AIDS Surveillance and Education Project (ASEP)

The education component of the AIDS Surveillance and Education Project (ASEP) is being implemented by PATH and selected private sector partners working in collaboration with the Philippine Department of Health (DOH), the U.S. Agency for International Development (USAID), and the World Health Organization (WHO).

Inputs and Intervention Strategies

At the interpersonal level, PATH and its non-government organization (NGO) partners assist vulnerable individuals to recognize and modify their HIV risk-taking behaviors. Education interventions are based on theories of social learning and communal and peer support for incremental risk reduction, based on the recognition that behavior change occurs slowly and in stages.

One-on-one education is combined with guided group interactions that foster solidarity and skills building for condom use, safer sex negotiation, and appropriate STD treatment-seeking. Interpersonal communication is reinforced by mass media messages designed to increase public awareness of STD symptoms and referral mechanisms, desensitize condom use, and encourage consistent use of condom among individuals who have multiple sex partners.

At the local level, the program facilitates institutional capacity building by organizing and supporting multisectoral committees to develop and coordinate city plans of action for STD/HIV/AIDS prevention targeted at the "hospitality" industry and the informal sex sector. Among others, these plans promote solidarity for 100% condom use in licensed establishments based on the premise that "What's good for entertainers is good for customers is good for business." Sex establishment owners are also encouraged to comply with provisions of the labor code prohibiting employment of minors and the Sanitation Code, which mandates regular STD check-ups for "hospitality" workers. Community organizing efforts among freelance sex workers serve a similar purpose of building solidarity and skills for condom use and refusal of unprotected sex.

At the national level, PATH coordinates closely with DOH's Field Epidemiology Training Program (FETP), which is managing the surveillance systems that monitor prevalence of HIV and high risk behaviors in ASEP sites. NGO collaborators contribute to surveillance objectives by facilitating access to vulnerable groups for HIV testing and behavioral surveys, and by providing post-HIV test counseling after surveillance rounds.

PATH and collaborators also work closely with the DOH's National AIDS/STD Prevention and Control Program (NASPCP) and the devolved health services to transfer know-how in STD syndromic case management to public and private service providers. Training inputs are followed-up with continuing STD case management practice. Once capacity for improved STD management has been strengthened, the program leverages resources from media concerns to disseminate public service announcements (PSA) designed to mobilize and refer symptomatic individuals to government and NGO service points for STD testing and treatment.

Prevention Effectiveness

Four independent reviews of the program have documented evidence to support the conclusion that ASEP is helping to moderate the spread of HIV in the Philippines . A mid-term program review in 1995 confirmed the efficiency of ASEP's targeted information, education and communication (IEC) intervention strategy and applauded the innovative public-private sector partnerships that the education component has fostered at local levels. Recognizing its potential as a "model for low HIV prevalence countries," the review team offered suggestions for fine-tuning ASEP's monitoring systems and education interventions, which have since been adopted and implemented by the DOH, PATH, and NGO partners

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Outreach education

The second evaluation (1997 Assessment) reviewed the program's functional and service outputs and progress toward intermediate objectives and concluded: "Knowledge about HIV infection routes and means of protection among general and high-risk populations has been increased by IEC efforts." PATH was also recognized as being "highly effective" in identifying and supporting NGOs in developing and implementing various education programs targeted at high-risk groups in local communities.

A third review of gender issues in USAID-assisted programs examined the strategies and approaches employed by ASEP NGO partners and documented the following lessons:

The staff and volunteers in these projects tend to be very compassionate and sensitive to the gender and power relations that drive women, men, and, increasingly, children, into commercial sex. The interventions include teaching of negotiation skills and simple tricks for "sex workers" to use with their clients. By analyzing the power relationships involved in the sex industry, the organizations working in HIV/AIDS prevention have also realized that it is necessary as well to work with vulnerable men and owners/managers of the commercial establishments that profit from the prostitution industry, and are developing strategies to this end."

A fourth review, conducted by the U.S. General and Accounting Office (GAO), examined ASEP's performance as part of a global assessment of USAID's response to the HIV/AIDS epidemic. In its testimony to Congress, the GAO reported the following findings with regard to ASEP:

In the Philippines , the USAID Mission's goals were to increase knowledge and to change attitudes and behaviors to prevent STD/HIV infection among high-risk groups and to collect comprehensive baseline data on the incidence of HIV and behavior in 10 sites. Our review of an independent evaluation and discussions with target groups in the Philippines indicated that USAID interventions had been effective in increasing awareness and changing behavior. Behavioral surveys demonstrated that USAID activities to expand knowledge about the disease lead vulnerable females to increase their use of condoms. Our reviews of evaluations and interviews with NGO staff also indicated that USAID increased the capacity of the NGO staff to implement AIDS prevention activities."

Re-engineering the Special HIV/AIDS Objective

Notwithstanding the above results and progress, the 1997 Assessment drew attention to the limitations of IEC strategies in combating "environmental and policy barriers that thwart risk reduction among ASEP target groups." In its final report to USAID, the Assessment team documented examples of societal factors contributing to HIV/STD vulnerability and spread in ASEP sites that present different challenges that require other strategies to complement prevention education. These include, among others: Poor access to STD treatment, sex establishment managers who discourage condom use, no public health monitoring of sex establishments for condom use, failure of the legal system to suppress child sex work, and inadequate financial support for STD/HIV prevention."

STD syndromic management training

High rates of syphilis prevalence documented by DOH surveillance and inflammation-causing STDs documented by ASEP/Family Health International (FHI) raised further concerns about the implications for rapid increase of HIV in cities where effective STD control measures are lacking. While the link between genital ulcers and HIV infection is particularly strong, the higher prevalence of gonorrhea and other inflammation-causing STDs in ASEP client groups suggests that these infections may play a larger overall role than syphilis in the spread of HIV in the Philippines.

Recognizing the need for complementary strategies to address structural and environmental determinants of HIV vulnerability and spread, USAID re-engineered the result framework of the Special HIV/AIDS Objective. The modified program supports policy research and advocacy activities for 100% condom use and improved STD control, and development of interventions tailored to the special needs of sexually exploited children under sixteen (SECUS). Through an amendment to PATH's cooperative agreement, incremental funding was made available in January 1998 for implementation of the modified program description, referred to as "ASEP Intervention."

Program Outputs