA
was not adequately apprised of the aims of PROCETSS prevention activities with high￾risk groups or the specific role that VIGIA funding would play in achieving the goals of
the ongoing prevention programs. While the MSM PEP outreach through the ALASKA
project in Lima and PROCETSS activities in other regions appears to have been
successful, it would be useful for PROCETSS and VIGIA to collaborate on an evaluation
and specifically analysis of cost-effectiveness and sustainability of this and other
programs.
RECOMMENDATION CONCERNING TRANSFER OF HIV/AIDS/STD
PREVENTION AND CARE ACTIVITIES TO VIGIA
Select Mechanisms for Maximizing Effectiveness of Future USAID Investment in
HIV/AIDS/STD Prevention in Peru: Current PROCETSS leadership possesses
considerable expertise in HIV/AIDS prevention planning and evaluation. For example,
the director has held his current position for five years, which is one of the longest
tenures in office among all program directors in Latin America. He participates in
USAID–sponsored evaluations of other HIV/AIDS–prevention programs in Central and
South America and the Caribbean. High turnover elsewhere in these positions has many
causes, including the high level of political sensitivity of HIV/AIDS/STD prevention and
high level of stress. Engagement of expertise from multiple disciplines in
HIV/AIDS/STD prevention in Peru could help ensure stability and continued
improvement of what has been accomplished and could promote more meaningful
linkages and coordination of HIV/AIDS/STD prevention and care activities across related
health programs.
Strong coordination at the level of the funding agency will encourage strong coordination
across program areas at the Ministry and other federal agencies. The 1996 AIDS Help
design was well thought out and stands up well to scrutiny now. However, it did not
recommend a full-time AIDS coordinator. Active development of an AIDS donor group
(with UNAIDS), of a national NGO network (with PROCETSS), and of policy, youth,
and women’s activities, should remain priorities for USAID in Peru, and might benefit
from a full-time HIV/AIDS/STD coordinator at USAID.
If VIGIA is the mechanism chosen to channel USAID support for HIV/AIDS/STD
prevention activities in Peru, there is a need for a clearer consensus on priority goals and
objectives between the VIGIA director and USAID VIGIA coordinator on the one hand,
and the PROCETSS director and USAID AIDS coordinator, if different from the USAID
33
VIGIA coordinator, on the other. Explicit criteria and processes for future use of the
VIGIA mechanism would appear to be necessary. These criteria and processes would
have to be jointly agreed upon by VIGIA and PROCETSS leadership and by USAID
counterparts. Such criteria could include the following: nonduplication of government￾sponsored efforts; compatibility with VIGIA and PROCETSS goals, policies, and activity
lines; and, addressing an important need in HIV/AIDS prevention. Concerning process,
it would be ideal to choose a long-term area of emphasis that can be endorsed by VIGIA
and then implemented by PROCETSS. Micromanagement and a shift in funding patterns
by VIGIA and a unilateral shift in focus by PROCETSS should be equally discouraged.
A minimum baseline budget for HIV/AIDS prevention over the course of the grant, plus
competitive access to VIGIA funds for program enhancement, would be helpful.
It is not clear that the VIGIA project is the best mechanism for extending the population
coverage and ensuring the quality of a new program or for expanding the program from a
technically sound focus on high-risk youth or for strengthening services for women. An
alternative would be an HIV/AIDS/STD program coordinator at USAID/Peru, who
oversees direct funding of PROCETSS in areas of current need for training and
supervision, IEC materials development, progress into new areas of counseling
approaches, prevention, and care, and who coordinates policy initiatives and funding for
expanded coverage and for extension to new target populations.
ADDITIONAL CROSSCUTTING RECOMMENDATIONS
Balance the need for consolidation and stability with the need for continued
expansion of community-based, regional/peripheral HIV/AIDS/STD prevention
activities in Peru. The highest priority for external support for HIV/AIDS prevention in
Peru is for training, monitoring, and supervision to ensure stability and consolidation,
followed by incremental improvements in coverage and quality of an innovative but
evidenced-based, technically sound program that represents a Latin American model for
decentralization. An ideal approach to supervision and monitoring includes annual visits
to every regional center and a sample of subregional health centers and posts by an
interdisciplinary team. Improved informatics infrastructure (which the University of
Washington could assist by providing training through its new Fogarty International
Center Informatics Training Program, which is based in Peru) is also important to
improve monitoring and analysis of the growing volume of data generated by the
program. However, the PROCETSS budget and activities for supervision declined
dramatically in 1999, and no such funds or activities have been identified for 2000. It is
important to ensure that supervision is not further jeopardized by health care reform at a
time when this new program is most dependent on closer supervision by people
acquainted with the program.
Balance the specific needs for a vertical system with the potential benefits of
horizontal integration, as appropriate to the stage of the epidemic and the evolving
science of HIV/AIDS prevention and care. HIV/AIDS prevention and care in Peru are
moving rapidly towards horizontal integration. This is most evident in health services at
the regional level; for example, the General Hospital medical director in Loreta stated
34
that he “does not think of PROCETSS as separate from any other services provided by
the hospital” and thinks of the counseling, testing, screening, STD and HIV care as
services integrated with the rest of the hospital. The PROCETSS coordinator at the
largest health centers works exclusively on HIV/AIDS and STDs, whereas at smaller
health centers, coordinators have combined responsibilities, usually combining
STD/HIV/AIDS with MCH but not with family planning. At the central level, blood
banking and surveillance have shifted from PROCETSS to the blood bank program and
to OGE, respectively. The next activities that could probably be shifted are the programs
for preventing congenital syphilis and vertical HIV transmission, which eventually will
be taken over by the MCH program; however, it would be a mistake to undertake this
transition now. The very successful efforts in Peru are new, the science is moving too
quickly, and the existing coordination is working very well.
Similarly, the STD and HIV/AIDS care programs should remain with PROCETSS for
different but important reasons. Rapidly evolving programs include implementation of
syndromic management for STDs at the periphery and in pharmacies, the
CERETS/UAMPS screening and treatment for STDs in FSWs and MSM, and care of
HIV/AIDS. The pediatric AIDS network in Lima represents a useful model for a health
care network at present. Integration of STD/AIDS prevention and treatment services
with family planning services has moved more slowly; while closer coordination is
desirable, the slow progress partially reflects basically different priorities with respect to
reproductive tract infections inherent in the separate missions of the two programs (e.g.,
prevention of complications of contraception and increased uptake of contraception
receive highest priority in family planning programs, whereas prevention of transmission
of STD and HIV/AIDS receiving highest priority from PROCETSS). The efficacy and
importance of peer-mediated outreach to high-risk populations (e.g., FSW, MSM, and
bridge populations) at best are foreign to family planners if not a distasteful, poorly
understood anathema to such programs. The paramount need for such well-established,
essential components of STD/HIV/AIDS–prevention programs together with the rapidly
moving science of STD/HIV/AIDS prevention represent the critical rationale for
sustaining selected vertical components within PROCETSS.
These data should be used not only to guide family planing and adolescent health
programs, for example, but also to evaluate and guide Peru’s programs to prevent
reproductive tract infections and their sequelae.
Disseminate information within USAID about the Peru HIV/AIDS/STD program—
its extensive use of peer outreach, focus on marginalized high-risk populations, scale
up to a national program, growing integration with MCH programs, and
encouraging signs of successful impact—as a potential model for Latin America.
APPENDICES
A: SCOPE OF WORK
B: SUMMARY OF EVALUATION ACTIVITIES
C: DOCUMENTS REVIEWED AND REFERENCES
D: PROCETTS ORGANIZATIONAL CHART
APPENDIX A
SCOPE OF WORK
(from USAID)
AIDS-HELP Final Evaluation
MAARD No. 527-0378-T-90108
SCOPE OF WORK
Objective One:
Assess progress toward achievement of desired results and identify reasons for shortfalls
and successes.
· Strengthened HIV/AIDS prevention activities by PROCETSS at central and regional
levels through technical assistance, training, supervision and monitoring;
· Increased understanding and commitment by Government of Peru to increase
HIV/AIDS prevention, care and support activities
· Established and operational National Advisory Council that includes representatives
from government, private sector and persons with HIV/AIDS
A. Primary Responsibility - Team Leader
Objective Two:
Determine current status of the project as well as potential activity lines related to IEC,
interaction with NGOs, and health care networks.
· Expanded participation and strengthened technical quality, management capacity and
sustainability of NGOs involved in HIV/AIDS prevention, care and support activities;
· Increased consultation by MoH with NGOs on research, technical assistance, training
and IEC efforts to reduce the spread of HIV/AIDS;
· Improved coordination among actors and within overarching environments to
increase and improve HIV/AIDS prevention actions and services
· Increased awareness in, and support from business and industry in HIV/AIDS
prevention, care and support activities
· Improved production and timely dissemination of essential HIV/AIDS and STD
knowledge and experience through research publications, conferences, workshops,
seminars and documentation center;
B. Primary Responsibility - IEC Specialist
Objective Three:
Evaluation of financial, institutional and social sustainability of the project..
· Increasing capacity within Peru to recover, obtain or generate financial resources
required for the continuity of HIV/AIDS prevention, care and support activities
without additional USAID assistance;
· Improved capacity of the MoH authorities to plan, manage, administer, monitor and
adjust project activities to ensure their effectiveness and continuity after USAID
project completion;
· Increased ownership by NGOs and other institutions of some Project activities;
· Established and operational Donor Group to encourage participation by donors in
support of HIV/AIDS prevention, care and support programming
C. Primary Responsibility - Team Leader
Objective Four:
Determine impact of transferring project activities to VIGIA Project.
· National Advisory Council (AIDS-Help) is being consulted by National Team
(VIGIA) on implementation of prevention and control components
· Donor Group promotes collaboration by donors in applied research and field
investigations for appropriate and cost-effective strategies of prevention and control
to be developed and implemented
· Increased involvement of NGOs and private sector in planning, design and
implementation of project activities
D. Primary Responsibility - Team Leader and IEC Specialist
DELIVERABLES
1. Detailed work plan that includes the evaluation methodology to be used, to be
submitted after the second day on-site in Lima
2. Preliminary report which includes key findings and recommendations (5 copies in
English)
3. Presentation of findings and recommendations in de-briefing at the USAID/Peru
Mission
4. Presentation of findings and recommendations at Ministry of Health
5. Final report, not to exceed 50 pages, to USAID/Peru no later than four weeks after the
on-site work is concluded. (10 hard copies each in English and Spanish and diskette
using Microsoft Word)
APPENDIX B
SUMMARY OF EVALUATION ACTIVITIES
SUMMARY OF EVALUATION ACTIVITIES
DATE DESCRIPTION EVALUATION TEAM
MEMBER(S) PRESENT
Briefing at USAID with Richard Martin, HPN Officer and L. Seminario,
Public Health Advisor
MINSA with Jesus Toledo, Director of the Unit for the Health of the
People
Overview of PROCETSS Epidemiological Surveillance
Presenter: César Cárcamo
KKH, AEG
UNAIDS with Adriana Gomez KKH
Instituto de Educación de Salud (IES) with
Alicia Quintana, Research Coordinator
Rocío Zumaeta, Youth Promotion Coordinator
AEG
February 12,
2000 in Lima
Overview of PROCETSS Institutional Strengthening
Presenters: Jorge Sánchez, José Ojeda, Rosa Galván KKH, AEG
USAID with Lucy Lopez, regarding the Cobertura con Calidad project KKH, AEG
Instituto Materno Perinatal with Carlos Velasquez regarding congenital
syphilis, STD counseling and prevention of vertical transmission
programs
KKH
Red SIDA Perú with Ana Maria Rosasco, Director of Via Libre; Jose
Luis Cairo Molina, former General Secretary of Red SIDA Perú and
Director of Germinal; Ruth Ramos, Board of Directors of Red SIDA
Perú and Representative of MHOL
Overview of PROCETSS BCC program
Presenter: Julia Campos
Movimiento Homosexual de Lima (MHOL)
AEG
Proyecto VIGIA with Victor Zamorra
COPRECOS Epidemiology Division KKH
Alejandro Mesanna Aquinaga, Ministry of Health;
Richard Martin
January 13
Gloria Nichtawitz, former USAID Technical Monitor for AIDS Help
project
KKH, AEG
Overview of PROCETSS FSW intervention
Presenter: Patricia Segura
MINSA with Agusto Meloni, External Affairs
All
USNAMRID, with Kevin Russell and Douglas Watts KKH, CC
Meeting with FSW PEPs from Central, East, and South Lima
January 14
Meeting with MSM PEPs from Central, East, North, South Lima, and
Callao
AEG
Overview of PROCETSS youth program
Presentation by Jenny Germaná and Julia Campos
Briefing with PROCETSS Regional Coordinator, Pilar Jarama Bardales;
Regional Coordinator, Lucía Ruiz Escalante; and, Regional Director, Dr.
Carlos Calumpa del Aguila
KKH, AEG January 15
Meeting with recently trained youth PEPs in La Victoria AEG
In Iquitos Field visit to canoas sex work setting KKH, AEG, CC
January 17
in Iquitos
Field visit to las carapas sex work setting KKH, AEG, CC
DATE DESCRIPTION EVALUATION TEAM
MEMBER(S) PRESENT
Visit to regional hospital of Loreto: Dr. Carlos Calampa del Aguila,
Regional General Director; Lucía Ruiz Escalante, Regional PROCETSS
Coordinator; Dr. Eduardo Chuecas, Director of the Regional Hospital of
Iquitos; María Herrera Grandes, PROCETSS Coordinator for Regional
Hospital Programs
Visit to the CERETS at the Centro de Salud San Juan
Met with Dr. Harold Cervantes Bastidas, Chief of the Health Center;
Pilar Jarama, PROCETSS coordinator; and, CERETS staff
KKH, AEG, CC
Meeting with FSW PEPs
Meeting with MSM PEPs
CC, AEG
January 17
in Iquitos
Meeting with Medicos del Mundi Coordinator, Bernhard Corbiere KKH
January 18 Reading/writing day All
January 19
in Chimbote
Visit to regional hospital
Meeting with Director of Health Territorial Unit, Dr. Elizabeth Llerena,
and UTES PROCETSS Coordinator, Pilar Javez
Tour in CERETS and family planning program
AEG
In Trujillo
Meeting with Regional Health Director, Dr. Henry Rebaza, and
PROCETSS Coordinator, Dr. Pedro Guevara
Visit to regional hospital and CERETS; also met with Maria Agreda,
Coordinator
Visit to Huanchaco Health Center to see integrated syndromic
management program
Meeting with MSM PEPs
KKH
In Chiclayo
Meeting with Dr. Victor Linares Baca (Director General Lambayeque)
and Ms. Isabel Lizarraga (PROCETSS Coordinator)
Visit to San Juan Olaya Clinic and Mercedes Hospital (CERETS)
Meeting with MSM PEPs and HIV–infected pregnant women
CC
Visits to NGOs
Red Peruana de Mujeres Viviendo con VIH/SIDA
Via Libre: Gisseli Flores, Elizabeth Aquino, Geovana Torres
INPPARES: Daniel Aspolcuete, Executive Director; Angela Montoro
Alvarez, Coordinator STD service; Celeny Goñgera Fernandez, IEC
Coordinator; Jorge Alcántara Chávez, STD Prevention Coordinator;
Edguardo Seguil, Youth Program; Anibal Velasquez, Director of
Planning
APROPO: Carola La Rosa de Luque, General Manager
Visit to health service appealing to youth: Youth Clinic at the Hospital
Nacional Arzobispo Loayza
Dr. Aldo Vivar Mendoza, PROCETSS Coordinator; Dr. Beatriz Chung
Joo, Obstetrician/Gynecologist; and Kathe Zevallos, Counselor
AEG
Visit to Carrion Hospital: Dr. Luz Juarez, Director, and Dr. Jorge
Candiote
Meeting with GAMs (Tomas Sinchi Contreras, coordinator)
CC
January 20
Attended graduation for youth PEPs in Lima
Discussion with UNAIDS and UNICEF representatives KKH
Debriefing at USAID
January 21 Field visit to mobile STD clinic services in Callao All
Follow-up meeting with Dr. Lourdes Kan and Julia Campos re: BCC
materials and counseling training AEG January 22
Dr. Celum returns to U.S.
January 23 Dr. Holmes and A. Ghee return to U.S.
APPENDIX C
DOCUMENTS REVIEWED AND REFERENCES
DOCUMENTS REVIEWED AND REFERENCES
DOCUMENTS REVIEWED
AIDS Help background documents:
ß Activity Design for Ayuda CONTRASIDA (AIDS Help), draft dated 1996
ß VIGIA project document
National STD and AIDS Plan (Plan Nacional de Control de las ETS y SIDA), 1997–
2000
National School and Adolescent Health Plan (Plan Nacional para la Atención Integral de
la Salud del Escolar y Adolescente), 1997–2001
Project AIDS Help Annual Reports, 1996–99
Project AIDS Help Final Report (Informe Final: Indicadores de Resultados), submitted to
USAID, January 2000
National program plans:
ß Intervención de Promotoras Educadoras de Pares de Trabajadoras Sexuales,
1997–99
ß Plan Nacional para la Prevención y Control de las ETS/HIV en Hombres que
Tienen Sexo con Otros Hombres, 1999
ß Campaña Nacional de Prevención de ETS/VIH/SIDA para Gente Joven del Perú,
undated
Regional/city level program documents from La Libertad, Lambayeque/Chiclayo, and
Trujillo
Example of multisectoral working group outputs: Summary of Strategic Planning
Workshop, Lima, October 11–15, 1999
Sentinel Surveillance Protocols, 1999
Antibiotic Susceptibility Monitoring Protocol, 1999
Portfolio of BCC materials produced by PROCETSS
Portfolio of media coverage of PROCETSS activity
STD/HIV/AIDS training manual
Program delivery guidelines and norms
Law Number 26626: “AIDS Law” 1996
Program descriptions from NGOs visited
Reports from NGO–implemented operations research activities
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Ainsworth, M., Franzen, L., and Over, M. Confronting AIDS: Evidence from the
Developing World. The European Commission, Brussels, Belgium, and the World Bank.
Washington, D. C. Office for Official Publications of the European Communities ISBN
92-828-4991-0, L-2985 Luxembourg, 1998. Catalogue number (10 15 05) CF-17-98-
572-EN-C.
Ainsworth, M. and Over, M. Confronting AIDS: Public Priorities in a Global Epidemic.
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Celentano, D.D. et al. “Preventive intervention to reduce sexually transmitted infections:
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Centers for Disease Control and Prevention. “HIV prevention through early detection
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Fisher, J. NGOs and the Political Development of the Third World. West Hartford:
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Gorbach, P.M., Phalla, T., Sopheab, H., Leng, H.B., Mills, S., Bennett, T., and Holmes,
K.K. “Sexual Bridging by Cambodian Men: Potential Importance for General Population
Spread of STD/HIV Epidemics.” In press. Sex Transm Dis 1999.
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Changalucha, J., Nicoll, A., ka-Gina, G., et al. “Impact of improved treatment of sexually
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Holmes, K.K. “Critical Review of Evidence for Effectiveness of HIV Prevention
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Buenos Aires, Argentina. April 10–13, 2000. Abstract 32.001.
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Diseases. Buenos Aires, Argentina. April 10–13, 2000. Abstracts 29.001–29.004.
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APPENDIX D
PROCETSS ORGANIZATIONAL CHART
PROCETSS ORGANIZATIONAL CHART
DIRECTOR
Jorge Sánchez, M.D., M.P.H.
ORGANIZATIONAL ADMINISTRATOR
José Ojeda, Ing, M.B.A.
ASSOCIATE DIRECTOR
Lourdes Kusunoki, M.D.
COORDINATION UNIT
Jorge Vergara, M.D.
ICC UNIT
Julia Campos, Dra.
STRENGTHENING UNIT
José Ojeda, Ing, M.B.A.
EPIDEMIOLOGY UNIT
Luis Suárez, M.D.
Roberto Flores Patricia Segura, Lic. Rosa Galván, Lic. Jenny Germaná, Lic.
Maria Figueroa, Lic.
Roberto Escudero P.
The Evaluation of the USAID AIDS Help Project was made possible through support provided by the
United States Agency for International Development (USAID)/Peru under the terms of Contract Number
HRN-C-00-99-0005-00. The opinions expressed herein are those of the authors and do not
necessarily reflect the views of USAID.
Additional copies of this report may be obtained by writing to:
1101 Vermont Avenue, NW Suite 900
Washington, DC 20005
(202) 842-2939
(202) 842-7646 (Fax)
or via e-mail at tvt@tvtassoc.com.