MID-TERM EVALUATION
HIV/AIDS/STI PREVENTION AND CARE PROJECT
USAID/DOMINICAN REPUBLIC
Prepared by:
The Synergy Project
TvT Associates, Inc.
Cristina Pimenta
Daniel Halperin
Elizabeth Gomez
May 2001
Acknowledgments
The mid-term evaluation of the HIV/AIDS/STI Prevention and Care Project was made possible
through the support of the United States Agency for International Development
(USAID)/Dominican Republic under the terms of the contract number 517-A-00-97-07103-00. 
The opinions expressed herein are those of the authors and do not necessarily reflect the views of 
USAID. 
The team would like to thank all government officials, international agencies, and
nongovernmental organizations contacted and interviewed for their availability and willingness
to participate in this evaluation process.
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)
e-mail at tvt@tvtassociates.com
web site: www.synergyaids.com
ACRONYMS 
ADOPLAFAM Asociación Dominicana de Planificación Familiar/Dominican Republic 
Association for Family Planning
AED Academy for Educational Development
ALA Support for the Dominican Elderly
ASA Amigos Siempre Amigos/Friends Always Friends
BCC behavior change communication
BSS Behavioral Sentinel Surveillance
CASCO Centro de Animación Socio-Cultural/ Center for Social Cultural Activities 
CEPAC Centro de Educación para el Desarrollo Comunitario/Center for 
Community Development and Education
CEPROSH Centro de Promoción y Solidaridad Humana, Inc./Center for the 
Promotion of Human Solidarity
CIAC/ASAP Centro de Investigación y Apoyo Cultural/Center for Cultural Support 
and Studies
Asociación para la promoción de la Salud Pública/Association for the 
Promotion of Public Health
COIN Centro de Orientación e Investigación Integral, Inc./Center for Integral 
Orientation and Studies 
CONASIDA Comisión Nacional de SIDA/ National AIDS Commission
CONEP Consejo Nacional de la Empresa Privada/National Business Council
COPRESIDA Comisión Presidencial del SIDA/ Presidential AIDS Commission
CSW commercial sex worker
DIGECITSS Dirección General de Control de las Infecciones de Transmisión 
Sexual y SIDA/ National Coordination for the Control of Sexually 
Transmitted Infections and AIDS
EEC European Economic Community
ENDESA Encuesta Demográfica y de Salud/Demographic and Health Survey
FHI Family Health International
GODR Government of the Dominican Republic
IDAC Instituto de Acción Comunitaria/ Institute of Community Action
IDCP Instituto Dermtológico y Cirurgía de la Piel / National Dermatological 
Institute
IDDI Instituto Dominicano de Desarrollo Integral, Inc./ Dominican Institute for 
Development
IEC information, education, and communication
INSALUD Instituto Nacional de la Salud/ National Health Institute
JICA Japan International Cooperation Agency
JSI John Snow International
MOSCTHA Movimiento Socio Cultural de los Trabajadores Haitianos /Social and 
Cultural Movement of Haitian Workers
MSM men who have sex with men
MTCT mother-to-child transmission
MUDE Mujeres en Desarrollo Dominicana, Inc. /Dominican Women in 
Development
NGO nongovernmental organization
ONUSIDA/UNAIDS Joint United Nations Programme on HIV/ AIDS
PAHO Pan American Health Organization
PAV Propuesta de Apoyo a la Vida/ Proposal for Life Support
PEN Plan Estrategico Nacional/National Strategic Plan for HIV/AIDS
PPT pre-packaged treatment
PREVIHSA Proyecto de Apoyo al Programa de Prevención de ETS/VIH/SIDA/
European Economic Community HIV/AIDS Prevention Project
PROCETS Programa de Control de Enfermedades de Transmisión Sexual y SIDA/ 
Control of STI/AIDS Programme
PROFAMILIA Asociación Dominciana Pro-Bienestar de la Familia, Inc./ Dominican 
Association for the Promotion of the Family
PROMESE Programa de Medicamentos Esenciales/National Essential Drug Program
PROPAS Fundación Dominicana para la Promoción y Acción Social/ Dominican 
Foundation for the Promotion of Social Action
PROSISA Programa de Reforzamiento del Sistema de Salud de la República 
Dominicana/ Program for the Enhancement of the Health System in the 
Dominican Republic
PSI Population Services International
REDOVIH+ Red Nacional de Personas que Viven con VIH /National Network of 
Persons Living with HIV/AIDS
SESPAS Secretaría de Estado de Salud Pública y Asistencia Social/ State Secretary 
of Public Health and Assistance
STD sexually transmitted disease
STI sexually transmitted infection
UNAIDS Joint United Nations Programme on HIV/AIDS
USAID US Agency for International Development
VCT voluntary counseling and testing
VIH/SIDA Virus de inmunodeficiencia humana/Síndrome de inmunodeficiencia 
adquirida)
VT vertical transmission
TABLE OF CONTENTS
Page
EXECUTIVE SUMMARY..................................................................................................... i
RESUMEN EJECUTIVO............................................................................................... vi
I. INTRODUCTION 
1.1 Purpose of Evaluation...................................................................................... 1
1.2 Methodology ................................................................................................... 1
II. BACKGROUND 
2.1 Country Context ............................................................................................. 2
2.2 Projects and Strategies..................................................................................... 4
2.3 Vulnerable/target populations .......................................................................... 4
III. KEY FINDINGS AND RECOMMENDATIONS 
3.1 Program Management and Implementation....................................................... 6
3.2 Stigma and Discrimination .............................................................................. 6
3.3 Behavior Change Communication .................................................................... 7
3.4 STI Prevention and Treatment ......................................................................... 13
3.5 Voluntary HIV Counseling and Testing............................................................ 14
3.6 Availability and Access to Condoms................................................................. 14
3.7 Program Monitoring and Evaluation ................................................................ 15
3.8 Involvement and Coordination with GODR...................................................... 16
3.9 Partners........................................................................................................... 16
3.10 Private Sector and Business Community......................................................... 17
IV. FUTURE DIRECTIONS .......................................................................................... 17
V. APPENDICES
A. SCHEDULE OF VISITS
B. LIST OF CONTACTS
C. DOCUMENTS REVIEWED 
D. STATEMENT OF WORK 
i
EXECUTIVE SUMMARY
The evaluation team found that, overall, the USAID/Dominican Republic revised Strategic 
Objective 2 (SO2) for the Health and Population sector for 1999-2004, “ Increased use of 
sustainable basic health services and practices,” and the Intermediate Result, IR1, under SO2 for 
HIV/AIDS/Sexually Transmitted Infections (STIs), “Increased access to HIV/AIDS/STI 
prevention and care services by at-risk and affected populations of the Dominican Republic,” 
remain valid and relevant for the country. USAID-supported projects are working toward 
meeting the intermediate results through the implementation of proposed strategies. 
USAID support for programs in the Dominican Republic (DR) (US$11,225,000.00) is 
recognized as the major source of financial and technical assistance for the development and 
implementation of a national response to the AIDS epidemic. USAID/DR’s active participation 
and support for the development of the Plan Estrategico Nacional de ITS/SIDA 2000-2003 
(PEN) (National Strategic Plan for HIV/AIDS, 2000-2003), in collaboration with other 
international and national agencies, facilitated the implementation of important public policies 
and programs. PEN is complemented by the Provincial Operative Plans, also developed through 
the strengthening of management and technical capacity of the Direccion General de Control de 
las Infecciones de Transmision Sexual y SIDA (DIGECITSS), or National Coordination for the 
Control of Sexually Transmitted Infections and AIDS, within the Ministry of Health System 
(Secrataria de Estado de Salud Publica y Asistencia Social).
USAID-supported projects have made progress toward increasing access to HIV/AIDS/STI 
prevention services, with some improvement of HIV/AIDS-related surveillance and reporting 
systems. A pilot project to promote STI pre-packaged therapy has also shown some success.
Additional successful results include greater involvement of civil society in the fight against 
AIDS via the creation of an NGO/AIDS Coalition and establishment of the Dominican Republic 
Network of Persons Living with HIV/AIDS (REDOVIH+). NGO intervention projects targeted 
to at-risk populations have led to reductions in high-risk sexual behavior.
Some of these projects have been identified as “best practices” and should be considered for 
expansion to other regions of the country. Such projects include: Project Clara for care and 
support of people living with HIV; behavior change interventions for sex workers implemented 
by the Center for the Promotion of Human Solidarity (Centro de Promoción y Solidaridad 
Humana, Inc. or CEPROSH); the Avancemos Project on STI treatment; and the “100% Condom 
Use” methodology pioneered in Thailand. Other successful interventions include projects that 
feature extensive involvement and participation of beneficiary populations, such as men who 
have sex with men (MSMs), youth, and commercial sex workers (CSWs). 
National AIDS prevention and control strategies implemented in recent years have resulted in 
demonstrable reductions in the number of sexual partners and increased condom use in the 
general population, thus reducing risk of infection. The government of Dominican Republic has 
been less successful, however, in increasing access to primary health care and incorporating 
HIV/AIDS/STI care into the public health system. Even though USAID/DR has played a 
ii
proactive and supportive role in collaborating with the National AIDS Commission/ National 
Coordination for the Control of Sexually Transmitted Infections and AIDS 
(CONASIDA/DIGECITSS), situational constraints caused by changes in government and a 
corresponding redefinition of roles and responsibilities resulted in delays in implementation of 
the public health reform process. In addition, some of the country’s most vulnerable populations 
are in need of greater prevention and care services (e.g., MSM sub-populations (young MSMs, 
male CSWs, transvestites, heterosexual men), the bateye (sugar mill/migrant worker) 
communities, and confined populations(i.e., prisoners)).
The following summary highlights overall findings and major recommendations made by the 
evaluation team in respect to USAID project approaches and strategies. The summary offers 
specific recommendations regarding activity implementation for current strategies and reinforces 
specific approaches for the project's next phase. Section III of this report provides further details. 
1. Stigma and Discrimination
High levels of stigma and discrimination continue to be directed toward Dominicans living with 
HIV/AIDS. Every institution visited and person interviewed for this report expressed concern on 
this topic. Though most agreed that stigma had diminished (if only somewhat) among the general 
population, a high level of discrimination remains, and many health professionals at major public 
hospitals and clinics continue to resist caring for AIDS patients. In addition, physicians continue 
to request HIV tests from patients who are eligible for surgery without their knowledge and 
refuse to assist them if the test result is positive. Businesses use HIV tests in hiring and firing 
decisions without obtaining the employee's consent or offering pre- or post-test counseling.
Recommendation: Implement in-service training and an information, education and 
communication (IEC) campaign directed toward health professionals of all levels, including 
training on biosafety procedures and information on the care of AIDS patients. Informational 
materials and posters on human rights, solidarity, and HIV transmission, especially in health care 
settings, should be developed and posted inside hospitals, clinics and other health facilities. 
Recommendation: Mechanisms for the dissemination and reinforcement of AIDS Law 55-93 
should be discussed with both government officials and the AIDS NGO Coalition.
2. Behavior Change Communication 
Although television and radio spots often focus on condom use, IEC/mass media prevention 
messages also emphasize partner reduction/fidelity, abstinence/postponement of sexual debut, 
and dissemination of information on STI treatment/prevention. This strategy of combined 
messages has made an impact on HIV infection, partly because it is appropriate to the cultural 
and sociopolitical context of Dominican Republic. However, discrimination, stigma and 
associated ignorance and misinformation about HIV/AIDS have not been adequately addressed. 
Mass media campaigns have not included MSM-oriented HIV prevention messages; this 
population (young MSMs in particular) may not be receiving an adequate level of information 
and/or services. 
iii
The bateye (migrant worker) communities dispersed throughout Dominican Republic constitute a 
large and important high-risk population for AIDS and other STIs. These impoverished and 
historically marginalized communities remain difficult to reach, and often have no access to 
health care services, condoms, or HIV/AIDS prevention programs. The prisoner population 
appears to be at high risk of HIV/STI infection but also tends to receive little in the way of 
effective treatment or prevention services. 
Recommendation: Gains in reducing risky sexual behavior should be maintained and extended 
through continuation of IEC campaigns oriented to prevention of sexual transmission of 
AIDS/STIs. Such campaigns should continue to involve a diverse approach, incorporating 
partner reduction and abstinence/fidelity messages, in addition to information on condom use.
Recommendation: IEC campaigns' focus on youth should be expanded to encompass young 
MSMs, including those who may not necessarily identify themselves as homosexuals. Programs 
to reach at-risk youth in the bateye communities should also be adequately supported and 
monitored to ensure that a sufficient level of HIV/AIDS/STI services is available to this 
marginalized population.
Recommendation: HIV/AIDS prevention programs and STI services for the adult bateye 
population should be integrated and should include bilingual IEC materials in Creole. Family 
planning and primary health care programs should also be integrated with HIV/STI prevention 
efforts.
Recommendation: HIV/STI prevalence and behavioral practices research among prisoner 
populations is needed to develop effective prevention and treatment programs. Research may be 
conducted in conjunction with NGOs or other interested organizations.
Recommendation: Peer counseling and other HIV education interventions implemented by 
people living with HIV/AIDS should be expanded. This can be achieved through collaboration 
with networks of HIV-positive persons, such as REDOVIH+ and Grupo Clara.
Recommendation: More research is needed to measure HIV and STI prevalence in MSMs and 
other men in order to better estimate the actual total of HIV infections and AIDS cases 
comprised of MSMs, which evidence suggests may be significant.
3. Condom Availability and Access
Condom availability in Dominican Republic is limited according to the purchasing capability of 
the population, thus severely restricting access to the most effective method of HIV/STI 
prevention among groups who are most vulnerable to HIV infection (i.e., youth and poor 
women). Persons living with HIV/AIDS also have limited access to condoms, thereby increasing 
their chance of transmitting HIV to uninfected partners.
Recommendation: Since the condom is still considered the most effective barrier method for 
prevention of sexually transmitted HIV and other STIs, there is an urgent need for coordination 
of, and advocacy for, a national condom distribution policy. Such a policy would guide the 
iv
activities of national and international agencies working in HIV/AIDS prevention and care, as 
well as those working in family planning. 
4. STI Prevention and Treatment 
STI diagnosis and treatment services are generally available in the major cities targeted by 
USAID's project. Nevertheless, STI services are more commonly found in clinical units 
segregated from other health care units, reflecting high levels of stigma associated with STI 
treatment. Stigma is also evident in the expectation that commercial sex workers seek STI 
services at different hours than the population at large.
STI Management
The USAID/AIDSMark strategy for capacity building in STI management and program 
decentralization within DIGECITTS includes allocation of funds and short-term technical 
assistance provided by a senior STI management consultant. The consultant assists with revision 
and validation of the STI management manual and the national training curriculum. Medical 
doctors have been trained at the central, provincial and municipal levels. In addition, 
DIGECITTS has incorporated a primary health worker model into its manual for care providers 
at the primary level.
STI Pre-Packaged Treatment (PPT) Pilot Project
This pilot project, developed in November 2000 by DIGECITSS, included design of an STI 
package for three health care centers–one serving CSWs, one serving military troops, and one 
serving the general population. Information and promotional materials were distributed to health 
professionals, drug stores and popular pharmacies or boticas populares. Medical registry and 
monitoring and evaluation forms were also designed and distributed. Preliminary results indicate 
high levels of acceptance of PPT by health professionals and satisfaction by both male and 
female clients.
Recommendation: STI syndromic management should be integrated into primary health care at 
all levels of the public health system: dispensary, rural or urban outpatient clinics, maternal and 
child health or family planning sites, and outpatient clinics at hospitals. 
Recommendation: Since the PPT pilot project was implemented in a specialized STI outpatient 
service at hospital sites in the capital city of Santo Domingo, it will be necessary to assess 
satisfaction by users of the PPT in other sites before expanding the model nationwide.
5. Capacity Building
Capacity building through short-term technical assistance and study tours has been helpful in 
improving staff skills within DIGECITTS for STI management and program implementation. 
Specific capacity building activities have included development of a National Strategic Plan for 
AIDS Prevention and Care, development of 12 provincial strategic plans, and NGO management 
workshops.
v
Recommendation: DIGECITSS should enforce adherence to the STI syndromic approach by 
focusing its activities on technical assistance in monitoring and evaluation. Activities should be 
implemented in the next 2 years.
Recommendation: Mechanisms and opportunities for sub-grantee organizations to exchange 
information about project experiences and intervention strategies should be offered. Such 
opportunities will increase information dissemination between persons who participate in 
training courses, seminars and conferences and other NGO staff.
6. Monitoring and Evaluation
Following a period of high staff turnover, AcciónSIDA–an HIV/AIDS NGO capacity building 
organization managed by the Academy for Educational Development (AED)–recently hired an 
outside consultant to revise its evaluation plan to include all project-level result (“output" and 
"outcome") prevention indicators. Previous indicators were revised to meet the needs for the SO2 
and IR1, and new ones were identified to meet the needs of specific project interventions and 
targeted populations. Prevention indicators have been defined according to available baseline 
data for 1999/2000. Results evaluation studies have been planned for 2002. Indicators are clearly 
linked to the strategic objective and intermediate results, as well as to the lower-level subresults 
as originally proposed by the project. Process indicators have also been identified and included 
in the evaluation plan. 
As it stands, no project situational analysis has been carried out. More specifically, no 
information is available about target populations or the social and cultural context related to STI 
and HIV transmission. Such information is needed to assess actual project coverage of proposed 
interventions. 
Recommendation:
AcciónSIDA should involve sub-grantee NGOs in the evaluation process to build in-house 
capacity and continuity of project monitoring based on standard indicators for future impact 
assessment. 
Recommendation:
A project situational analysis is needed to integrate epidemiological, behavioral and 
socioeconomic data to illustrate the dynamics of the epidemic at both the provincial and local 
levels. 
vi
RESUMEN EJECUTIVO
El equipo de evaluación ha llegado a la conclusión de que, en términos generales, el “mayor uso 
de los servicios y prácticas sanitarias básicas viables” potenciado por el Objetivo Estratégico 2 
(SO2) revisado de USAID/República Dominicana para el sector de la salud y la población para 
el período de 1999-2004 y la “mejora en el acceso a la prevención y servicios médicos para el 
tratamiento de VIH/SIDA/Infecciones de Transmisión Sexual por parte de la población en 
peligro y afectada de la República Dominicana” potenciado por el Resultado Intermedio (IR1), 
bajo SO2 en referencia a VIH/SIDA/ITS, siguen siendo válidos y relevantes para el país. Los 
proyectos sostenidos por USAID pretenden cumplir con los resultados intermedios mediante la 
implementación de las estrategias propuestas. 
La ayuda que USAID presta a los programas que se desarrollan en la República Dominicana 
(US$11,225,000.00) es la mayor fuente de asistencia financiera y técnica en el proceso de 
desarrollo e implementación de una respuesta nacional a la epidemia del SIDA. La participación 
y asistencia activas de USAID y la República Dominicana para el desarrollo del Plan Estratégico 
Nacional de ITS/SIDA 2000-2003 (PEN), 2000-2003, en colaboración con otras agencias 
internacionales y nacionales, facilitan la implementación de importantes planes y programas 
públicos. El PEN se ve reforzado por los Planes Operativos Provinciales, que también han sido 
desarrollados mediante el reforzamiento de la capacidad administrativa y técnica de la Dirección 
General de Control de las Infecciones de Transmisión Sexual y SIDA (DIGECITSS), que 
pertenece a la Secretaría de Estado de Salud Pública y Asistencia Social. 
Los proyectos suscritos por USAID han conseguido ampliar el acceso a los servicios de 
prevención de VIH/SIDA/ITS, y una cierta mejora en los sistemas de supervisión y notificación 
de casos de VIH/SIDA. También se ha conseguido avanzar en la promoción de una terapia 
preempaquetada para el tratamiento de las infecciones de transmisión sexual.
Entre los logros adicionales se cuentan un aumento de la participación de la sociedad civil en la 
lucha contra el SIDA, a través de la creación de una coalición entre organizaciones no 
gubernamentales y la fundación de la Red de Personas que viven con VIH (REDOVIH+) de la 
República Dominicana. Los proyectos de intervención de las ONG centrados en el sector de la 
población expuesto a un mayor riesgo han supuesto la reducción de los tipos de comportamiento 
sexual más arriesgados.
Algunos de estos proyectos han sido declarados “prácticas óptimas” y se deberán considerar para 
su expansión en otras regiones del país. Estos proyectos son: el Proyecto Clara destinado a 
ofrecer atención y asistencia a las personas que viven con VIH; las intervenciones concebidas 
con el fin de cambiar el comportamiento de los trabajadores del sexo y que puso en práctica el 
Centro para la Promoción de la Solidaridad Humana (CEPROSH); el Proyecto Avancemos para 
el tratamiento de las enfermedades de transmisión sexual; y la metodología de “uso de condones 
al 100 por 100” de la que fue pionera Tailandia. Entre las demás intervenciones que se han 
llevado a cabo con éxito se cuentan proyectos que implican la plena participación de la población 
beneficiaria, como pueden ser los hombres que tienen relaciones sexuales con otros hombres, los 
jóvenes, y los trabajadores comerciales del sexo. 
vii
Las estrategias nacionales de prevención y control del SIDA que han sido puestas en práctica en 
los últimos años han resultado en reducciones demostrables del número de parejas sexuales y el 
aumento del uso de condones entre la población en general, con lo cual se ha conseguido reducir 
el riesgo de infección. Sin embargo, el gobierno de la República Dominicana no ha tenido tanto 
éxito en su esfuerzo por ampliar el acceso a la atención médica primaria y en la incorporación de 
la atención al VIH/SIDA/ITS en el sistema de salud público. Aunque USAID y la República 
Dominicana han jugado un papel proactivo en su colaboración con la Comisión Nacional del 
SIDA/Coordinación Nacional para el Control de las Infecciones de Transmisión sexual y el 
SIDA (CONASIDA/DIGECITSS), ciertos factores debidos a cambios en el gobierno y la 
redefinición correspondiente de papeles y responsabilidades tuvieron como consecuencia 
demoras en la puesta en práctica del proceso de reforma de la salud pública. A esto hay que 
añadir que parte de la población más vulnerable del país necesita más servicios de prevención y 
atención sanitaria (por ejemplo, la población de hombres que tiene relaciones sexuales con otros 
hombres (jóvenes homosexuales, trabajadores del sexo varones, travestís, hombres 
heterosexuales), las comunidades de los bateys (trabajadores temporeros y de las azucareras) y 
las poblaciones confinadas (presos)).
El resumen siguiente destaca los resultados generales y las principales recomendaciones 
redactadas por el equipo evaluador en relación con los enfoques y estrategias del proyecto 
USAID. Este resumen ofrece recomendaciones específicas sobre la puesta en práctica de 
actividades para desarrollar las estrategias vigentes y hace hincapié en enfoques concretos 
durante la siguiente fase del proyecto. La Sección III de este informe expone detalles adicionales. 
4. Estigma y discriminación
Los dominicanos con VIH/SIDA todavía sufren una gran discriminación. Todas las instituciones 
y personas entrevistadas para la redacción de este informe expresaron su preocupación al 
respecto. Aunque la mayoría pensaban que el estigma había disminuido (aunque sólo fuera un 
poco) entre la población en general, todavía existe discriminación y muchos profesionales 
sanitarios en los principales hospitales y ambulatorios se resisten a atender a los pacientes que 
sufren de SIDA. Además de esto, los médicos siguen ordenando análisis de VIH para los 
pacientes que van a sufrir una operación quirúrgica sin que ellos lo sepan y se niegan a asistirles 
si el análisis resulta positivo. Las empresas se sirven de los análisis de VIH para contratar y 
despedir a sus empleados, sin obtener su consentimiento previo ni ofrecerles asesoramiento antes 
ni después del análisis.
Recomendación:
Implementar una campaña de capacitación en el trabajo, y de información, educación y 
comunicación dirigida a los profesionales de la salud en todos los niveles, que incluya la 
formación sobre procedimientos de bioseguridad e información sobre la atención que necesitan 
los pacientes de SIDA. También será necesario diseñar y colocar folletos informativos y carteles 
sobre los derechos humanos, la solidaridad y la transmisión del VIH, especialmente en centros 
sanitarios. Este material informativo también se deberá poner a disposición del público en 
hospitales, ambulatorios y otros centros de salud. 
Recomendación:
viii
Se deberán tratar los mecanismos de difusión y refuerzo de la Ley 55-93 sobre el SIDA, tanto 
con los funcionarios del gobierno como con la coalición de ONG para el SIDA.
5. Difusión de la información sobre cambio de comportamiento
Aunque los anuncios en la televisión y la radio suelen centrarse en el uso de condones, los 
mensajes de prevención de información, educación y comunicación en los medios de 
comunicación de masas también enfatizan la importancia de la fidelidad y de la reducción del 
número de parejas, la abstinencia y el retraso de las primeras relaciones sexuales, y la difusión de 
información sobre el tratamiento y la prevención de las infecciones de transmisión sexual. Esta 
estrategia de mensajes combinados ha influido en la reducción de la diseminación de la infección 
por VIH, en parte porque es apropiada para el contexto cultural y sociopolítico de la República 
Dominicana. El problema es que no se ha trabajado lo suficiente en reducir la discriminación y el 
estigma, y la ignorancia y falta de información sobre el VIH/SIDA que los acompañan. Las 
campañas en los medios de comunicación de masas no contemplaban la inclusión de mensajes de 
prevención del VIH dirigidos a los hombres que tienen relaciones sexuales con otros hombres; 
este sector de la población (especialmente los más jóvenes entre ellos) pueden no estar 
recibiendo un nivel adecuado de información y servicios. 
Las comunidades de los bateys de trabajadores temporeros que están dispersas por toda la 
República Dominicana constituyen un grupo numeroso e importante de personas en riesgo de 
contraer SIDA y otras ITS. Estas son comunidades empobrecidas y marginadas históricamente y 
es difícil hacerles llegar la información necesaria, con el problema adicional de que muchas 
veces no tienen acceso a servicios médicos, condones ni programas de prevención del 
VIH/SIDA. También la población carcelaria parece ser muy vulnerable a la infección de 
VIH/ITS y además no suele recibir un tratamiento eficaz ni servicios de prevención. 
Recomendación:
Los avances logrados en la reducción de la conducta sexual arriesgada se deben mantener y 
ampliar mediante la continuación de las compañas de información, educación y comunicación 
centradas en la prevención de la transmisión por vía sexual de SIDA/ITS. Tales campañas 
deberán seguir incorporando un enfoque diverso, con mensajes que refuercen la idea de la 
reducción de las parejas sexuales, además de la abstinencia o la fidelidad, además de información 
sobre el uso de condones.
Recomendación:
El enfoque que las campañas de información, educación y comunicación tienen en la juventud se 
debe ampliar con la inclusión de los hombres que tienen relaciones sexuales con otros hombres, 
sin olvidar aquéllos que no se consideran a sí mismos homosexuales. Los programas destinados a 
transmitir los mensajes a los jóvenes más vulnerables en la comunidades de los bateys deben ir 
acompañados de la asistencia y el control esenciales para garantizar que esta población marginal 
dispone de los servicios de VIH/SIDA/ITS que necesita.
Recomendación:
Los programas de prevención del VIH/SIDA y los servicios de ITS para la población adulta de 
los bateys deben estar integrados e incluir material de información, educación y comunicación 
ix
bilingüe en criollo. En el programa de prevención del VIH/ITS también se deben incluir 
programas de planificación familiar y de conocimientos sanitarios básicos.
Recomendación:
Será necesario iniciar una investigación de la presencia de las infecciones y el comportamiento 
de la población carcelaria para poder desarrollar programas eficaces de prevención y tratamiento. 
La investigación se podrá realizar en colaboración con las ONG y otras organizaciones 
interesadas.
Recomendación:
Se recomienda la ampliación de la participación de personas que viven con VIH/SIDA en las 
tareas de educación de pares y en otras intervenciones para la educación sobre el VIH. Esto se 
puede conseguir a través de la colaboración con organizaciones de personas seropositivas, como 
por ejemplo la REDOVIH+ y el Grupo Clara.
Recomendación:
Será necesario investigar más a fondo para evaluar la presencia de VIH y ITS entre los hombres 
que tienen relaciones con otros hombres, y otros sectores de la población masculina, para poder 
estimar mejor el total real de infecciones de VIH y de casos de SIDA en el grupo de hombres que 
tienen relaciones con otros hombres, ya que se piensa que puede ser una cifra significativa.
6. Disponibilidad y acceso a los condones
La disponibilidad de condones en la República Dominicana se ve limitada por el poder 
adquisitivo de la población, por lo que los grupos más vulnerables a la infección de VIH (los 
jóvenes y las mujeres pobres) son también los que menos acceso tienen a este importante método 
de prevención del VIH/ITS. Las personas que viven con VIH/SIDA también tienen un acceso 
limitado a los condones, por lo que aumenta el riesgo de que le transmitan el virus a su pareja.
Recomendación:
Debido a que los condones se consideran todavía el mejor método de barrera que existe para la 
prevención del VIH de transmisión sexual y otras ITS, es urgente la creación y difusión de una 
política nacional de distribución de condones. Tal política guiaría las actividades de las agencias 
nacionales e internacionales que trabajan en la prevención del VIH/SIDA y la atención a los 
enfermos, así como aquéllas que trabajan en el sector de la planificación familiar. 
4. Prevención y tratamiento de las ITS
Los servicios de tratamiento y diagnóstico suelen estar disponibles en las principales ciudades 
objeto de los esfuerzos del proyecto USAID. El problema es que los servicios de ITS se 
encuentran generalmente en unidades independientes de otros centros médicos, lo cual refleja el 
gran estigma asociado con el tratamiento de las ITS. Este estigma se hace evidente también en la 
expectativa de que los trabajadores del sexo comercial asistan a los servicios de ITS a horas 
distintas que el resto de la población.
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Gestión de las ITS
La estrategia USAID/AIDSMark para aumentar la capacidad en la gestión de las ITS y la 
descentralización de programas dentro de la DIGECITTS incluye la asignación de fondos y la 
asistencia técnica a corto plazo de la que se encarga un asesor especializado en la gestión de ITS. 
El asesor asiste en la revisión y aprobación del manual de gestión de ITS y en currículo nacional 
de capacitación. Siguiendo esta misma línea, en los ámbitos central, provincial y municipal se ha 
entrenado a médicos. Además, la DIGECITTS ha incluido un modelo de trabajador sanitario en 
su manual destinado al personal en el nivel de atención primario.
Proyecto piloto de Tratamiento Preempaquetado de las ITS (PPI)
Los resultados preliminares indican un gran nivel de aceptación por parte de los profesionales de 
la salud y de satisfacción entre los clientes, tanto mujeres como varones. Este proyecto piloto, 
desarrollado en el mes de noviembre de 2000 por la DIGECITSS, contenía el diseño de un 
paquete de ITS para tres centros de atención sanitaria–uno dedicado al sector de la prostitución, 
otro a las tropas y otro al público en general. Se distribuyó información y material promocional 
entre profesionales de la salud, farmacias y boticas populares. También se asignaron y 
distribuyeron partes médicos y formularios de supervisión y evaluación.
Recomendación:
La gestión sintomática de las ITS se debe integrar en todos los niveles de la atención sanitaria 
primaria del sistema de salud pública: dispensarios, ambulatorios rurales y urbanos, centros de 
salud materno infantil y de planificación familiar, y ambulatorios en hospitales. 
Recomendación:
Como el proyecto piloto PPI fue puesto en práctica en servicios ambulatorios especializados en 
ITS instalados en hospitales de la ciudad de Santo Domingo, será necesario evaluar la 
satisfacción de los usuarios del proyecto en otros sitios antes de aplicar el modelo a toda la 
nación.
5. Aumento de la capacidad
El aumento de la capacidad mediante asistencia técnica a corto plazo y giras de observación ha 
ayudado a mejorar la competencia del personal dentro de la DIGECITTS en la gestión de las ITS 
y la puesta en práctica del programa. Entre las actividades concretas destinadas a aumentar la 
capacidad se encuentran el desarrollo del Plan Estratégico Nacional para la Prevención y 
Cuidado del SIDA, el desarrollo de 12 planes estratégicos provinciales y la creación de talleres 
de gestión de las ONG.
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Recomendación:
La DIGECITSS tendrá que insistir en el cumplimiento del enfoque sintomático en las ITS. Para 
hacerlo será importante centrar los esfuerzos en actividades de asistencia técnica sobre 
supervisión y evaluación. Estas actividades se deberán poner en práctica en los próximos años.
Recomendación:
Se deben ofrecer mecanismos y oportunidades para que organizaciones subdonatarias 
intercambien información sobre las experiencias que han tenido con los proyectos y con las 
estrategias de intervención. Estas oportunidades permitirán la difusión de la información entre 
las personas que participen en cursos de capacitación, seminarios y conferencias y el resto del 
personal de las ONG.
7. Supervisión y organización
Después de un período de cambios constantes en el personal, AcciónSIDA–una organización no 
gubernamental que trabaja en el sector del VIH/SIDA, dedicada al aumento de capacidad de las 
ONG y bajo la administración de la Academia para el Desarrollo Educativo (AED)–contrató 
hace poco a un asesor independiente para que revisara su plan de evaluación de forma que 
incluyera todos los indicadores de prevención de resultados de los proyectos (tanto el 
rendimiento como los efectos). También se revisaron los indicadores previos para que se 
adaptaran al SO2 y al IR1, y se identificaron otros nuevos para ciertos proyectos de intervención 
específicos y poblaciones concretas. Los indicadores de prevención se definieron según los datos 
de referencia existentes para 1999/2000. También se han planeado estudios de evaluación de 
resultados para 2002. Los indicadores están claramente ligados al objetivo estratégico y a los 
resultados intermedios, así como a los subresultados de niveles inferiores como se propuso al 
principio del proyecto. Los indicadores de procesos también han sido identificados e incluidos en 
el plan de evaluación. 
En estos momentos, todavía no se ha realizado un análisis situacional de los proyectos. En 
concreto, no se dispone de información sobre los grupos de población objeto ni el contexto 
sociocultural en relación con la transmisión de las ITS y el VIH. Esta información es necesaria 
para evaluar la cobertura real de los proyectos de intervención propuestos. 
Recomendación:
AcciónSIDA debe conseguir la cooperación de las ONG subdonatarias en el proceso de 
evaluación, para ampliar así la capacidad interna y garantizar la continuidad de la supervisión de 
los proyectos según los indicadores estándar, y poder evaluar así el impacto en el futuro. 
Recomendación:
Se necesita un análisis situacional de los proyectos para integrar los datos epidemiológicos, de 
comportamiento y socioeconómicos para ilustrar la dinámica de la epidemia en el ámbito 
provincial y en el local. 
1
I. INTRODUCTION 
1.1 Purpose of Evaluation
The overall objective of this evaluation was to assess the midterm progress achieved towards the 
expected results for Intermediate Result 1, "Increased access to HIV/AIDS/Sexually 
Transmitted Infection (STI) prevention and care services by at risk and affected 
populations of the Dominican Republic" (IR 1) under the Strategic Objective 2, "Increased 
use of Sustainable Basic Health Services and Practices", and to provide recommendations to 
USAID to strengthen or modify the IR 1 strategy.
Specific objectives were to determine whether the assumptions and strategies considered by 
USAID/Dominican Republic (DR) are still valid, to analyze the progress achieved toward 
obtaining the stated results, and to determine if capacity building is taking place and is effective. 
1.2 Methodology
The evaluation team was composed of three members: an HIV/AIDS program management and 
evaluation specialist/team leader, a behavior change communication and HIV/AIDS research 
specialist, and an epidemiologist HIV/STI specialist. The methodology used in this evaluation 
included: 
a) A review of the enhanced Scope of Work, project documents, project papers and reports, and 
studies and research papers related to the HIV/AIDS situation in the Dominican Republic 
prior to the beginning of the evaluation and throughout the evaluation process. 
b) Group and individual meetings and interviews were conducted with the following: Synergy 
Project staff, Latin America/Caribbean (LAC) Bureau and HIV-AIDS Division staff at 
USAID/Washington, USAID/DR staff, senior officials from U.S. Government AIDS 
commissions and programs, key officials from the health sector, staff of the Joint United 
Nations Programme on HIV/AIDS (UNAIDS), European Economic Community (EEC) 
officials, staff of the Academy for Educational Development (AED) (AcciónSIDA), Family 
and Health International (FHI) representatives and funded nongovernmental organization 
(NGO) staff. Meetings and interviews focused on project performance to assess whether 
interventions were effectively applying strategies, and whether the approach and strategies 
used were effective in integrating components into various levels of health care and related 
sectors. The team also focused on determining the level of inter-agency coordination and 
sub-grantee achievement related to project activities. Interviewees were asked to assess 
project activities in relation to relevance, complementarity, and ability to reach target 
populations. 
c) Site visits to Santo Domingo and Puerto Plata were conducted to assess project activities 
targeting groups such as bateyes (sugar mill/migrant workers), commercial sex workers 
(CSWs), youth, people living with HIV/AIDS, and people attending STI clinics. These visits 
included observations, interviews, and discussion groups to assess the level of project 
2
implementation and relevance to target populations, as well as the level of knowledge and 
participation of project staff in management, monitoring and evaluation, and decisionmaking. 
Focus groups were also conducted with youth in Puerto Plata and a semi-rural area near the 
second largest city, Santiago, to assess the impact of HIV/AIDS information, education, and 
communication (IEC) programs.
d) Debriefings were conducted at the presentation of the draft report to USAID/DR, and were 
followed by a presentation of the draft report to the National Coordination for the Control of 
Sexually Transmitted Infections and AIDS (Direccion General de Control de las Infecciones 
de Transmision Sexual y SIDA or DIGECITSS), and Accion SIDA.
e) Debriefings were also conducted via telephone with Synergy, with regular coordination on 
follow-up redrafts submitted to USAID for review and comment, and final revisions 
incorporating the comments.
A list of contacted individuals and institutions and an agenda for evaluation team activities are 
included in Appendix A and B of this report.
II. BACKGROUND
2.1 Country context
Taking into account substantial under-notification of AIDS cases to the national epidemiological 
data system, by July 2000 there were a total of 10,738 reported HIV infections and 5,440 
cumulative AIDS cases in Dominican Republic, of which 72% correspond to sexual transmission 
(mostly reported as heterosexual transmission). Even though the number of cases in the female 
population has increased considerably, the number of cases in the male population has remained 
steady for a decade, as has the male-to-female ratio of AIDS cases at 1.8:1.
Analysis of sentinel surveillance data from 1991 to1997 for pregnant women at health centers in 
five sites indicates that HIV seroprevalence for women of reproductive age in the general 
population is 1.2%. Prevalence data on CSWs ranges from 2% to 9%, and STI clinics report an 
HIV prevalence of 3.2% for STI patients in the general population. Seroprevalence data for 
blood donors is less than 1%. HIV prevalence among Dominicans who applied for a US resident 
visa from 1988 through 1997 averaged 0.2%. UNAIDS estimated that at the end of 1999, HIV 
prevalence in the adult population was 2.2%, with approximately 130,000 people infected.
It appears that the HIV epidemic in DR has either leveled off or begun to decline in the past 5 
years, although it must be noted that prevalence data within several important high-risk 
populations have not been collected since the early- to mid-1990s, including among men who 
have sex with men (MSMs), bateyes, and confined (i.e., prisoner) populations.
Recent studies indicate that the incidence of tuberculosis (TB) in DR is around 5% for adults. 
Among people with HIV infection, the incidence of TB increases to 14.5%. In addition to the 
impact on health care costs due to increased incidence of TB associated with AIDS, other 
3
problems, such as the appearance of drug-resistant strains of TB, make treatment more difficult 
and costly.
STI incidence and prevalence are particularly high in the Dominican adult population. 
Chlamydia is the main STI among CSWs who seek medical treatment; prevalence in this group 
is reported at 15 %. Since 1984, gonorrhea and syphilis infections have declined; however, it 
should be pointed out that 75% of Neisseria gonorrhea infections occur among persons who are 
resistant to penicillin.
After acute diarrhea and respiratory infections, the main reasons for consultations among women 
attending primary health care centers are vaginal discharge and lower abdominal pain. The 1996 
Demographic and Health Survey (Encuesta Demografico y de Salud or ENDESA-96) found that 
30% of women surveyed reported an STI in the 12 months prior to the interview.
The team found clear evidence of political willingness and commitment by the government of 
DR (GODR) to make the fight against AIDS a priority, as demonstrated by the recently created 
(September 2000) Presidential AIDS Commission (Comision Presidencial del SIDA or 
COPRESIDA). The decree creating the Commission proposed a multisectoral approach to the 
fight against HIV/AIDS through the involvement of each of the following institutions: State 
Secretary of Education and Culture; Secretary of Tourism; the Armed Forces and National 
Police; the National Council for Superior Education; the National Business Council (CONEP); 
the Network of Persons Living with HIV (REDOVIH+); and the NGO Coalition for AIDS. 
The proposed 2001 budget for COPRESIDA is US$ 7,822,000, which covers primary 
prevention, vertical transmission, post exposition prophylaxes and care for AIDS patients, 
epidemiological research, institutional strengthening, and legal support. 
COPRESIDA will also be responsible for managing additional funds to complement 
implementation of the National Strategic Plan for HIV/AIDS (Plan Estrategico Nacional or 
PEN). Funds are being negotiated with several agencies, including the World Bank (for a 4-year, 
US$20 million loan), other government sectors, UNAIDS, EEC, and the private sector. The 
Japan International Cooperation Agency (JICA) has donated US$170,000 through the World 
Bank for COPRESIDA start-up activities.
The concern about AIDS in DR dates back to 1983 when the first AIDS case was identified. In 
1987 the National Sexually Transmitted Disease (STD) and AIDS Control Program (Programa 
de Control de Enfermedades de Transmisión Sexual y SIDA or PROCETS), was created within 
the Secretary of Public Health and Social Assistance (Secretaría de Estado de Salud Pública y 
Asistencia Social or SESPAS) to implement prevention and surveillance strategies. 
Consequently, CONASIDA was formed. In 1998, DIGECITSS replaced PROCETS and began to 
focus on a national coordination and normative role for HIV/AIDS prevention and control for 
DR. With the creation of COPRESIDA, DIGECITSS will maintain the role of representing 
SESPAS within the Presidential Commission. 
4
2.2 USAID Project and Strategies 
For approximately the past decade, USAID/DR has supported the coordination and improvement 
of public and private service delivery and the establishment of prevention interventions for the 
control of HIV/AIDS. In 1998, USAID/DR revised its Strategic Objective 2 for the Health and 
Population Sector, following Hurricane George. The 1999-2004 Strategic Objective was 
modified to: “Increased Use of Sustainable Basic Health Services and Practices.” The 
Intermediate Result 1 under SO2 for HIV/AIDS/STI became: “Increased access to 
HIV/AIDS/STI prevention and care services by at-risk and affected populations of the 
Dominican Republic.”
USAID strategic areas of intervention are:
1. Increasing knowledge, risk perception and health-seeking behavior among the most 
vulnerable groups;
2. Promoting the expansion of STI/HIV/AIDS information and services to ensure universal 
access of couples and individuals;
3. Encouraging community, private, and GODR collaboration and involvement;
4. Improving availability and use of data to monitor STI/HIV/AIDS prevalence and trends;
5. Advocating a policy environment that continues to allocate increased resources in the 
national budget;
6. Supporting community-based programs to provide care and support to people infected and 
affected by HIV/AIDS.
Proposed target populations include youth, women, STI patients, people living with and affected 
by HIV/AIDS, and core transmitter groups. Major partner organizations in country are: 
UNAIDS, to move the HIV/AIDS prevention agenda forward, the Pan American Health 
Organization (PAHO), to provide technical assistance to the national AIDS program, the 
European Union-EEC, to support mass communication and pilot community interventions, and 
local NGOs.
2.3 Vulnerable/target populations 
Youth: A major focus of the national plan and USAID’s HIV prevention strategy has been on 
youth, a cohort with high HIV/STI infection rates. While programs directed mainly at 
heterosexual youth have begun to be implemented, it appears that young MSMs have not been 
sufficiently targeted under current strategies and remain at high risk of HIV infection. This 
group, including underage male CSWs, may represent a substantial proportion of overall 
HIV/STI transmission among youth.
Women: Women also continue to be a major focus of prevention efforts, and while these efforts 
have had some impact among female CSWs, other at-risk women, such as those in longer-term 
affairs (parejas de confianza), domestic workers, and bateye residents, remain largely outside the 
purview of current programs. Prevention efforts have also failed to address the high risk of HIV 
transmission posed by anal intercourse, in part due to strong cultural taboos. Because of these 
5
taboos, condoms are less likely to be used during anal intercourse than during vaginal sex, and 
most women in the community (along with many health professionals and prevention workers) 
appear to be unaware of the unusually high risk of HIV infection during heterosexual anal sex. A 
1996 study found that certain bisexual men, known as bugarrones, report especially high rates of 
anal sex with their female (and male) partners. However, health promoters and HIV educators in 
Puerto Plata and Santo Domingo, for example, report that while the most commonly asked 
questions asked during AIDS “raps” (charlas) concern the risk of oral sex, (heterosexual) anal 
intercourse is “never asked about.” In addition, so-called “dry sex” appears to increase risk of 
heterosexual HIV infection.
Bateyes: These sugar mill/migrant worker communities (or former sugar plantations) continue to 
constitute an important high-risk population for AIDS and other STIs. Due to conditions of 
abject poverty, a lack of health services, and a history of high mobility and sociocultural￾linguistic marginalization, bateyes remain an immense, far-flung, and highly challenging target 
population for HIV/STI services and prevention campaigns. 
Men: During the past 10-13 years, the proportion of male AIDS cases has remained fairly 
constant, hovering around 65% of total cases (SESPAS/DIGECITSS). While 3.5% of cumulative 
AIDS cases have been reported as homosexual transmission and another 4.3% as bisexual 
infection, different surveys in 1987, 1994 and 1998; biological studies in 1997 and 2000; and 
qualitative and anecdotal evidence suggest that the actual proportion of total HIV infections due 
to MSM activity may be higher than is officially reported. The accumulation of such evidence 
leads to a possible hypothesis that the DR may have a bisexual HIV epidemic, which would help 
explain the epidemiological situation of the nearly constant 1.8:1 male-to-female ratio 
maintained over the past 10 years. In more purely heterosexual epidemics, such as in most of 
sub-Saharan Africa, a 1:1 ratio is typically reached within a few years into the epidemic. 
Due to the intense stigma surrounding homosexuality in Dominican society, many men who at 
least occasionally engage in MSM activity, especially those who are married and are mainly (or 
ostensibly) heterosexual in orientation, tend to engage with male partners in a very discreet or 
"invisible" manner. For this reason, and also because they may be unaware of the extremely high 
risk of HIV transmission through anal sex, such men, if found to be infected, are likely to be 
reported (and self-identified) as cases of heterosexual transmission. 
Health care professionals interviewed for this evaluation expressed a “strong intuition” that 
“perhaps a large majority of infected men are probably bisexuals.” The fact that condom use 
among female CSWs appears to have reached levels of up to 90% in cities where there have been 
constant interventions for a number of years, lends further weight to the possibility that a large 
proportion of male HIV cases are in fact due to MSM transmission.
Although one fairly small NGO has led a dedicated campaign among gay men, mostly in the 
capital, other MSM populations have largely been ignored, including male CSWs, transvestites, 
bisexuals, MSMs in rural areas and residents of bateyes, youth/boys engaged in male sex work or 
other MSM activity, prisoners/confined populations, as well as male heterosexuals and the male 
population at large. 
6
A number of risk factors are present for rapid heterosexual spread of HIV/AIDS in DR, including 
extensive multiple partnering, high prevalence of STIs, “dry sex” practices, and lack of male 
circumcision, which is associated with increased risk of female-to-male HIV infection. 
Prisoners/confined population: This group represents another largely neglected, high-risk 
population. Male as well as female inmates are reported to engage in CSW or MSM activities 
and possibly other risky practices. Contributing factors include lack of condom availability and 
STI/HIV treatment services, and gaps in institutional responsibility for health care delivery and 
prevention programs.
III. KEY FINDINGS AND RECOMMENDATIONS
3.1 Program Management and Implementation
Reported program implementation on sub-result areas 1, 2, 3 and 4–including IEC, policy 
support and information dissemination, access to STI/HIV/AIDS services, and technical 
assistance and capacity building to both government and nongovernmental organizations–has 
been quite successful. Through interviews with the staff of different USAID-funded projects, the 
team was able to assess satisfaction with AcciónSIDA's established management processes. 
AcciónSIDA seems to have well-trained staff available to attend to subgrantees in the diverse 
areas of support that are required for project implementation. However, the monitoring and 
evaluation component of the program has suffered due to high staff turnover. 
Disbursement delays, supervision problems and funding interruptions have also plagued 
AcciónSIDA's NGO projects, mostly as a result of an unsuccessful initial partnership with Plan
International. Though AcciónSIDA's contract with Plan International has been terminated and 
affiliated NGOs are pleased with their professional and supportive relationship with 
AcciónSIDA, they are still concerned with the project’s capacity to manage monthly financial 
reports and disbursements. Delays on programmed disbursement of funds continue to pose 
problems.
Recommendation: The workplan for submission of monthly financial reports for reimbursement 
of expenses by subgrantees should be evaluated for practicality and administrative effectiveness. 
Recommendation: An assessment of more dynamic administrative and financial procedures 
might be useful for new project approval and contract extensions in order to avoid 
discontinuation of disbursements. Under such procedures, interruption of activity 
implementation and dismissal of trained NGO staff due to delay of project extension approvals 
might be avoided.
3.2 Stigma and Discrimination
High levels of stigma and discrimination continue to be directed toward Dominicans living with 
HIV/AIDS. Every institution visited and person interviewed for this report expressed concern on 
this topic. Though most agreed that stigma had diminished (if only somewhat) among the general 
population, a high level of discrimination remains, and many health professionals at major public 
7
hospitals and clinics continue to resist caring for AIDS patients. In addition, physicians continue 
to request HIV tests from patients who are eligible for surgery without their knowledge and 
refuse to assist them if the test result is positive. Businesses use HIV tests in hiring and firing 
decisions without obtaining the employee's consent or offering pre- or post-test counseling.
Recommendation: Design and implement in-service training and IEC campaigns directed 
toward health professionals of all levels, including in-service training on biosafety procedures 
and information about the care of AIDS patients.
Recommendation: Informational materials and posters focusing on human rights, solidarity, 
and how HIV can and cannot be transmitted in health settings, should be developed and placed in 
hospitals, clinics and other health facilities.
Recommendation: Informational materials and posters focusing on the need for pre- and post￾test counselling should be developed and distributed in health facilities and workplaces.
Recommendation: Mechanisms for the dissemination and reinforcement of AIDS Law 55-93 
should be discussed with both government officials and the AIDS NGO Coalition.
3.3. Behavior Change Communication (BCC)
Sexual Conduct and Behavioral Change Background
According to available survey, focus group and interview data, and further corroborated in 
accounts by prevention professionals and anecdotal information, a significant reduction in risky 
sexual behavior has occurred among substantial segments of the Dominican population. Notably, 
men report more frequent condom use for CSW-based and other casual sexual encounters and an 
overall reduction in numbers of partners. 
Beginning in 1996, qualitative evidence emerged from male and female focus groups conducted 
by the Dominican Association for the Promotion of the Family (Asociación Dominciana Pro￾Bienestar de la Familia, Inc. or PROFAMILIA)–an International Planned Parenthood Federation 
affiliate and subgrantee of AcciónSIDA–that indicated a change in male behavior due to 
awareness and fear of AIDS. Both genders reported reductions in the number of sex partners and 
increased condom use with sex workers or partners they did not know well. The 1996 DHS 
survey earlier found that 85% of a national random sample (urban and rural) of 2,273 men 
claimed changes in sexual behavior because of their concern over AIDS. The 1997-98 
PROFAMILIA Sexual Behavior Change study of 1,400 male respondents found that 27% 
reported consistent condom use during the previous 60 days. Recent data by one of the same 
investigators indicate that such behavioral changes, which continue to stem from a palpable fear 
of contracting HIV, have continued essentially unchanged. Similar fears do not appear to apply 
to STI infection other than HIV.
In effect, widespread, unprotected multiple partner practices, which were reportedly common 10 
or more years ago, have decreased substantially, although considerable levels of multiple 
partnering and, at times, low condom use persist among some populations of teenagers/young 
people. Also, condom use in stable relationships and more “trusting” affairs generally continues 
8
to be low. Nevertheless, HIV and STI rates in DR have leveled off or a decreased since the mid￾1990s. It should be noted that HIV seroprevalence (as well as behavioral survey) studies have not 
been conducted (or at least analyzed) among some important high-risk populations (e.g., MSMs, 
bateye residents, inmate), since the early- to mid-1990s.
Mass Media BCC Campaigns
Most large-scale IEC efforts have been oriented to prevention of sexual (usually strictly 
heterosexual) HIV transmission. Although television and radio spots often focus on condom use 
(either explicitly or by suggestion), IEC/mass media prevention messages also emphasize partner 
reduction/fidelity, abstinence/postponement of sexual debut (e.g, the recent “El Sexo Puede 
Esperar” campaign), and dissemination of information on STI treatment/prevention. With 
support from the media, this strategy of combined messages has made an impact on HIV 
infection, partly because it is appropriate to the DR cultural and sociopolitical context. However, 
there is a need for greater “bottom-up” input into the design and evaluation of public prevention 
campaigns.
Discrimination, stigma, and associated ignorance and misinformation about HIV/AIDS have not 
been adequately addressed in media campaigns (a notable exception was a briefly aired, highly 
regarded TV spot many years ago, showing an HIV-positive person celebrating his birthday with 
coworkers who freely embrace and comfort him). A 2001 Knowledge, Attitudes and Practices 
(KAP) survey by AccionSIDA of bateye residents near the capital, for example, found that 54% 
believe that HIV can be transmitted through use of public toilets; 59% believed that HIV can be 
transmitted through mosquito bites.
In addition, there is evidence of a widespread lack of information among lay people–across all 
socioeconomic and regional strata–regarding STIs other than HIV/AIDS. In a focus group 
conducted with a dozen youth living in a semi-rural community near Santiago, only three could 
name any STI, and none, including a community health worker, had heard of genital herpes, a 
common and incurable STI. An AccionSIDA-sponsored TV spot recently attempted to address 
discrimination against and the rights of people living with HIV/AIDS, and is considering 
addressing the popular myths surrounding casual transmission and associated stigma in a future 
TV spot. 
Mass media prevention campaigns have also neglected to address the significant proportion of 
HIV infections due to MSM activity. This is not surprising, given the historically conservative 
nature of various religious and cultural institutions. Prevention of HIV infection among MSMs 
will continue to be an important and highly challenging aspect of BCC/IEC campaigns in DR.
Recommendation: The gains that have been achieved in reducing risky sexual behavior should 
be maintained and extended through continuation of IEC campaigns oriented to prevention of 
sexual transmission of AIDS and other STIs, and should continue to involve a diverse approach, 
including partner reduction and abstinence/fidelity messages, and dissemination of information 
on condom use.
9
Recommendation: Greater “bottom-up” input is needed in both design and post-screening 
evaluation of mass media prevention campaigns This can be implemented, for example, through 
the use of focus groups carefully selected to embody a representative sampling of the target 
population.
Recommendation: Notwithstanding the obvious sociocultural limitations, mass IEC campaigns 
should pay at least minimal attention to (or at least a subtle suggestion about) the risk of 
HIV/STI infection for MSMs, in addition to the infection risks for heterosexuals.
Recommendation: Further attention must be paid to reducing the stigma and associated lack of 
accurate information concerning the risk of casual transmission of HIV/AIDS.
Peer Education, Theater, and Community Involvement (by Sector) 
Youth: Several NGOs have been working with youth, mainly through utilization of face-to-face 
peer health promoter networks, popular theater approaches, and other appropriate forms of “low￾tech” IEC. Such methodologies for the prevention of HIV/STIs among youth include a 
PROFAMILIA project that integrates the youth “information multiplier” method, discussion 
groups, and theatrical presentations into communities and schools. This program relies on parent 
involvement within a youth-friendly clinical setting for the diagnosis and treatment of STIs, 
counseling and provision of family planning methods, and condom distribution. PROFAMILIA 
also works with barbershops, beauty salons, and other community-level actors such as 
firefighters, policemen and the Red Cross, who can serve as examples/mentors to youth. 
Prevention efforts among the bateye population are now focusing exclusively on youth. An 
extensive peer health promoter intervention is being implemented in a number of bateyes, mainly 
located near the capital. 
Some IEC efforts have encouraged parents to openly discuss sexuality with their children. 
However, many youth report that their parents rarely, if ever, address sexuality or HIV/STI￾related themes at home.
Because youth programs have been primarily directed at preventing heterosexual HIV 
transmission, it appears that current strategies are not reaching young MSMs (including underage 
male CSWs, many of whom, along with other MSM youth, do not self-identify as openly 
homosexual); this group continues to be at high risk of HIV infection. 
Recommendation: The focus on youth should continue, and organizational efforts to reach 
harder-to-access youth populations need to proceed and expand. 
Recommendation: Programs to reach at-risk youth in the bateye communities should be 
adequately supported and monitored to ensure that a sufficient level of services is delivered to 
this economically, culturally, and linguistically marginalized population.
Recommendation: Encouragement of greater participation by parents in their children’s sexual 
education, and discussion of sexuality within the family context, should be continued and 
strengthened.
10
Recommendation: The focus on youth should expand to encompass young MSMs, including 
those who do not necessarily self-identify as homosexual.
Women: Due in part to the dedicated work of NGOs (e.g., the Center for Integral Orientation 
and Studies (Centro de Orientación e Investigación Integral, Inc. or COIN) and the Center for 
the Promotion of Human Solidarity (Centro de Promoción y Solidaridad Humana, Inc. or 
CEPROSH)), condom use among female CSWs appears to have risen impressively. In one study, 
between 92% (street CSWs) and 100 % (in formal CSW “houses”) of sex workers reported using 
condoms during encounters with their previous five clients. STI services for female CSWs have 
also improved somewhat, although STI treatment and prevention in this population requires 
greater attention. Other organizations such as Dominican Women in Development (Mujeres en 
Desarrollo Dominicana, Inc. or MUDE) have been working with rural and other female 
populations, although a greater level of input is required to reach additional high-risk and hard to 
reach women, including those involved in longer term “trusting” affairs (parejas de confianza), 
domestic workers, and bateye residents. 
Due to cultural taboos, prevention programs have not educated the public about the high risk of 
HIV infection through (receptive) anal intercourse. Due in part to a strong reluctance to discuss 
anal sex, condoms are less likely to be used for this practice, which is associated with an HIV 
infection risk 12-20 times higher than that of receptive vaginal intercourse (and much riskier still 
than forms of oral sex). One possible approach to disseminating this type of prevention 
information could be to emphasize the high-risk nature of certain practices such as anal 
intercourse and dry sex, as opposed to specifying particular populations (e.g., MSM) that are 
viewed as more likely to engage in such activities. Furthermore, the Church and other 
traditionally conservative cultural institutions may not necessarily oppose IEC efforts focused on 
the high risk of anal sex, since such messages would be consistent with their ideologies regarding 
such practices. 
Recommendation: Preventive, clinical and other HIV/STI services for at-risk women must 
continue in order to maintain and extend the gains that have been realized in HIV prevention in 
this population. Education efforts should aim to reach high-risk and marginalized women, such 
as domestic workers and bateye residents. 
Recommendation: Where appropriate (e.g., perhaps beginning with a pilot project on the North 
Coast), IEC campaigns should be developed to inform women (in addition to MSMs) of the 
unusually high risk of anal intercourse in addition to the additive risk of cultural practices such as 
dry sex.
MSMs: Early in the country’s AIDS epidemic, much of both public risk perception and of 
prevention programming was concentrated on this population. In subsequent years, greater 
attention has been placed on women, youth and other at-risk groups. Current prevention 
strategies need to address the fact that a considerable share of new HIV infections among men 
continue to be associated with MSM practices. Available data support this finding despite 
indications that cases among women and heterosexuals continue to comprise a large proportion 
of overall HIV transmission. If nearly all IEC and other prevention efforts are directed at 
11
heterosexual transmission, a real danger exists that MSMs (and young MSMs in particular) may 
not be receiving an adequate level of HIV/AIDS/STI services and information, particularly 
concerning the high risk of receptive anal sex. 
One small but dedicated NGO, Friends Always Friends (Amigos Siempre Amigos or ASA) has 
been leading an ongoing campaign among MSMs, but most of its work has focused on those who 
are more or less “out” as homosexuals. Given the magnitude of effort required, it is unlikely that 
a small NGO would be capable of implementing and managing such programs single-handedly 
throughout the country. Meanwhile, other MSM populations are largely ignored, including 
transvestites, who have been found to have by far the highest HIV prevalence levels of any group 
(34% in a 1994 study), male CSWs, bisexuals, and MSMs in the bateyes (also typically not 
openly “gay”). Other neglected groups include MSMs in rural areas (in fact, in most areas 
outside the capital, including the North Coast), prisoners/confined populations, and male 
heterosexuals. 
Recommendation: Increased input is urgently needed to expand successful prevention efforts 
among homosexual men in the capital to other subpopulations and regions, including male 
CSWs, transvestites, bisexuals, MSMs in other cities and rural areas, residents of bateyes, young 
men/boys engaged in CSW or other MSM activity, prisoners/confined populations, and the 
evidently sizeable group of “hidden” MSMs in the general population.
Recommendation: One potential approach for reaching men would be to focus some prevention 
efforts on male heterosexuals or the male population in general (i.e., without specifying any 
sexual orientation in particular).
Recommendation: Because a single NGO with limited personnel resources (ASA) is 
presumably not capable of reaching all MSM subpopulations in all regions of DR, collaboration 
between ASA and other NGOs such as COIN and CEPROSH should be investigated. Working 
together, these groups may be able to develop effective programs targeting male sex workers, 
transvestites, MSMs in the North Coast, young MSMs, and other previously underserved MSM 
populations.
Recommendation: More research is required to measure HIV and STI prevalence in MSMs and 
other men, thereby strengthening estimates of the actual proportion of total HIV infections or 
AIDS cases comprised of MSMs.
Recommendation: The feasibility (e.g., projected client use, cost-benefit analysis) of developing 
an STI treatment clinic specifically oriented to the MSM/male population should be investigated.
Bateyes: In recent years, HIV/AIDS prevention programs have increasingly focused on sugar 
mill/migrant communities, which are located throughout DR and continue to form a large and 
important high-risk population for AIDS and other STIs. However, due to socioeconomic 
marginalization and cultural and linguistic limitations, providing health care services, condom 
access, and HIV/AIDS prevention programs to these poor communities remains a challenge. The 
evaluation team did not evaluate the Center for Social Cultural Activities' (Centro de Animación 
Socio-Cultural or CASCO) now-terminated prevention program among bateye adults.
12
Recommendation: Continuous monitoring and evaluation of the Bateye Project is recommended 
to insure an adequate level of direct service delivery to the target youth population.
Recommendation: Development of prevention programs and (STI/primary health) clinical 
services for the adult bateye population is recommended, in addition to development of a youth 
program.
Recommendation: Development of IEC campaigns (including perhaps radio/audio materials) in 
Creole is recommended.
Recommendation: Integration of family planning (and primary health) programs with HIV/STI 
prevention efforts is needed for the bateye population.
Inmates/Confined Populations: Time and logistical constraints precluded a site visit to a 
prison, but according to research and discussions with professionals working with the prisoner 
population, inmates appear both to be at high risk of HIV/STI infection through sexual (and 
possibly drug-related) transmission and also tend to receive very little in the way of effective 
treatment or health prevention services. In general, these at–risk populations have “fallen 
between the cracks;” the government has not accepted any responsibility for prisoners' health 
care and other needs.
Recommendation: Analysis and publication of existing KAP data should be completed. In 
addition, HIV/STI seroprevalence and possibly behavioral practices studies should be conducted 
in different confined populations. 
Recommendation: Development of HIV/STI prevention and treatment programs for prisoners 
and other confined populations is needed, possibly in conjunction with NGOs or other interested 
organizations.
Persons Living with HIV/AIDS (PLWHAs): In addition to the aforementioned crucial need for 
greater IEC efforts to reduce discrimination, stigma and misinformation faced by PLWHAs–not 
to mention a variety of unmet treatment/care/support needs–there is a great need for broader 
participation by this group in HIV/AIDS prevention programs.
Recommendation: Demand for peer counseling and other HIV education interventions 
performed in part or in full by PLWHAs should be increased. Such interventions should be 
developed and staffed through networks of HIV-positive persons, such as the National Network 
of Persons Living with HIV/AIDS (Red Nacional de Personas que Viven con VIH or 
REDOVIH+) and Grupo Clara.
Target Population Recommendation: Surveillance, epidemiological, and sociocultural data–
although not always complete or recently updated–suggest that while HIV infection rates in 
some antenatal sites remain relatively significant, the epidemic is still largely concentrated 
among “core transmitter” and other high-risk groups (i.e., CSWs, MSMs, and bateye residents). 
Therefore, the national prevention strategy should continue to focus on both the general (female 
13
and male) population as well as high-risk subpopulations. In addition, it is important to note that 
most prevention, care and other HIV/STI programs continue to function largely as pilot programs 
in the capital and to some extent in the North Coast, while other regions continue to lack service 
delivery.
3.4 STI Prevention and Treatment
STI Management
The USAID/AIDSMark strategy for capacity building in STI management and program 
decentralization within DIGECITTS includes allocation of funds and short-term technical 
assistance provided by a senior STI management consultant. The consultant assists with revision 
and validation of the STI management manual and the national training curriculum. Medical 
doctors have been trained at the central, provincial and municipal levels. In addition, 
DIGECITTS has incorporated a primary health worker model into its manual for care providers 
at the primary level.
An absence of drugs, together with widespread client inability to pay for drugs, has resulted in a 
limited prescriptive practice among physicians who have attended STI training. The general 
population is not aware of the importance of early treatment of STIs, nor do they have sufficient 
information on STIs to be able to recognize their symptoms. Female CSWs are an exception. 
They have been targeted by intervention projects managed by AccionSIDA (i.e., CEPROSH and 
COIN) that promote behavior change and mandatory periodic health exams.
Recommendation: Integration of STI syndromic management into primary health care at all 
levels of the public health system is needed. This includes dispensary, rural or urban outpatient 
clinics, maternal and child health or family planning sites, as well as hospital outpatient clinics.
Pre-Packaged Treatment (PPT) Pilot Project
In November 2000, DIGECITTS completed a pilot project to promote the use of PPT for STI 
treatment. STI syndromes to be treated via PPT included GUS, urethra discharge, vaginal 
discharge, and both vaginitis and cervicitis. The project included design of an STI package for 
three health care centers–one serving CSWs, one serving military troops, and one serving the 
general population. Information and promotional materials aimed at health professionals were 
disseminated through drug stores and popular pharmacies or “boticas populares.” Medical 
registry and monitoring and evaluation forms were also distributed. Drugs were provided by the 
public health system (SESPAS-PROMESE). 
The project's main objective was to assess client and provider acceptability and satisfaction 
regarding PPT. The project was implemented in specialized STI outpatient clinics at hospital 
sites in the capital city of Santo Domingo, where two of the services are targeted to female 
CSWs and their clients, and the third to military personnel.
14
Preliminary findings include: 
ß 44% of all patients who received PPT returned for a second consultation. STI symptoms 
disappeared for 88% of patients. 
ß 33% reported condom use with a regular sexual partner; 26% reported use with casual 
partners. 
ß 85% read the information on the PPT kit, and 67% gave referral cards to their sexual 
partner. 89% reported satisfaction with PPT; 5% were not satisfied due to persistence of 
symptoms or side effects.
ß Men returned for treatment more frequently than women, as did military troops and 
persons with a previous history of STIs. 
ß The project manager reported operational problems in completing forms and clinical 
histories. This has been documented as a major problem in maintaining medical registry 
and vital statistics in DR.
Recommendation: Client satisfaction with PPT should be measured in other cities before 
considering national scale-up of the pilot project. 
3.5 Voluntary HIV Counseling and Testing (VCT)
The “Dominican Model for VCT” has completed its first stage of development. There is wide 
consensus among NGOs and the public health sector that VCT is a feasible strategy for DR and 
there is need for strengthening referral centers and creating new ones, based on service contract 
agreements between the private and public sectors. Major participation and commitment on the 
part of both private and public sectors is needed. A first-year plan for implementation of VCT 
services is available as an instrument for resource allocation.
Recommendation: The private sector should be engaged in a VCT strategy, since it serves as 
the major provider of HIV testing services.
Recommendation: A VCT strategy should be linked with a policy dialogue component through 
the enforcement of AIDS Law 55-93, which prohibits the indiscriminate use of HIV testing, 
especially without appropriate counseling services. 
3.6 Availability and Access to Condoms 
The initial condom social marketing strategy implemented by USAID through PSI/AIDSMark 
and John Snow, Inc. was not effective due to several constraints, including incoming contraband 
shipments of low-priced socially marketed condoms from Haiti. The well-known “Pante” 
condom was introduced to the market at a lower price than the official socially marketed 
condoms for DR. In addition, local counterpart contributions within the decentralized health 
system did not occur on schedule. There is some distribution of “ family planning project 
condoms” via family planning services and clinics.
Recommendation: Coordination of, and advocacy for, a national condom policy is urgently 
needed. This policy should provide access to condoms for poor and marginalized populations in 
15
DR, and should involve a coordinated effort among international and national agencies in family 
planning and HIV/AIDS prevention and care.
Recommendation: Condom distribution must be made available for targeted populations who 
are vulnerable to HIV and have limited access to resources (i.e., persons living with HIV, poor 
women and youth in bateye populations, prison inmates and other confined populations, clients 
of STI clinics, and CSWs).
3.7 Program Monitoring and Evaluation (M&E)
NGOs
Strategic planning exercises have provided an opportunity for NGOs to review strategies, 
develop monitoring and evaluation frameworks to ensure coverage of programmatic areas, and 
set up mechanisms for data dissemination. Engagement in the decentralization of the health 
system was intended to bring planning and resource allocation to the provincial level. 
USAID's M&E framework includes well-defined program goals, target populations, objectives, 
and process indicators. The M&E plan was implemented through information gathering and 
monitoring of individual projects but without feedback to or participation of appropriate 
community or NGO staff. The process was also carried out without evaluating how project 
implementation feeds back into the overall USAID program plan.
DIGECITSS
Supporting effective program implementation through providing quality and timely assistance to 
NGOs is an important component of the USAID project. Technical assistance consultants 
provided to DIGECITSS through the "Limited Scope Grant,” complemented by FHI/IMPACT 
and AIDSMark, have been helpful and supportive, but some program areas remain in need of 
continuous support. DIGECITSS has acquired new, more accommodating office space and has 
implemented appropriate staff organizational development and capacity activities to take a 
leadership role in setting norms and coordinating HIV/AIDS/STI programs in DR.
However, the same result has not been achieved in program M&E. The staff perception of 
DIGECITSS is that development of information systems capacity for program M&E will be 
achieved through equipment and human resources such as computers, networks, software, 
computer training, data entry personnel, and information resource coordination. Staff place a lot 
of importance on the design and use of forms as a way to supervise activities in the absence of a 
well-designed process for M&E of programs and projects. 
As a consequence, DIGECITTS is not using all available funds and has not developed a design 
for monitoring implementation of the National Strategic Plan for HIV/AIDS. Achievement of 
expected results is reported by activity, and only in some cases by subproject, thereby making it 
difficult to assess overall results and impact. In addition, while outcome indicators have been 
introduced more widely in project design (logical framework), it is difficult to demonstrate how 
project results from program- and facility-based data allow for program monitoring, or how 
16
population-based biological/behavioral data allow for impact assessment. Identification of best 
practices is made difficult in the absence of clear process indicators, which are critical to 
guarantee sustainability. 
Recommendation: Training and technical assistance should be focused on a module on 
monitoring and reporting progress.
Recommendation: NGO staff should be provided with tools and training in processing and 
analysis of data and information.
3.8 Involvement and Coordination with GODR
SESPAS, through PROMESE, has already included STI drugs in its essential drugs list, since 
they are used to treat non-STIs such as respiratory infections. For outpatients, the availability of 
these drugs through the “boticas populares” is irregular though they are available at low cost . A 
recent agreement between DIGECITTS and PROMESE has guaranteed provision of both drugs 
and materials to assemble PPT kits, as well as resources to further assess (in the same areas of 
previous pilot intervention) the social marketing of PPT. 
Recommendation: Additional pilot sites should be selected for testing of PPT, and marketing of 
PPT should be expanded beyond pilot sites. One idea is to introduce PPT in locations that are 
already beneficiaries of other intervention projects. 
Recommendation: More operational research is needed to assess the affordability of PPT and 
feasibility of STI treatment and control in family planning and other settings.
Recommendations: Further intervention trials and feasibility studies are needed for community￾wide clinical and behavioral interventions.
Recommendation: Promote community-based integrated care systems for STI control that 
combine behavior change messages absorbed by community members through mass media and 
interpersonal strategies.
3.9 Partners
Government and non-government officials expressed agreement that coordination in the use of 
financial and technical resources for AIDS control and prevention has improved, as has 
collaboration among donors in implementing major HIV/AIDS strategies established under the 
National Strategic Plan.
Recommendation: USAID should promote continuous dialogue among donors and participation 
in policy discussions. Mechanisms established in country by UNAIDS thematic and technical 
theme groups should be utilized to determine which intervention areas are priorities.
17
3.10 Private Sector and Business Community
Private sector involvement in HIV/AIDS activities in DR has been minimal and inconsistent. 
Though the tourism and hotel industries have participated in some HIV/AIDS/STI prevention 
efforts, project sustainability has been limited. Executive managers of hotel chains are often 
located outside of the capital and occasionally outside the country, making it difficult to 
negotiate availability of personnel dedicated to HIV/AIDS prevention activities.
Recommendations: Efforts should be directed toward contacting private companies and 
multinational enterprises active in DR to engage in HIV/AIDS prevention, in accordance with 
internationally recognized norms. 
Recommendation: Contacts with the National Business Council (CONEP) should be 
systematized.
IV. FUTURE DIRECTIONS 
Despite successful efforts made in DR to control the HIV/AIDS epidemic, conditions exist for a 
rapid spread of infection in the general population. These conditions are evident in high STI 
rates; high birth rates among youth and adolescent women; active migration to and from DR; a 
growing number of sex workers; "hidden" homo- and bisexual practices; and widespread 
stigmatization of AIDS, which precludes open discussion of the disease.
Constant migration of people to and from DR leaves the country particularly vulnerable to rising 
infection rates. More than 2 million tourists visit DR each year. More than 500,000 Haitians are 
estimated to be residing legally or illegally in DR, most of whom are young male migrant 
workers in construction or agricultural trades. An estimated 1 million Dominicans reside in the 
United States, with a high concentration in New York City, and Dominican women often migrate 
to Europe, Haiti and the rest of the Caribbean, in many cases to engage in sex work.
In addition to addressing the risk of HIV infection among migrants, it is imperative that 
prevention efforts reach Dominican youth. Studies carried out among DR adolescents indicate 
early and unprotected sexual debut. In 1998, 23% of all pregnancies occurred among women and 
girls under age 20.
Taking these factors into account–and in addition to the recommendations outlined above that 
relate directly to USAID/DR Strategic Objective 2 and Intermediate Result 1–the team offers the 
following recommendations to be considered on a long-term basis. 
Recommendations:
1) Promote second-generation surveillance studies, including behavioral surveillance of general 
population groups such as women at antenatal clinics, as well as high-risk groups and core 
transmitters.
18
2) Expand research activities to include serosurveillance of HIV/STIs and behavioral practices 
in diverse populations (e.g., MSMs, bateyes, inmates) and regions of the country (e.g., 
Santiago) where there is no data collected on HIV/AIDS. 
3) Commence research on risk factors including anal sex (MSM and heterosexual) and dry sex, 
and begin surveillance studies on STIs including Herpes-Simplex Virus-2, a still incurable 
and in many regions increasingly important STI implicated in HIV transmission.
4) Support implementation of proven interventions to prevent mother-to-child transmission. 
Such interventions have been carried out with success in four DR hospitals, and are 
scheduled to be replicated in additional sites. 
5) Investigate safe alternatives for artificial feeding of babies and support related services such 
as milk banks and liquid formulas, and provision of information and counseling for mothers.
6) Promote exchange of best practices and successful interventions in clinical sectors between 
cities such as Puerto Plata and Santo Domingo, and between physicians in military hospitals 
and other public hospitals, regarding issues such as mother-to-child transmission, biosafety, 
and voluntary counseling and testing.
7) Promote greater involvement by church leaders and members in HIV/AIDS care and 
prevention. This largely untapped and critical sector has the potential to curtail a national 
epidemic. 
APPENDICES
A. SCHEDULE OF VISITS
January 15 Arrival in Washington, D.C.
January 16 Evaluation Team briefing by:
TvT/Synergy: Saha AmaraSingham, Barbara De Zalduondo, Lori Salins
USAID/Washington LAC Bureau and G/PHN/HIV-AIDS Division: 
John A. Novak and Carol J. Dabbs
Travel to Dominican Republic
January 17 Entry meeting with USAID/DR: María Castillo, David Losk and Marina Taveras 
Team planning meeting
January 18 AcciónSIDA: Tito Coleman, Tanya Medrano, Ceneyda Brito, 
Victor Pérez and Hoisex Gómez
Health Secretary/ DIGECITSS: William Hernández Basilio
January 19 ONUSIDA: Ernesto Guerrero
COPRESIDA: Luis Emilio Montalvo Arzeno
AcciónSIDA: Tito Coleman, Tanya Medrano, Ceneyda Brito, 
Victor Pérez and Hoisex Gómez
January 20 Evaluation Team progress review meeting
January 22 PROSISA: Antonio Sánchez
REDOVIH+: César Castellanos
ASA: Leonardo Sánchez
PROFAMILIA: Magaly Caram de Alvarez
January 23 ADOPLAFAM: Ramón Portes Carrasco
COIN: Santo Rosario, Luis Moreno
CASCO: Bethania Betances, Elizardo Puello, Batey Project team
DIGECITSS; Sofía Khoury, Mayra García, María Isabel_____ and Clara
Morillo
IDCP: Rafael Alcántara
INSALUD: Guillermo de la Rosa
INSALUD/PREVISA: Jaime de la Rosa 
REDSALUD: Patricio Murgeytio
January 24 Batey “Bienvenido”, Haina, San Cristóbal
Batey “Esperanza”, San Pedro de Macorís
January 25 Puerto Plata
CEPROSH - Avancemos and 100% Condom CSW-Projects: Bayardo Gómez , 
Héctor Jerez and Alexandra Lister. 
CLARA - care and support for persons with HIV/AIDS 
Puerto Plata – site visit with CEPROSH (nocturnal) prevention educators 
January 26 Puerto Plata - Hospital Francisco Limardo 
Santo Domingo:
PROFAMILIA –Youth Project Intervention
January 27 Evaluation team report preparation meeting
January 29 Field visit and focal group to Santiago by one team member
Licey Village – Rural Area, Santiago - MUDE
Report preparation 
January 30 Report preparation
Meeting with USAID/DR
Meetings with Eddy Perez-Then and Aldo Conde
January 31 Draft report completed and reviewed
Meeting with Julia Hasbún 
February 1 Presentation of draft report to USAID/DR 
February 2 Presentation of draft report to DIGECITSS and AccionSIDA
B. LIST OF CONTACTS
AcciónSIDA: Tito Coleman, Project Director - Tanya Medrano 
ADOPLAFAM: Dr. Ramón Portes Carrasco, Executive Director 
ALCONDE: Lic. Aldo Conde
ASA: Lic. Leonardo Sánchez, Executive Director 
CASCO: Lic. Bethania Betances, Project Director; Elizardo Puello
CENISMI: Dr. Eddy Pérez, Sub-Director
CEPROSH: Dr. Bayardo Gómez, Executive Director
COIN: Lic. Santo Rosario, Executive Director
COPRESIDA: Dr. Luis Emilio Montalvo Arzeno, Executive Director
DIGECITSS: Dr. William Hernández Basilio, General Director
Fundación Génesis: Dra. Martha Butler de Lister, Executive Director
IDCP: Dr. Rafael Alcántara, Project Coordinator
INSALUD: Lic. Guillermo de la Rosa, Executive Director
ISH: Lic. Tony de Moya, 
INSALUD/PREVISA: Lic. Jaime de la Rosa 
ONUSIDA: Dr. Ernesto Guerrero, Country Representative
PROCETS: Dr. Luis B. Martínez, Director
PROFAMILIA: Lic. Magaly Caram de Alvarez, Executive Director
PROSISA: Dr. Antonio Sánchez, Director
PSI/FHI: Lic María del Carmen Weisse, Manager
REDOVIH+: Lic. César Castellanos, Executive Director
REDSALUD: Dr. Patricio Murgeytio, Director 
USAID/Washington: Carol L. Dabbs, Chief, Population Health and Nutrition Team and 
John A. Novak, Monitoring and Evaluation Advisor
USAID-DR María A. Castillo, David Losk and Marina Taveras
Evaluation Consultant Lic. Julia Hasbún
MUDE (Licey village near Santiago) Alta Gracela Urena
Hospital Provincial Ricardo Limardo Dr. Benjamín Reyes, Subdirector 
Hospital Provincial Ricardo Limardo Dra. Sonia Ramírez, Epidemiologista
Hospital Provincial Ricardo Limardo Dra. Ruth Lantigua 
C. DOCUMENTS REVIEWED
USAID
· USAID Grant Agreement between the US and DR Governments. September, 1999
· Workplan for FY99 PROCETS - FHI/IMPACT and PSI/AIDSMark, FY 1999
· USAID Contract with AED. June, 1997
· AcciónSIDA Overview
· AcciónSIDA Quarterly Narrative Report for Oct-Dec/1998
· AcciónSIDA Quarterly Narrative Report for January-March, 1999
· AcciónSIDA Workplan, October 1, 9999 - September 30, 2000
· AcciónSIDA Quarterly Report, January 1 - March 31, 2000
· AcciónSIDA Informes Trimestrales ONG’s Julio/Sept., 2000
· USAID/AIDSCAP. Options in STD/HIV/AIDS Programming in the Dominican Republic, 1996.
· PROCETS. Boletín Epidemiológico del Departamento de Vigilancia Epidemiológica. Marzo, 
1999.
· PROCETS. Boletín Epidemiológico del Departamento de Vigilancia Epidemiológica. Marzo, 
1999.
· PROCETS. Boletín Epidemiológico del Departamento de Vigilancia Epidemiológica. Marzo,
1999.
· SESPAS - Estrategia Nacional de IEC para la Prevención del VIH/SIDA. Julio, 2000
· SESPAS - La Estrategia de Descentralización de la SESPAS. República Dominicana. Enero, 
2001
· SESPAS, Dirección General de Epidemiologia. Estadisticas de Mortalidad Registrada 1986-1998. 
Documento tecnico 1999.
· SESPAS/PROCETS - Organizational Development and planning workshop report. Santo 
Domingo. October 21-25, 1998.
· SESPAS/PROCETS - PSI/FHI – Documento de Trabajo del Taller Pruebas Voluntarios y 
Consejería (PVC). Juan Dolio. 17 al 19 de noviembre, 1999
· SESPAS/PROCETS - PSI/FHI – Informe del Taller Seminario Desarrollo de un Modelo 
Dominicano de Prueba de VIH/SI DA Voluntarias con Consejería (PVC/VCT). Juan Dolio, 17 al 
19 de noviembre, 1999
· SESPAS/PROCETS. Plan Nacional para la Prevención y Control del SIDA de la República 
Dominicana (1997-2001).
· The Caribbean Regional Strategic Plan of Actions for HIV; 1999.
· USAID-funded contraceptive prevalence study (WHS 1985); 1987-1998: PROFAMILIA, 
Prevalence KAP studies of Dominican men.
· USAID/AIDSCAP. Options in STD/HIV/AIDS Programming in the Dominican Republic, 1996
UNAIDS/UNDP
· UNAIDS/DR - The Thematic Group and Technical Group: Plan de Acción Integrado ONUSIDA 
República Dominicana, 2000-2001
· UNAIDS/DR - Epidemiological Fact Sheet on HIV/AIDS and Sexually Transmitted Infections, 
2000 update
· Common Country Assessment (CCA), UNDP Dominican Republic 1999.
DHS
· CESDEM/PROFAMILIA/ONAPLAN/Macro International Inc.: Encuesta Demográfica y de 
Salud (ENDESA). 1996.
· CESDEM/PROFAMILIA/ONAPLAN/Macro International Inc.: Encuesta Demográfica y de 
Salud (ENDESA). 1999.
NATIONAL
· Strategic Objective Two Pact, October 1999 - September, 2004
· Prevention Project: Technical Proposal. April 21, 1997
· CONASIDA: Plan Estratégico Nacional de ITS/VIH/SIDSA, 2000-2003
· Marco Estratégico de USAID/Santo Domingo
· Limited Scope Grant Agreement between the US and DR Governments. September, 1998
· Amendment Number One to the Limited Scope Grant Agreement. June, 1999
· Décimo Foro Nacional de Salud – Compromiso con Acción: El Gobierno y la Sociedad Civil 
Contra el SIDA
· Program Progress, Analysis and Design of Market Research related to PROFAMILIA’s 
contraceptive social marketing program; 1998 Report - Edward C. Green, Development 
Associates.
· The Socioeconomic Impact of HIV/AIDS in the Dominican Republic, 1991-2005 - Elizabeth 
Gómez, Martha Butler, Eddy Pérez; Lori Bollinger, Charlotte Calvin - The Futures Groups 
International, Policy Project
· COPRESIDA - Informe al Presidente de la República.
· Decreto 32-01 Creación del Consejo Presidencial del SIDA, Agosto 1, 2001
· CASCO, ASA, CEPROSH, MUDE, COIN - Planes de IEC 1999 – 2002
· COIN - Registros de Estudios, 1990-1999
· IDCP - Proyecto “Manejo Sindrómico de las Enfermedades de Transmisión Sexual a Nivel de 
Atención Primaria en Salud” - Región Suroeste – República Dominicana. 1997
· INSALUD/PROCETS - Informe del Taller de Formulación del Plan Operativo ITS/VIH/SIDA 
para el Sector Bateyes. Santo Domingo. Abril, 2000
· CESDEM/DIGECITSS - Informe Preliminar Proyecto Piloto Terapia Pre-empacada. Santo 
Domingo. Enero, 2001
· Informe sobre la Epidemia Mundial de VIH/SIDA – ONUSIDA Junio del 2000
· Plan Estratégico Nacional de ITS/SIDA 2000 – 2003 CONASIDA, Noviembre 1999.
· PROFAMILIA. Estudio en grupos focales. Citado por Edward Green y Aldo Conde, 
¨Changing sexual behavior for good¨, Global AIDS link #57, Julio/agosto/septiembre 1999.
PAPERS
· Cáceres, F; Duarte, I; de Moya, A; Pérez Then, E; Hasbún, J; and Tapia, M. Análisis de la 
Situación y la Respuesta al VIH/SIDA en República Dominicana, 1998.
· De Moya, E. A. and R. Garcia. AIDS and the Enigma of Bisexuality in the Dominican Republic. 
In Bisexualities and AIDS: International Perspectives. P. Aggleton, eds. Pp. 121-135. Bristol, PA: 
Taylor & Francis. 1996.
· De Moya, A. and R. Garcia. Three Decades of Male Sex Work in Santo Domingo. In Men Who 
Sell Sex: International Perspectives on Male Prostitution and AIDS. P. Aggleton, eds. London: 
Taylor & Francis. 1998.
· Gómez, E. Situacion epidemologica de la infeccion VIH y el SIDA. Implicaciones para una 
politica integral en salud publica. Conferencia Magistral de la Decima Jornada del Foro Nacional 
de Salud, Santo Domingo, 10-12 Noviembre 1999.
· Green, E. Sexual partner reduction and HIV infection. Sex. Trans. Inf. 2000; 145.
· Guerrero and col. COIN; Johns Hopkins School of Public Health, The Horizon Project. Durban 
Abstract, 2000. Willingness to have sex without a condom: female sex workers interventions with 
secret clients in the Dominican Republic.
· Frias, M. M. and S. S. Lara. Actitudes y Comportamiento Sexual en Hombres de 18-27 Años en 
Santo Domingo. Universidad Autonoma. 1987.
· Halperin, D.T. Heterosexual anal intercourse: Prevalence, cultural factors, and HIV infection and 
other health risks, part II. AIDS Patient Care, 14(8), in press, 2001.
· Halperin, D.T. Las practicas del “sexo seco” y la infeccion VIH en Republica Dominicana y 
Haiti. Rumbo, 352:50-51. 2000.
· Halperin, D.T., Bailey, R.C. Male circumcision and HIV infection: Ten years and counting. 
Lancet, 354(9192): 1813-1815. 1999.
· Halperin, D.T. Dry sex practices and HIV infection in the Dominican Republic and Haiti. 
Sexually Transmitted Infections, 75(6): 445-446. 1999.
· Halperin, D.T. Heterosexual anal intercourse: Prevalence, cultural factors, and HIV infection and 
other health risks, part I. AIDS Patient Care, 13(12):717-730. 1999.
· Halperin, D.T. Breastfeeding and HIV transmission: The realities may be much more complex 
than “breast vs. bottle.” Global AIDSLink (58):8-10. 1999.
· Halperin, D.T., Weiss, H., Klausner, J., Auvert, B., Caldwell, J., Hayes, R., Padian, P., Potts, M., 
Ronald, A., Short, R., Williams, B., Coates, T. Male Circumcision and HIV in Rakai, Uganda 
and sub-Saharan Africa: Program Development or Need for More Research? New England 
Journal of Medicine, under review, 2001.
· Halperin, D.T. Neglected Risk Factors in Heterosexual Transmission of HIV: Anal Sex, Male 
Circumcision, and Dry Sex. World AIDS Conference, July 11, 2000, Durban, South Africa.
· Halperin, D.T., Shiboski, S., Palefsky, J., Padian, N. High level of HIV infection due to anal 
intercourse: A neglected risk factor in heterosexual AIDS prevention. Journal American Medical 
Association, submission, 2001.
· Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human 
immunodeficiency virus type 1. N Engl J Med;342:921-29.2000.
· Weiss H, Quigley M, Hayes R. Male circumcision and risk of HIV infection in sub-Saharan 
Africa: A systematic review and meta-analysis. AIDS; 14:2361-70. 2000.
D. STATEMENT OF WORK
BACKGROUND:
USAID/DR revised its Strategic Objective 2 for the Health and Population sector in 1998, 
following Hurricane George. The 1999-2004 Strategic Objective was modified to become 
“Increased Use of Sustainable Basic Health Services and Practices.” The Intermediate Result 
No. 1 under the SO2 for HIV/AIDS/STI is “Increased access to HIV/AIDS/STI prevention and 
care services by at-risk and affected populations of the Dominican Republic.” Achieving the 
intermediate result should result in increased knowledge and use of practices that reduce the risk 
of HIV/AIDS/STI among the Dominican population.
Over the past years, USAID/DR has supported the coordination of a national program, the 
improvement of public and private service delivery and the establishment of sustainable 
interventions. USAID has also contributed to increased public and private support, innovative 
approaches to increasing public knowledge, behavior change interventions, and sexually 
transmitted disease treatment. Recent studies have indicated that these approaches have been 
effective in encouraging the adoption of safe sex practices by target population. In addition, at 
this stage of the epidemic, USAID will support community-based interventions in support of 
people infected and affected by HIV/AIDS as part of the prevention care continuum.
Assistance has been channeled through three components: (1) a Cooperative Agreement for a 
five year sub-grant program to Dominican non-governmental organizations (NGOs) and 
community groups, to strengthen their institutional capacity, serve as catalysts for NGO 
advocacy, and improve collaboration/coordination amongst NGOs and between NGOs and the 
government of the Dominican Republic (GODR); (2) direct assistance to the GODR (US$1.5) to 
provide support to the Ministry of Health (SESPAS) and the National HIV/AIDS Directorate 
(DIGECITSS) to increase their institutional capacity in sentinel surveillance and case reporting, 
in STI Management, testing and counseling and other areas; and (3) funds allocated to the Global 
Bureau for Field Support to access specialized technical assistance and services in support of the 
activity.
The principal partners identified to achieved this result are AED/Plan Int., indigenous NGOs, 
SESPAS (DIGECITSS, Provincial Directorates), CONASIDA, UNAIDS and EEC. Other 
members of our extended team are PSI/AIDSMARK , FHI/IMPACT, JSI and Futures Group. 
On June 30th, 1997 the USG signed a Strategic Objective Agreement with the GODR, through 
the Technical Secretariat of the Presidency to implement in the Dominican Republic the health 
portfolio. Among the activities included are: (a) a five-year STI/HIV/AIDS Prevention Project 
with the Academy for Educational Development (AED) for the total amount of 
US$11,225,000.00; (b) a limited Scope Grant Agreement with PROCETS/DIGESITS for 
US$585,000 and activities under the centrally funded projects IMPACT, AIDSMARK and 
POLICY.
AED has over the past two years granted NGOs sixteen sub-grants amounting to (US$3,260 
million). The purpose of these sub-grants is to contribute to STI/HIV/AIDS prevention efforts 
with the most vulnerable groups (adolescents, youth and women) as well as to promote the 
dissemination of STI/HIV/AIDS information and services to ensure access of couples and 
individuals. Three of the sub-grants have been granted to INSALUD, COALICION SIDA and 
REDOVIH+. These institutions worked on the policy arena on issues that dealt with sexual 
education in public schools, legal counseling and support for persons living with HIV. They 
have also worked on the dissemination of the AIDS Law to key players in the labor and tourism 
sectors and training for state court justices and the attorney general on the AIDS law.
The National Direction for the Control of Sexually Transmitted Infections and AIDS 
(DIGECITSS) developed a National Strategic Plan for HIV/AIDS Prevention for 2000-2003 
with the participation of key representatives of the public and private sector. This Plan serves as 
the framework for public and private sector activities during the coming years. As a result of the 
National Strategic Plan, twenty-six Provincial and Municipal operating plans have been 
developed. The additional funds required to implement the activities outlined in the National 
Strategic Plan were not budgeted in the 2000 National Budget. The new President, Hipolito 
Mejia, has formed on August 22, 2000 a Presidential Commission on AIDS (Comisión 
Presidencial del SIDA - COOPRESIDA) which will study the actual situation on HIV/AIDS, 
look for possible solutions and make the necessary recommendations to the President to prevent 
the spread of HIV/AIDS. This commission is headed by Dr. Luis Emilio Montalvo. Other 
members are the president of the network of people living with HIV+, as well as the head of 
UNAIDS in the country.
OBJECTIVE OF EVALUATION
The general objective is to assess the progress achieved towards the expected IR1 results and 
provide recommendations to USAID to strengthen and/or modify the IR1 strategy.
The specific objectives are:
1) To determine whether assumptions are still valid. Revise them in case it is necessary.
2) To determine whether sub-activities funded under the HIV/AIDS Prevention Activity are 
supporting the achievement of the IR, Increased access to HIV/AIDS/STI prevention and 
care services by at-risk and affected populations, and further the Strategic Objective Two: 
Increased use of Sustainable Basic Health Services and Practices.
3) To analyze the progress achieved towards the obtainment of the expected results.
4) Identify success stories, problems and delays and their causes.
5) Recommend adjustments needed for the remaining years of AED’s Cooperative Agreement 
to guarantee the achievement of the IR outcomes.
6) Recommend changes/modifications to the IR1 strategy.
STATEMENT OF WORK 
The contractor shall conduct the evaluation and respond to all points included in the objective of 
this statement of work and submit a report, which provides clear and concise findings, 
conclusions and recommendations. The evaluation report shall also provide a statement of 
lessons learned and future directions that may emerge from the exercise.
The key aspects of the Project to be addressed are listed below:
1. Approach: 
The Intermediate Result Number 1 interventions focus on innovative approaches to increasing 
public knowledge, behavior change through adoption of safe sex practices, and treatment of 
sexually transmitted diseases. The principal approaches under the sub-grant activities have been 
to involve local non-governmental organizations, to focus resources on the most vulnerable 
groups (adolescents, youth and women), to promote dissemination of STI/HIV/AIDS 
information and services to ensure access of couples, and to address policy issues that deal with 
sexual education in public schools, legal counseling and support for persons living with HIV.
Questions that should be addressed are:
· Are the interventions effectively applying the above strategies?
· Does the approach need to be revised or reinforced?
· How effective has the project been at integrating its components into health care systems 
at various levels?
· Is the input level adequate or too high/low for the intended outputs? Has the absorptive 
capacity of implementers been reached?
· Is capacity building taking place? What further efforts need to be taken?
· Are the effects of the project being produced at an acceptable cost? 
· Is the input level adequate or too high/low for the intended outputs?
· What proportion of the financial and technical resources were contributed by the 
government? 
Primary Responsibility – Team Members
2. Behavior Change Communication: 
The project has focused on behavior change efforts through targeted interventions to vulnerable 
groups, prevention strategies and counseling for HIV/AIDS/STI clients. 
Questions that should be addressed are:
· Is there a clearly defined BCC strategy, or what is the implied strategy given the multiple 
interventions that have been carried-out under this component? What are the 
strengths/weaknesses and lessons learned? How can the strategy be strengthened in the 
immediate future and recommendations for the follow-on? 
· What impact-type data is or might be available regarding the training received (under each 
component)? Health educators, peer educators, contact investigators, regional coordinators. 
How did participants utilize training received? 
· How effective are interventions to reach targeted groups such as adolescents, youth and 
women (from the perspective of these group members). How might these interventions be 
strengthened? 
· How successful have the sub-grantees been in helping empower women and increasing 
adolescent and youth involvement? What are the lessons learned and barriers/constraints 
encountered?
· To what degree have the project and NGOs achieved expected results in the activities for 
advocacy and in the recruitment of media support for those activities?
· What has been the extent of the financial support from the government for these activities? 
Primary Responsibility – Behavior Change Communication Specialist
3. STD Prevention and Treatment Services
Questions that should be addressed are:
· What are the prescriptive practices of physicians and/or other health care providers (private 
and public sectors) who have attended training in syndromic management of STIs? 
· Which activities are having the greatest impact in terms of Risk Perception and health￾seeking behavior? Which activities are having the greatest impact in providing services and 
support for the infected/affected populations? Which are having lesser impact? Which 
activities respond to national priorities as identified by the National Strategic Plan?
· What outreach program activities are being conducted by the STI component? 
· How reliable are the data reporting mechanisms at the STD clinics? What have been the 
barriers to capturing the data from the clinics? How might they be resolved? 
Primary Responsibility – STI/STD Program Specialist
4. Implementation
Issues to consider include:
 
· Is implementation on track and achieving satisfactory progress towards its stated 
objectives? 
· How effective have the partners been in implementing the project (SESPAS, DIGECITSS 
and AED)? How complementary are their activities?
· Are SESPAS/DIGECITSS and subgrantees reaching target populations, including access 
to services? If not, what are the barriers? How can they be overcome?
· To what degree has AED achieved coordination with DIGECITSS in policy and services? 
How effective has the coordination been? 
· How effective is the relationship between AED and partner NGOs? To what extent has 
the monitoring system been adequate for assessing subgrantees internal weaknesses, 
performance and measuring impact? 
· To what extent has AED technical assistance been adequate, including training, financial 
and administrative systems, sustainability, service delivery, and quality of services and 
Management Information Systems? Does the monitoring of the administrative and/or 
financial aspect need strengthening? 
· Has the collaboration between AED and PLAN been successful? If not, what have been 
the resulting problems in technical assistance. How can they be remedied?
· Has the staff composition, duties and level of effort in AED been sufficient and adequate 
to comply with the agreement requirements?
Primary Responsibility – Program Management & Evaluation Specialist 
5. Attribution: 
· Is the host country (which includes central/state governments, public sector and private 
sector) and/or other donors providing support in any of the AED activity areas?
· If yes, what is the nature of their intervention and what is the amount of the resources 
involved? 
· Does the project significantly influence the direction of the host country and/or other 
donor resources; i.e. did the USAID activities help to leverage funds? If yes, how did the 
project accomplish this? 
· Are interventions under the project leading to replication of similar activities by the host 
country and/or other donors, i.e. did it have a demonstration effect? 
· Based on these do the indicators accurately reflect the manageable interest of the project? 
Primary Responsibility – Team Members
6. Future Direction: 
Based on the progress to date the Team is requested make recommendations regarding the 
initiation of new activities in the project 
· What other areas could be addressed by the current sub-activities to achieve the IR1 
outcomes? What needs that are not addressed should be addressed under a new activity?
Primary Responsibility – Team Members
METHODOLOGY
In order to examine the above issues, the following methodology should be considered:
1. Review of documents such as project paper, project agreement, project amendments, 
project implementation letters, tripartite agreement, Result Review and Resources 
Request (R4) etc.;
2. Meetings and discussions with concerned officers at USAID, AED, other donors;
3. Review of monitoring and evaluation reports;
4. Site visits to project-funded areas by APAC and other agencies;
5. Interaction with target groups;
6. Other information such as case studies, observational and anecdotal data may also be 
used as appropriate.
It is recommended that the team considers conducting interviews with key government, donor 
agencies and NGO representatives. Field visits are also recommended, depending on the 
familiarity of the team with grantee activities. These should preferably occur during the first ten 
days of the assignment. These visits will enable the team to have contact with the service 
providers and the beneficiaries of the assistance. 
REPORTS
The contractor will submit an evaluation report, preferably under 20 pages, in accordance with 
the requirements specified below. Three days prior to departure, the consultants will submit a 
draft report to USAID/DR for review and discussion. They will also debrief AED, SESPAS and 
DIGECITSS on the conclusions and recommendations. The tem coordinator will ensure that all 
reasonable comments on the draft report are incorporated into the final draft report. The final 
report will be due 30 days after leaving the Dominican Republic.
The format for evaluation report is as follows:
· Executive Summary – concisely state the most salient findings and recommendations (2pp);
· Introduction – purpose, audience, and synopsis of task (1pp);
· Background - brief overview of HIV/AIDS/STI in Dominican Republic (1pp);
· USAID’s Assistance Approach – describe the USAID program strategy and activities 
implemented in response to the problem (1pp);
· Findings/Conclusions/Recommendations – for each SOW area (6 pp);
· Lessons Learned (1pp)
· Issues – provide a list of key technical and/or administrative, if any (1pp);
· Future Directions (2-3pp)
· Annexes – useful for covering evaluation methods, schedules, interview lists, and tables –
should be succinct, pertinent and readable (not to exceed 10 pp)
DELIVERABLES
Prior to departing the country the team will present a draft report in English. The team will also 
be asked to present the highlights of the reports to Mission, SESPAS/DIGECITSS and AED 
staff, the final week of the consultancy. The final report in original, with three (3) copies and 
one copy on diskette, should be forwarded to USAID/DR within three weeks. The report will 
contain a brief executive summary section in both English and Spanish. The table of contents of 
the report will be mutually agreed upon by the team and USAID.
RELATIONSHIPS AND RESPONSBILITIES
The principal contact for this assignment will be Maria Castillo, Project Manager in the Health 
and Population Team (SO2). Logistic support for field visits will be coordinated with AED 
AccionSIDA NGOs. Other key contacts within USAID include: David Losk (Team Leader); 
Sarah Majerowicz (Health Reform); Kelva Perez (Nutrition and Community Development); 
Marina Taveras (Program Development Office/SO2); Elisane Alemar (Controllers Office/SO2); 
Norma Paredes (Project Assistant SO2); Rosanna Medina (Secretary SO2).
The principal contacts for SESPAS/DIGECITSS and the Academy for Educational Development 
(AED) are Dr. William Hernández, National Director and Eric Coleman, Director. Other key 
contacts are: Dr. Ernesto Guerrero, UNAIDS, Antonio Sanchez, Director, PROCISA, and Dr. 
Jaime de la Rosa, EEC Previsa project. 
PERFORMANCE PERIOD
The expected period of performance will be from January 16, 2000 through February February 8, 
2001.
DOCUMENTS
The documents listed below will be provided to the team prior to their travel to the Dominican 
Republic. Other documents will be provided upon arrival:
ß Limited Scope Grant Agreement with SESPAS/DIGECITSS
ß Project paper
ß AED Proposal
ß Documents related to the Cooperative Agreement with AED
ß PSI AIDSMARK Documents and correspondence
ß FHI IMPACT documents and correspondence
ß 1999-2003 National Strategic Plan for the Prevention of HIV/AIDS/STI
ß Strategic Objective Two Pact
ß 1999 Revised SO2 Strategy
ß 1999 and 2000 Results Review and Resource Request (R4) Report
General Information
1. Demographic and Health Surveys 1991, 1996 and 1999.
2. Estudio de Condones (OMSA/PROFAMILIA)
3. Provincial Operational Plans (Key provinces)
4. Sectorial Plans (Bateyes, Armed Forces)
USAID Documents
1. Strategic Objective Two Pact
2. 1999 Revised SO2 Strategy
3. 1999 and 2000 Results Review and Resource Request (R4) Report
Project Documents
1. Project Paper 
2. AED Proposal
3. Cooperative Agreement (517-A-00-97-07103-00)
4. Base line studies conducted by AED for Target Population