PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
To continue strengthening PMTCT services through twinning activities at the border provinces of Elias Pina
and San Juan.
New/Continuing Activity: Continuing Activity
Continuing Activity: 18413
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
18413 11869.08 U.S. Agency for Partners in Health 8090 5986.08 Twinning at $150,000
International Border (RFP)
Development
11869 11869.07 U.S. Agency for Partners in Health 5986 5986.07 Twinning at $100,000
Program Budget Code: 02 - HVAB Sexual Prevention: AB
Total Planned Funding for Program Budget Code: $1,180,000
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
02-HVAB Sexual Prevention: AB
Note: Due to late initiation of the new USAID contract with AED, FY07 USG funds were partially used to extend the CONECTA
project one more year so the two projects would overlap and the transition to the USG HIV/AIDS program to Region V and the
border areas would be smoother. CDC and DOD also experienced delays in starting implementation. Therefore, FY09 is the first
year for most USG support to be concentrated in Region V and the border areas. The border areas lack the basic infrastructure
needed to support a comprehensive HIV/AIDS program, and hence FY08-09 funding will focus on improving infrastructure and
strengthening NGOs.
Program Area Context/Services
According to the 2008 UNAIDS report on the Dominican Republic, HIV seroprevalence is an estimated 1.1% (.9%-1.2%), with
64,400 individuals (approximately 2,000 adults and 12,400 children) infected with HIV. Significant differences are found by
geographic area and educational and socio-economic levels, with Regions V and VII having the highest prevalence rates, as do
women with little or no education and people in the lowest socio-economic quintile. The 2007 DHS showed that HIV prevalence
among women without formal education was almost 7 times higher than in women with higher education (2.6% and 0.4%,
respectively) and 3 times higher than the general population. Women in the bottom wealth quintile had an HIV prevalence rate
almost 5 times higher than women in the top quintile (1.8% and 0.4%, respectively). Although men still account for the majority of
HIV cases, the male to female ratio is decreasing. DIGECITSS 2005 statistics indicate that young women aged 14-24 account for
71% of all new HIV/AIDS infections. A 2006 CDC assessment found that HIV incidence in young women ages 15-24 is almost
twice that of males the same age.
Early sexual debut, multiple concurrent partners, cross-generational sex, MSM behavior and commercial/transactional sex all are
driving forces of the DR HIV epidemic. The 2007 DHS reports that 15% of females and 24% of males initiated sex before age 15,
and 46% of women report having had sexual relations prior to age 18. Of these sexually-active adolescents, 28%, 7% and 10%
reported 2, 3 and 4 or more sexual partners respectively in the previous12 months. In two border cities, 28% of sexually-active
adolescents reported having a first sexual relation before age ten. Such early sexual debut can be a characteristic of sexual abuse
(not generally detected or considered, much less punished, in the DR), informal transactional sex and/or cross-generational sex,
all of which put young people (especially young women) at greater risk of HIV/AIDS. Fully 23% of women ages 15-49 reported
having had sex with partners at least ten years older than themselves, including 29% of women in the lowest economic quintile
and over 30% of women living in Health Regions IV and VII. Having a partner ten or more years older than oneself is a major risk
factor for HIV/AIDS among young women.
MARPs in the DR include persons engaged in prostitution, MSM, people living in and around bateyes, migrant populations, both
internal migration as well as migrants from Haiti and prison inmates. DR has an estimated 187,000 female and an unknown
number of male prostitutes. In a 2005 study, 99% of female prostitutes reported using a condom in the last sex act with a new
client and 95% with a regular client. However, only 58% used a condom the last time they had sex with a trusted partner. An
estimated 6-9% of the adult male population engages in MSM behavior, although only 3% of adult males admit to having had a
same-sex relation. As in many Latin American countries MSM behavior is stigmatized and therefore may be underreported.
Approximately 4% of patients attending STI clinics are HIV+. HIV prevalence in the batey population is 3.2, with 8.7% in men aged
40-44 and 8.9 in women aged415-49. The DR has 600,000 to one million undocumented Haitian immigrants and residents,
including those working in DR hotels, agricultural sector, construction and other industries that are considered to be at high risk of
acquiring STIs and HIV.
Certain segments of the general population engage in high-risk behaviors. While data suggest that the general adult population
knows the health benefits of reducing the number of sex partners, 1 in 5 men in union has outside partner(s), and in young
couples aged 15-19, 1 in 3 men has outside partner(s). In one study, 2% of women of reproductive age and 27% of men aged 15-
59 admitted having an average of two or more partners during the last twelve months. For men aged 25-29, that number climbs to
50%. Men used condoms only 50% of the time with a casual partner and women of all ages did so only 3% of the time. While HIV
prevalence rates in the Dominican Armed Forces (FFAA) are unknown, most of the military population falls within the vulnerable
or "at risk" population for STIs and HIV.
The PSI social marketing program, once funded by USAID/DR and now by KfW, has distributed through NGOs more than 62
million PANTE condoms through retail shops, brothels and other sex sites throughout the country. Social marketing of condoms
has also begun in bateyes, using NGOs supported by USAID and trained by PSI. GODR, through COPRESIDA and its GF grant,
imported 2 million no-logo condoms for distribution in prisons, the Armed Forces and at VCT sites. Approximately 400,000 more
condoms will be distributed through PROFAMILIA's social marketing family planning program. KfW has assumed procurement
and distribution of PANTE condoms, though it is asking USAID to share costs in FY09 and FY10.
During FY08, USG/USAID-funded NGOs provided AB prevention messages and support to 20,746 youth and adolescents and to
46,183 MARPS including SWs and their clients and referred them to STI/HIV services, including VCT.
Leveraging/Linkages
USAID originally funded a condom social marketing program with PSI that included condom distribution in non-traditional outlets
and a very successful mass media campaign (trusted partner). KfW took over this project in July 2007 and developed a soap
opera. In FY09 USG/USAID will share costs of this program with KfW. The GF grant will support a mass media prevention
campaign in FY09. GF and MOH funds ensure that people engaged in HIV/AIDS risk behaviors in the USG focus geographic
areas have access to government prevention messages and health programs for HIV/AIDS, STI, OI and TB counseling and
testing, care and treatment. COPRESIDA, using GF grants, sponsors a life skills training program in public schools through an
agreement with the Ministry of Education (MOE). UNICEF is evaluating that program. Local NGOs provide HIV/AIDS and STI
prevention messages for out-of-school youth and also integrate HIV/AIDS prevention activities with family planning for adults and
older adolescents. USAID's Rule of Law Project strengthens legal services for victims of domestic violence and sexual abuse. A
new Global Development Alliance being formed between USAID/DR and Major League Baseball (MLB) will leverage MLB
resources from players, teams and fans to reach at-risk Dominican youth with AB messaging for 12-14 year olds and ABC
messages after age 15. USAID will provide $150,000 in HIV/AIDS funding to be matched by MLB. USG also promotes corporate
social responsibility related to HIV/AIDS and has succeeded in getting 8 corporations to develop anti-stigma and discrimination
workplace policies.
FY09 USG Support
In FY09, using results from the UNICEF evaluation, USG/USAID will continue to work with MOH and MOE to improve the life skills
program in public schools. That program addresses AIDS awareness, AB education, and prevention of gender-based violence,
cross-generational sex and sexual abuse/coercion. Youth identified at risk for HIV/AIDS are referred to other prevention programs
and to health services, as appropriate. This program has been piloted in the border area and Region V, where early sexual debut
is common and 79-87% of children attend primary school. The program will be coordinated with similar initiatives on the Haitian
side of the border by USAID/Haiti. As a wraparound activity, USG will support extracurricular activities, such as sports, to promote
healthy behaviors, reduce risky behaviors and link with community organizations. USG will also help integrate this curriculum into
private schools, including faith-based ones. Public and private school teachers and administrators will be trained to implement the
life skills program effectively in primary schools, supervise, monitor and evaluate the system and make referrals for health,
community and other services.
NGOs will continue using community outreach to reach batey residents and migrants, especially men, in Region V and the border
areas and to support the mass media campaign messages at the community level. They conduct peer education, group education
exercises, and one-on-one sessions, and work with PSI as social marketing condom distributors. They address harmful social
norms, partner reduction, gender-based violence, and transactional and cross-generational sex. Empowerment of girls/women is
promoted to help them have a stronger voice in their sexual lives and thus prevent disease. USG also supports coordination of
cross-border work with migrants, market ladies, traders and SWs. Because of the challenges of reaching highly mobile
populations, workplace behavior change activities (e.g. at construction, tourist and agricultural sites, including bateyes) will help
reach them effectively. USG will continue to solicit employer involvement to increase corporate social responsibility.
In FY09, USG/USAID will continue to support indigenous NGOs to take AB messages to street children and youth outside the
school system. Trained peer educators teach about HIV/AIDS and provide a link between street children and counseling, testing,
care, treatment and OVC programs.
In FY09, Peace Corps will continue to target sexually-active adolescents with ABC messages and community activities
implemented by NGOs and PC volunteers through the Escojo Mi Vida (I Choose Life) program. This effort supports local public
and private organizations to teach youth about healthy decision- making, prevent HIV/AIDS/STI infections and reduce teen
pregnancy. Escojo works primarily with low-income and at-risk youth in marginalized rural and urban communities to promote
healthy sexual decisions among individuals and groups formed by volunteers. Sexual and reproductive health training will
continue to be provided to peer educators who then work with their fellow adolescents to transmit abstinence and other prevention
messages. Peace Corps volunteers provide community education on correct, consistent condom use, and sensitize community
members with anti-stigma and discrimination messages.
USG will also continue to support the "100% Condom Strategy" carried out by partner NGOs targeting prostitutes, their clients and
business owners in areas with commercial sex activity in Region V and the border areas. At these sites, they promote correct and
consistent condom use, distribute condoms, encourage decreased use of alcohol and other drugs, promote HIV and STI
screening, conduct education activities and distribute prevention information. These NGOs also train sex workers and other
women in condom negotiation skills. NGOs also provide referrals to HIV counseling and testing, care and treatment services. In
the geographic focus areas, USG will continue to support NGOs providing prevention outreach to MSM, including peer-to-peer
counseling in gay bars and other outlets, and referrals to STI and HIV services.
In addition to promoting condom availability and use, in FY09 USG/USAID will continue to work with GODR to develop and
implement a national condom policy stipulating responsibilities of the GODR and the commercial sectors to comply with national
AIDS legislation (e.g., no taxes on condoms), while also providing access to condoms for MARPS. Policy development will include
projecting the quantity of condoms required by each target population and establishing responsibilities for financing, procuring and
distributing condoms within the public sector.
In FY09, DOD will train master trainers and peer educators and provide ABC messages to officers and enlisted personnel in the
Dominican Armed Forces (FFAA). Personnel in leadership positions will also be trained and encouraged to integrate prevention
education into their military training curricula. DOD will work with the FFAA to adopt an aggressive prevention program to reduce
STIs and HIV/AIDS via promoting safer sexual practices, including abstinence and easy access to condoms, partner reduction,
educating the military to be more supportive and compassionate towards PLH, and training FFAA in behavior change
communications that also address gender norms. Recruits, personnel stationed on the border and individuals in military training
institutions will be targeted. To support these activities, education materials will be produced or adapted. HIV/AIDS awareness
and prevention education will be integrated into standard training for all FFAA recruits, enlisted and officers.
In FY2007, USG supported a BSS+ study to gather information on SWs, IDUs and MSM. When results from the BSS+ are
available, USG will use this information to design prevention activities targeting these hard-to-reach populations. Such activities
will include condom and other promotion messages delivered and disseminated through social networks. The activities will also
build capacity for conducting future behavioral surveillance and provide good data on prevention behaviors in the most at-risk
populations
Sustainability
Both high profile and popular public information campaigns and song contest are attractive to other donors as shown by past
collaboration. In 2006 the MOH used its own resources to air a number of spots produced by USAID on reducing stigma and
discrimination. The MOE is responsible for providing health and life skills education to youth. USG will work closely with the MOE,
in collaboration with COPRESIDA, UNICEF and other donors, to improve the AB strategy module, support teacher training and
implement the module in public primary and secondary schools. Once it has been introduced and teachers have been trained,
USG in collaboration with COPRESIDA will train MOE school district supervisors so they can monitor the quality of the health
education provided, and, if necessary, retrain teachers. The approval and implementation of a national condom policy is key to
ensuring sustainable availability of condoms.
Table 3.3.02:
To continue twinning adult care in border provinces of Elias Pina and San Juan.
Continuing Activity: 18415
18415 11895.08 U.S. Agency for Partners in Health 8090 5986.08 Twinning at $125,000
11895 11895.07 U.S. Agency for Partners in Health 5986 5986.07 Twinning at $100,000
Table 3.3.08:
To provide VCT twinning services in the border provinces of Elias Pina and San Juan.
Continuing Activity: 18414
18414 11886.08 U.S. Agency for Partners in Health 8090 5986.08 Twinning at $75,000
11886 11886.07 U.S. Agency for Partners in Health 5986 5986.07 Twinning at $100,000
Program Budget Code: 15 - HTXD ARV Drugs
USG does not plan to provide ARV drugs in FY09 since all ARVs drugs are supplied through the Global Fund Grant with
COPRESIDA.
Program Budget Code: 16 - HLAB Laboratory Infrastructure
Total Planned Funding for Program Budget Code: $250,000
16-HLAB: Laboratory Infrastructure
Note: Due to late release of FY08 PEPFAR funding, many planned activities have not yet taken place. Most activities planned for
FY08 will actually be carried out in FY09, using FY08 funds. The narrative below primarily reflects plans only for FY09-financed
activities. This narrative also assumes that FY08 planned activities will occur concurrently with the initiation of FY09 activities.
The Dominican Republic's laboratory infrastructure faces several urgent challenges. At the present time, there are 256 public
laboratories doing rapid HIV testing, six laboratories with CD4 testing capacity (four public and two private) and two laboratories
with PCR capacity (one public and one private). Although most of the pieces are in place, the DR continuously faces serious
issues with procurement, distribution of materials and reagents and equipment repairs. Maintaining international standards of
good practice and adherence is often complicated by irregular electricity, lack of staff and poor water supply. There is no
standardized national quality assurance and quality control system. Also, there is no information system that would allow the
laboratory network to communicate, document and analyze the data currently been produced. All logs are maintained manually
and their use is not consistent, which hinders any efforts to establish a standardized national reporting process.
As identified during two CDC assessment of the DR's laboratory infrastructure in 2006 and 2008, no national HIV testing algorithm
is in place. The need for this algorithm became especially apparent when in 2008 the country faced significant problems with the
performance of a nationally distributed HIV antibody rapid test. At the request of the Ministry of Health, CDC conducted an Epi-
Aid and provided specific recommendations to assist the DR to avoid and detect this type of situation in the future.
To screen the general population and high risk groups, the GODR has been using rapid HIV tests, but they have not been able to
take full advantage of this technology and rapid test results are usually given a week to a month after testing. Test kits are
purchased by COPRESIDA through a GF grant, but test procurement is often based on funding availability and some regions
have experienced several stock-out periods. To avoid this situation, some hospitals purchase supplemental tests, but this is taking
place without any clear guidance from the MOH as to which supplemental tests have been validated and approved. In Region V,
USG/USAID-supported laboratories have improved their tracking of test kits and medical supplies, thus improving the testing
services. USG/USAID has also supported training for health personnel to improve their capacity to offer quality services.
There is no network among the laboratories for transporting blood samples and reporting results. In addition, no quality control
program has been implemented. To ensure that CD4 tests were sent to the PROFAMILIA laboratory in the north of the DR for
processing, the Clinton Foundation agreed to finance the development and implementation of a network for transporting blood
samples. Clinton Foundation funding for this activity ends in March 2009, when USG/USAID/AED will take over. USG/USAID will
replicate this activity in region V where the Columbia/Clinica de la Familia MIR is processing CD4s tests for patients in Health
Region V. We expect to gather lessons learned from this activity and expand the network as funding becomes available.
The GODR underestimated the number of CD4 tests needed for 2008, and contracted for approximately 4,000 tests per year
when nearly 36,000 were actually needed. To assist the GODR, USAID and Columbia University through the PROFAMILIA grant
and Fundación MIR, have made CD4 testing available to a significant number of patients, though many more still need them.
The lack of a laboratory network and limited manpower has also had a negative impact on PLH access to quality clinical
management. Although the GODR through COPRESIDA provides viral load testing at the National Laboratory, this system has
not been consistent. Logistical challenges, problems in procuring reagents and costly equipment repairs have severely hindered
the provision of this service. During 2008, approximately 1,300 DNA PCR tests for infant diagnosis were provided through the
USAID/Clinton Foundation agreement. No local capacity to conduct this test existed and samples were sent to a laboratory in
South Africa. Through the Columbia University/ Fundacion MIR agreement, infant diagnosis has continued to be provided in
Region V. During FY09, with USG/CDC support, the necessary equipment and training will be put in place at the National
Laboratory. Again, with USG support, a network for sending dry blood samples and returning results to the families will be
developed.
The DR needs to enforce national policies that support a quality assured, tiered network of laboratory services that reflect local
patient referral networks and re-enforce good clinical practices. These policies and ensuing practices should be updated to reflect
the ongoing national health reform process. Additionally, a national strategic plan that provides an accelerated timeline for
improving public health laboratory infrastructure and practices must be adopted.
Leveraging/Referrals
CDC is currently working with the DOD to build a cold storage room for the National Laboratory. It is expected that this room will
be built by April 2009. In collaboration with the Clinton Foundation, COPRESIDA will purchase rapid test kits that will be
distributed by the MOH to public hospitals and NGOs working with USG throughout the country. USG/USAID will continue to use
CSH/Infectious disease funds to strengthen TB laboratory networks, including HIV screening of TB patients. Current USG support
includes AMR work.
In FY2009, USG will continue to work closely with GF's principal recipient, COPRESIDA, and the MOH to leverage support for
laboratory activities in the DR. USG will also leverage support from COPRESIDA, through the Global Fund to establish the HIV
laboratory network and strengthen the surveillance system. UNICEF and UNAIDS have provided TA and financial support to
strengthen HIV surveillance.
The success of provincial programs for prevention, care and treatment requires early detection and the establishment or
reinforcement of on-going local referral networks both within public and NGO/FBO implementing partners. Cumulatively, these
local networks will provide the support structures for re-establishing the country's national network of tiered laboratory services.
They are also an efficient mechanism for referrals for complex testing and validation of new technologies or testing algorithms in
the absence of a national network.
To give some continuity to the only HIV laboratory network that is currently operational in the country, in FY09 USG/USAID will
take over the funding of a network funded by the Clinton Foundation in 2008. The USG will gather lessons learned from this
network and assess how it can be expanded and implemented through the country. During this process, the USG will continue to
work with the GODR to train staff and transfer the management and maintenance of the established network.
The USG/USAID will provide technical assistance to COPRESIDA to strengthen their existing supply chain. Building on the
lessons learned through the technical assistance provided to the TB program, we expect to structure and systematize the fragile
supply chain management system, overcome stock outs and minimize changes with supply and demand.
USG/USAID and Columbia University through the PROFAMILIA grant and Fundación MIR, will continue to make CD4 testing
available to patients in Region V. Through PROFAMILIA, USG/USAID will continue to make CD4 testing available to the GODR
as needed. It is expected that at least 10,000 CD4 tests will be conducted by PROFAMILIA. In addition USAID, through a grant
agreement with Partners in Health (PIH) for twinning activities, will provide access to laboratory tests for people living near the
border. USG/USAID will continue to work in the geographic focus areas to improve laboratory infrastructure and make emergency
funds available for test supplies.
To expand the availability of HIV testing for high risk populations, in FY09 (with FY07 funds) USG/USAID will acquire two
customized vans that will be used as mobile units for counseling and testing and for transporting the blood samples required for
CD4 tests. With these vans, the MOH and NGOs will be able to access hard to reach populations and areas where people do not
normally have access to VCT services. The mobile units will prioritize work in the USG geographical focus areas.
In FY2009, with FY07 and FY08 funds, DOD will strengthen laboratory facilities by providing commodities, equipment and training
to the Dominican Armed Forces (FFAA) to support HIV/AIDS-related activities. Laboratory standards to enhance reporting and
quality assurance/quality control will be supported and aim to create linkages to other national lab referral systems. To expand
CD4 testing within the DR's military network, DOD will provide a CD4 machine to the Armed Forces Central Hospital, using FY08
funds. It is expected that at least 5,000 CD4 tests will be conducted through this mechanism.
As noted above, to build the capacity of the National Laboratory to receive and store blood samples from other facilities, in April
2009 the DOD, in collaboration with the CDC, will build a cold room. This room will provide enough space to accommodate
existing refrigerators and sufficient space for new units. Having a cold room will allow closer monitoring and supervision, reduce
the maintenance and financial burden of existing generators which feed the refrigerators during power outages, and clear much
needed space for other laboratory equipment.
As the health sector reform timeline is defined and the lab services are strengthened, diagnostic services will become more
sustainable. However, as noted, basic health packages under the new Social Security law do not recognize the costs of
specialized diagnostic tests and laboratory services associated with these and do not include specialized tests such as CD4s, viral
load or PCR DNA. In addition, public sector surveillance responsibility is not included in the costs associated with the basic health
packages. USG and its national and international partners will advocate for changing this situation.
Table 3.3.16:
