HIV/AIDS in Ecuador: Showing the Need for Further Assistance

Submitted to:

Ms. Kim Johnston, Mercy Corps Program Operations Director P.O. BOX 2669 Portland, OR 97208-2669

Submitted by:

Kelly Blevins 3140 Lundin Dr. #10 Manhattan, KS 66503

December 9, 2005

Table of Contents List of Figures………………………………………………………………………………. List of Tables……………………………………………………………………………….. Abstract……………………………………………………………………………………...

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Introduction………………………………………………………………………………….

6

Statistics & Demographics of Ecuador……………………………………………………...

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HIV/AIDS in Latin America………………………………………………………………...

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Ecuadorians & HIV/AIDS………………………………………………………………….. Ecuador’s HIV/AIDS Social Situations…………………………………………….. Ecuadorian Adolescents & the Elderly……………………………………………... Ecuadorian Adolescents…………………………………………………….. Ecuadorian Elderly People………………………………………………….. Ecuador’s Health Sector & Legislation Patterns……………………………………. The Health Sector…………………………………………………………… Monitoring the Reform……………………………………………... Structure of Medical Practice……………………………………….. HIV/AIDS & the Legislature………………………………………………..

10 11 11 12 14 15 15 16 16 17

Domestic Efforts in Response to Epidemic………………………………………………… Governmental Response……………………………………………………………. Non-governmental Response……………………………………………………….. Current NGOs: Structures & Services……………………………………... HIV/AIDS Needs Addressed by NGOs…………………………………….. NGOs’ Weaknesses………………………………………………………….

18 18 20 20 21 22

International Efforts in Response to Epidemic……………………………………………... Funding……………………………………………………………………………... HIV/AIDS Programs of International Organizations……………………………….. Coalitions……………………………………………………………………………

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Conclusion…………………………………………………………………………………..

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References…………………………………………………………………………………...

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Appendix A: Appendix B: Appendix C: Appendix D:

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Maps of Ecuador…………………………………………………………….. Kimirina Projects…………………………………………………………….. List of Institutions for HIV Testing………………………………………….. List of Organizations for People Living with HIV/AIDS……………………

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List of Figures 1. Cases of HIV/AIDS in Ecuador…………………………………………………………...

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List of Tables 1. HIV-Transmission Modes in South America…………………………………………….

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2. Knowledge of Behaviors Associated with Risk of Contracting HIV……………………

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Abstract HIV/AIDS epidemic analysis Blevins, Kelly. 2005 December 9. HIV/AIDS in Ecuador: Showing the Need for Further Assistance. Mercy Corps International, a non-governmental organization based in the United States, is looking to expand its HIV/AIDS assistance work to South America. This report compiles and analyzes information to prove that Mercy Corps should begin its South American services with Ecuador. Ecuador’s cases of HIV/AIDS have rapidly increased over the last decade, and although cases are still mainly localized in urban centers, a widespread epidemic is imminent. Various cultural factors, such as male dominance and Catholicism are shown to both hinder prevention efforts and contribute to the spread of this epidemic. Ecuador has put forth strong efforts in HIV/AIDS acknowledgement and care since 1987, but because it is such a poor country, one recovering from crises in the 1990s, fighting its HIV/AIDS epidemic is abnormally difficult. Ecuador’s governmental and non-governmental organizations are moving towards unity in this fight, yet they are limited and need international assistance. Despite grants and efforts from international organizations, such as the Global Fund and the International HIV/AIDS Alliance, a great need remains. This report provides a foundation for Mercy Corps to research further and plan appropriate HIV/AIDS assistance for Ecuador. Key Terms: HIV, AIDS, Ecuador, Latin America, health, epidemic, non-governmental organizations

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HIV/AIDS in Ecuador: Showing the Need for Further Assistance

INTRODUCTION Every region of the world is suffering from the HIV/AIDS pandemic. The spotlight has naturally been on regions with the most severe epidemics, such as sub-Saharan Africa and South-East Asia. Increasing epidemics in Latin America, however, are causing some of the HIV/AIDS focus to shift to that region. Because much has been learned from over 2 decades of support and assistance given to the former regions, it is important to use that knowledge to stop these rising epidemics in Latin America. One example of a country in need is the South American nation of Ecuador. Two years ago, in Guayaquil, Ecuador, a married couple named the Alvarados faced a difficult truth. HIV/AIDS was a real part of their community, yet was not talked about. When Michele Alvarado found out her husband’s conditions of tuberculosis and hepatitis B were a result of him being HIV-positive, they were horrified. Dudley quotes Michele’s comments of their medical doctors (2005) saying, “They said ‘He’s got HIV and he’s going to die.’ That was it. There was no psychological help at all” (as cited in Dudley, 2005). Michele lost her 29-year-old husband less than a week later, and after being diagnosed HIVpositive herself, became severely depressed with suicidal thoughts (Dudley, 2005). This is one story showing the reality of HIV/AIDS victims in Ecuador. Ecuador is one of Latin America’s poorest countries and is on the brink of a widespread HIV/AIDS epidemic.

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In this report, I describe and analyze Ecuador’s HIV/AIDS situation to show that Ecuador should be the site of Mercy Corps’ first South American HIV/AIDS assistance. Mercy Corps is known for being an organization determined to “alleviate suffering…and oppression by helping people build secure, productive and just communities” (Mercy Corps, 2005). This organization is well-versed in international HIV/AIDS work. It understands that intricacies and implications are different for each country and knows how to handle those. We, the members of the Latin-American operations taskforce, are eager to begin work in South America and Ecuador is the place to start. Before planning can begin, however, it is essential to understand Ecuador’s specific HIV/AIDS situation and analyze the scope and success of the HIV/AIDS work in order to determine what assistance is feasible. With this information, our taskforce will be better prepared to expand our assistance. We will be more effective and more efficient in planning after we know what needs exist and what kind of assistance works in this country. This report synthesizes a lot of data and is organized into 5 main sections. The first provides statistics and demographics of Ecuador to give a base for the issues and concerns discussed later. Then I put Ecuador in context with the rest of Latin America in terms of HIV/AIDS. In the third section, I discuss Ecuadorian attitudes, beliefs, and cultural values, because these aspects have an impact on how HIV/AIDS spreads and what assistance is given. The remaining 2 sections give an analysis of domestic and international efforts, meaning governmental and non-governmental work, to stop a growing epidemic in Ecuador. To conclude, I remind us why Mercy Corps should provide assistance to Ecuador by summarizing ideas and making a few recommendations. STATISTICS & DEMOGRAPHICS OF ECUADOR According to the World Factbook (2005), Ecuador is located in the Andes region of South America and has a diverse landscape. The country of approximately 13.3 million people is divided into 22 provinces (See maps in appendix A). It is a nation scarred from past economic crises, and a nation suffering from an unstable democratic government and disorganized medical sector (Pan American Health Organization [PAHO], 2004). Ecuadorians are ethnically diverse (65% Mestizo, 25% Amerindian, 10% Spanish and others) and are primarily Roman Catholic (95%). They are relatively young, life expectancy is in the mid 70s for males and females, and the population is increasing (Central Intelligence Agency [CIA], 2004). According to Ecuador’s Ministry of Public Health [MPH] (2005), 6132 cases of HIV/AIDS were registered between 1984 and 2004, which was less than 1% of the population. The actual number of people living with the virus, however, is estimated between 30,000 and 50,000. In the 1990s, reported cases rose rapidly (See Figure 1), specifically among women. According to a Joint United Nations Programme on HIV/AIDS (UNAIDS) case study in 2001, there was a 94.8% increase in reported cases between 1996 and 1999 (Reaching out, 2001, p. 33). The World Health Organization [WHO] (2001) states that the virus is mainly transmitted sexually through heterosexual relations. The infected male-female ratio as of 2000 was 2:1 and was 7:1 in 2004, showing a large increase in the number of female cases (Green, 2004). Cases of HIV/AIDS are mostly along the Pacific coast, in the Guayas province, home to Ecuador’s biggest city, Guayaquil. It makes sense that the center of Ecuador’s epidemic is in an urban area, because as of 2000, 64% of Ecuadorians lived in

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urban areas, and since then, many more people have moved into cities (Reaching out, 2001, p. 33). Figure 1: Cases of HIV/AIDS in Ecuador CASES OF HIV/AIDS BY YEAR ECUADOR 1984 - 2005

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Adapted from: Ecuador’s Ministry of Public Health. Retrieved November 5, 2005. Programa Nacional de Control y Prevencion del VIH/SIDA/ITS-Datos VIH/SIDA.

Realistically, this information only hints at the number of Ecuadorians affected by this disease. We must focus on the fact that the HIV-infection rate is increasing and act on the United Nations’ (UN) warning that a generalized national epidemic is imminent (Green, 2004). These statistics provide an introduction to Ecuador that is needed to proceed in this report. I put Ecuador in context with the rest of Latin America in terms of HIV/AIDS in the next section. HIV/AIDS IN LATIN AMERICA Although there are only 2 countries in Latin America that have an HIV-infected population percentage higher than 1% (Guatemala and Honduras), other countries are facing grave localized epidemics (America Latina, 2004) and the UNAIDS estimates over 2 million people are living with HIV/AIDS in the region (as cited in Lewis, 2005, p. 1). First, I will describe some common tendencies of Latin American countries and peoples. Then I will discuss main modes of HIV-transmission in various countries and how some modes could be reflections of Latin American tendencies. The Latin American region has a unique mix of problems that hinders the prevention of HIV/AIDS and also encourages the spread of HIV/AIDS. According to The Lancet’s June Blevins, K. 8

2000 issue, this mix of problems primarily consists of widespread poverty, political and economic instability, a “machismo” culture, and common early sexual encounters. Widespread poverty encourages the spread of HIV/AIDS because poverty is often associated with unsanitary conditions, insufficient funding and health coverage, and low education levels. For example, Honduras, which as of 2000 had nearly 50% of the population impoverished, is one of the countries most affected by HIV/AIDS in Central America (Anonymous, 2000). Political and economic instability is a problem that hinders HIV/AIDS prevention because non-cohesive governments have difficulty taking quick action, and poor economies cannot provide the funding and supplies necessary. The economic instability is often compounded when a natural disaster hits, such as a hurricane or volcano, because vital exporting materials such as fruit and oil are damaged and much recovery work is needed. Public health outbreaks are also common with natural disasters, increasing the probability that HIV would spread. Latin America has a “machismo” culture, meaning people are raised with the idea of male dominance. This aspect of Latino culture impacts the spread of HIV/AIDS greatly. According to the WHO (2005), this machismo culture encourages high levels of homophobia, where acts against homosexuals range from social stigmatization and discrimination to hatred and murder (Lewis, 2005). This cultural response causes many homosexuals and bisexuals to hide their practices and therefore “increases the likelihood that individuals will engage in high-risk behavior, such as rapid and secretive sex…and sex in situations where the use of a condom is unlikely” (Lewis, 2005, p. 2). This all explains the fact that one of the main modes of HIV transmission in Latin America has always been through sex occurring between men. As of 2001, 43% of all HIV cases reported in Latin America were from men having sex with men (Lewis, 2005). Along with these conditions, another aspect of sexuality in Latino culture is that many men who have sex with men do not consider themselves homosexual. Instead, they comply with social standards, meaning many are married and have sex with women, but keep their homosexual acts secretive (Lewis, 2005). This issue is a big barrier to prevention and stopping the spread of HIV/AIDS. Many countries, particularly in Central America and the Andes region of South America, are seeing a change of affected peoples as the epidemic spreads. Reported HIV/AIDS cases used to be from sex professionals, their clients and men having sex with men, but now the disease is spreading to spouses and other partners of these men (America Latina, 2005). I will mention two other common concerns of the HIV/AIDS crisis: Latin America’s strong ties to the Roman Catholic Church, and relief efforts not correlating to needs of a particular country. The Catholic Church says a person should abstain from sex until marriage, and afterwards, should not use contraceptives, including condoms. Therefore, many issues arise relating to HIV/AIDS among Catholic societies, including high percentages of people having unprotected sex and the lack of prevention education allowed in Catholic schools (HIV/AIDS response, 2000). The last concern is that a country’s epidemic relief efforts do no correlate to needs of a particular country. For example, most countries tend to allocate funding for HIV/AIDS programs for sex professionals, when, as will soon be discussed, this high-risk group does not usually have the highest HIV-transmission rates. This incongruence is likely because of political convenience, stigmatization, and manpower limitations (Lewis, 2005, p.

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2). More appropriate attention would be to enhance programs for men having sex with men and programs to deal with the mentioned societal issues. Now that I have given a general background of HIV/AIDS in Latin America, I will discuss situations more specifically based on modes of transmission. Brazil, which is South America’s powerhouse, has the most widespread HIV/AIDS epidemic but also has the most comprehensive treatment and prevention programs. This nation’s epidemic began among men having sex with men but has since become prevalent among drug users, and the most recently reported transmissions are mainly because of heterosexual sex (America Latina, 2005). Drug use is a big epidemic-spreading factor in other southern nations in South America, such as Argentina and Uruguay (HIV/AIDS response, 2000). In response, Argentina is advanced in their drug assistance programs and Uruguay has aired effective HIV-prevention campaigns on TV. Central American countries are facing mainly urban epidemics, with cases primarily from men having sex with men, but as mentioned, bisexual activities are becoming a big factor in the spread of HIV/AIDS (America Latina, 2000). Table 1 below lists main modes of HIV-transmission and whether antiretroviral treatments were widely available as of 2000 for several South American countries. This table illustrates how, despite the common Latin American tendencies mentioned, each country has its own epidemic and methods of combating it. Table 1: HIV-Transmission Modes in South America Country Primary Mode of Transmission Antiretroviral Treatment (2000) Ecuador Heterosexual Peru Homosexual Bolivia Heterosexual Chile Homosexual  Argentina Injected Drug Use  Paraguay Homosexual Uruguay Hetero- and Homosexual Brazil Heterosexual  Information taken from: HIV/AIDS response differs among Latin American countries. 2000. AIDS Alert, 15(5), S1. Retrieved October 2, 2005.

This information confirms that there is indeed a significant HIV/AIDS situation in Latin America and each country needs to face this within their societies. With this context established, I can discuss the HIV/AIDS situation specifically in Ecuador, further showing why this particular country needs assistance. ECUADORIANS & HIV/AIDS The HIV/AIDS epidemic in Ecuador is at a critical point. As mentioned, HIV-infection rates are rapidly increasing and the rising percentages of women and children becoming infected is a sign that “the epidemic is advancing out of control” (as cited in HIV/AIDS epidemiology, 2004). To better understand the climate encouraging this epidemic, I have gathered various articles discussing Ecuadorian attitudes, beliefs, and social situations relating to HIV/AIDS. After describing these, I will explain experimental studies of Ecuadorian adolescents and the elderly and how those reveal HIV/AIDS risks. Finally, I will describe aspects of Ecuador’s

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health sector and legislation patterns, which will give us a better understanding of how things function in this country. Ecuador’s HIV/AIDS Social Situations Ecuador has all the mentioned aspects of Latin American countries, including poverty, political and economic instability, and a machismo culture. Thus all the responses mentioned to these aspects are also found in Ecuador, such as homophobia, stigmatization and discrimination of people living with HIV/AIDS, and inadequate prevention activities. I will describe some specific social situations based on various articles on the subject. In 1999, The Lancet published an article calling the HIV/AIDS epidemic in Ecuador a “looming threat” and yet in 2001, Ecuadorians still thought their risk of HIV-infection was low (Quevedo, 2001). During these years, Ecuador was in a worse state of economic distress and the government’s priorities were more focused on economic recovery and health threats of malaria and Dengue fever than they were on the growing HIV/AIDS problem (Quevedo, 2001). These years saw a steep increase in sexually transmitted diseases (STDs) in general, and there were widespread misconceptions of HIV/AIDS. For example, in 2001, over 40% of women surveyed believed that mosquito bites could transmit HIV (Quevedo, 2001). Along with misconceptions, various beliefs about people living with HIV/AIDS existed. Many people felt that contracting HIV was a person’s own fault and care would be a waste of money since that person would die regardless. Because of this, many people saw justification only for HIV-prevention work. These beliefs lead to serious social implications where people living with HIV/AIDS would not admit their status and would only seek hospital care in advanced stages of AIDS for fear of discrimination (Dudley, 2005). For example, Margarita Quevedo, director of a leading HIV/AIDS organization in Ecuador, said in her 2001 article that health professionals frequently refuse services to people living with HIV/AIDS. These social situations are beginning to change in Ecuador thanks to many governmental and community-based efforts calling attention to the epidemic, of which I will discuss in detail in the remaining sections of this report. An important point, however, is that general beliefs and attitudes of Ecuadorians are still the same as in years past and they are seriously hindering the fight against the spread of this epidemic. For example, Ecuador’s MPH has a weak surveillance system and HIV/AIDS data collection underestimates “the total number of cases and the percentage of cases contracted by men sleeping with men due to strong cultural taboos against homosexual behavior” (Park, Sneed, Morisky, Alvear, & Hearst, 2002). The available data give us ideas of the situation in Ecuador, but without a stronger, more objective surveillance system, it will be difficult to fight the epidemic. The next section will explain more of Ecuador’s HIV/AIDS situation based on two population groups: adolescents and the elderly. Ecuadorian Adolescents & the Elderly In the past 3 years, 2 experimental research studies were done in Ecuador that are relevant to

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this discussion. One, which was published in 2002, “examined the relationship of HIV knowledge, demographics, and psychosocial factors with HIV risk behavior among high school students in urban and rural regions” (Park et al., 2002). The second study is not specifically about HIV/AIDS or Ecuador, yet it discusses how poor nutritional status of the elderly in the developing world increases the likelihood of contracting infectious diseases, and makes comparisons of people living with AIDS to these elderly people (Meydani, Ahmed, & Meydani, 2005). Examining each study will further define the HIV/AIDS situation in Ecuador. Ecuadorian Adolescents Adolescence is a crucial time in life where much is learned, social awareness begins, feelings of invincibility are common, and habits are formed that affect the rest of a person’s life. Relating to HIV, a large amount of cases are reported between ages 20 and 29 (39% in Ecuador), which means that HIV-transmissions must have occurred sometime in adolescence. This assumption follows the fact that HIV has an average latent period of 10 years before a person is diagnosed with AIDS (as cited in Park et al., 2002). This age group, therefore, is particularly important to discuss while assessing Ecuador’s HIV/AIDS situation. This study surveyed students in 10th through 12th grades in 8 high schools, half being in urban Quito and half in Tena, an Amazon jungle basin town. The survey contained 10 categories: “sociodemographics, family structure, sexual history, perceived risk for contracting HIV, HIV education received, HIV knowledge, perceived peer attitudes, peer sexual behavior, alcohol and drug use, and educational aspirations” (Park et al., 2002). Results demonstrate that Ecuadorian adolescents are engaging in risky behaviors and interventions are needed. For example, among those surveyed, 43% were sexually experienced and of that group 40% had had 4 or more sexual partners. In addition, 50% had never used a condom and 70% did not use a condom during the last sexual experience. Despite these alarming percentages, only about 18% of those surveyed considered themselves at risk for contracting HIV (Park et al., 2002). The study also found males were more likely to have sex and to have more partners. This is not surprising when put in the context of machismo culture where society accepts male sexual behavior more than female. The participants’ knowledge of behaviors associated with contracting HIV is the most important section of this study for discovering beliefs and attitudes of Ecuadorians. Table 2 on the next page lists results, divided into high-risk and low-risk behaviors. The table indicates that Ecuadorian adolescents are fairly knowledgeable of what behaviors are high-risk and low-risk for contracting HIV, yet a substantial amount of misconceptions exist. The study found that 65% of the group correctly identified the high-risk behaviors as being likely to transmit HIV (Park et al., 2002). Adolescents’ misconceptions are mainly that various low-risk behaviors, such as being bit by an insect, are actually high-risk behaviors.

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Table 2: Knowledge of Behaviors Associated with Risk of Contracting HIV

Taken from: Park, I. U., Sneed, C. D., Morisky, D. E., Alvear, S., & Hearst, N. 2002. Correlates of HIV risk among Ecuadoriam adolescents. AIDS Education and Prevention, 14(1), 73. Retrieved September 27, 2005.

This study made some interesting correlations. For example, it found that individuals with higher education aspirations were associated with lower HIV-risk activities. HIV risk also declined when individuals were more confident in their refusal skills to unsafe sex and had higher condom use self-efficacy (Park et al., 2002). Another correlation compared urban and rural school results. The individuals in the rural areas reported living in more poverty, having more sex, and using fewer condoms than those in urban areas. The study also confirmed that more indigenous peoples live in rural areas, and these people are less likely to address sexuality issues. The fact that people living in rural areas are more impoverished means they often place more importance on basic necessities than on sexual health. These rural towns also have limited access to quality education and contraceptives (Park et al., 2002). All these correlations and results give a good idea of the beliefs, attitudes, and practices of Ecuadorian adolescents. Next I will explain how the next study’s conclusions of malnutrition among the elderly in developing nations can be applied to people living with AIDS in Ecuador.

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Ecuadorian Elderly People From what I gathered, there is no data available that defines the HIV/AIDS prevalence among the elderly (ages 60 and above). This makes sense because this disease is spread mainly through younger sexually active individuals. Therefore, instead of discussing HIV/AIDS risks among this population group, I will take information on other elderly concerns and apply that to people living with AIDS. The elderly populations living in less-developed nations, including Ecuador, often have immune systems functioning similar to those of people living with AIDS (Meydani et al., 2005). This comparison is based on poor nutritional status and declining immune functions of the elderly and is important to discuss while dealing with the HIV/AIDS topic. Like I mentioned, many health professionals in Ecuador tend to see HIV/AIDS as strictly a medical issue and therefore could overlook the nutritional status of patients as a key factor in their health. The United States is faced with this problem as well, and nutrition professionals are striving to implement nutritional aspects to HIV/AIDS care. Emphasizing the importance of nutrition as part of HIV/AIDS care can get beyond this report’s focus, but I will further define this comparison and mention specific data from a study of Ecuadorian elderly people. Through many previous studies of the elderly and through common observance, it is clear that the immune system declines with age, and Meydani et al. call this phenomenon “immune senescence.” Immune senescence among the elderly makes this population group highly susceptible to infectious diseases. The authors discuss results from a study of elderly people in neighborhoods of Quito, Ecuador, saying that immune senescence is probably more pronounced in the elderly of less-developed areas compared to those in a developed country such as the United States. Without adequate nutritional, social, and economic support, which is often the case in poorer countries like Ecuador, the elderly have less capacity to fight diseases (Meydani et al., 2005). This leads to the second detrimental factor of health among the elderly: nutritional status. Meydani et al. discuss the strong correlation of nutritional deficiencies and poor immune functions, noting infections are more common among undernourished individuals. They also describe how malnutrition and infections are cyclical problems, each having a cause and effect on the other. For example, “many infectious diseases reduce nutritional status by decreasing nutrient absorption, increasing nutrient loss, [and] reducing energy stores” (Meydani et al., 2005, p. 5). To summarize, the authors discussed two factors that increase the elderly’s likelihood of getting diseases: immune senescence and poor nutritional status. I will now compare the elderly to people living with AIDS by using these two factors. People living with AIDS also experience a sort of “immune senescence.” The difference is that instead of it being caused by “old age” it is a result of the auto-immune destruction of HIV. Thus, diseases that a healthy immune system can normally handle become debilitating and life-threatening for both the elderly and people with AIDS (Meydani et al., 2005). Another comparison is nutritional status. Proper nutrition is as important a factor in immune health among people living with AIDS as it is among the elderly. This is especially the case in Ecuador where people living with AIDS are faced with many socioeconomic concerns and proper nutrition may be a low priority.

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This comparison of Ecuadorian elderly people and people living with AIDS will be useful during our assistance planning because we are now more aware of the immune system vulnerability of people with AIDS and may keep nutrition in mind as a serious component of AIDS care. Ecuador’s Health Sector & Legislation Patterns Now that I have discussed Ecuadorian social situations and age groups relating to HIV/AIDS, I will explain the nature of Ecuador’s health sector and legislation patterns. This information is beneficial because so much of the assistance work dealing with HIV/AIDS deals with these two aspects. The Health Sector The health sector in Ecuador is struggling to function more efficiently and effectively. It has many roles, summarized by the PAHO to include “management, regulation, planning, insurance, human resources development, and services provision” (PAHO, 2004). However, the way the sector is structured has long been causing poor communication, a weak information infrastructure, and unnecessary duplication of investments. Ecuador’s health services are highly inconsistent, where institutions are “governed by different types of policies, healthcare models, and financing schemes” (PAHO, 2004). The delivery of health care thus is funded by various separate methods. This structure makes it easy to have such organizational problems. Ecuador has recognized these issues as roadblocks in successful healthcare, and since 1994, there has been a reform for improvements. According to the PAHO, the first efforts were to develop a health sector model that combined “equity with efficiency and a common plan of action among providers” (PAHO, 2004). Then in 1997, a national consultation defined more specifically the roles of the State in health, which were health promotion, guaranteeing equitable access to care, and decentralized delivery of services. The consultation also defined the health sector’s 3 levels of political action: “intersectoral (health promotion and social participation); sectoral (health insurance, medical practice, allocation and use of resources, etc.); and institutional (essential public health functions and coordination of international cooperation)” (PAHO, 2004). These defined roles began organizing Ecuador’s health sector. One role, namely decentralizing services, played a big part in reform attempts. The State Decentralization and Social Participation Act of 1997 gave guidelines for transferring resources from the national level to provincial councils and municipalities (PAHO, 2004). The way Ecuador is monitoring this progression will be discussed momentarily. Once these new regulations were in place, the health sector began improving their work. 1999 was an appropriate year for the health sector to “shine” as Ecuador was in the midst of a crisis from various natural disasters, and public health outbreaks were rampant. They implemented malaria and tuberculosis controls and expanded the public health laboratory network to enable surveillance of these diseases. However, because of a lack of trained professionals and an integrated national health information system, there were limited helpful effects. Another effort the health sector made in 1999 was to spread the news of the newly created National AIDS Institute. The creation of this institute led to AIDS awareness and

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care efforts, which I will discuss under domestic governmental responses. The following statistics are meant to show the scope of the individual health care services available in Ecuador. In 1999 there were roughly 2,800 outpatient care facilities and 541 hospitals (PAHO, 2004). There were 1.5 beds for every 1,000 people, and in 2003, 1.7 physicians existed for every 1,000 people. For a comparison, the United States had about 2.8 physicians for every 1,000 people. The percentage GDP health expenditure in 2003 was 2.4%, whereas the United States spent 13% (Candib, 2004). Clearly, the health sector is reflecting the impoverished status of its country as a whole, and because of this, Ecuadorians are limited in what services they receive. Monitoring the Reform Ecuador is using a new system called the “benchmarks of fairness instrument” to monitor its reform. Generically, this system was created as an evidence-based tool to evaluate “the effects of health-system reforms on equity, efficiency, and accountability” (Daniels, Flores, Pannarunothai, Ndumbe, & Al, 2005). Daniels et al. say Ecuador adopted this system to find out which reform efforts have been successful and which need improvements. More specifically, these benchmarks are “measuring the impact of decentralization and financial reforms on the delivery of public health services” (Daniels et al., 2005). A team of representatives from governmental and non-governmental organizations are involved in pressuring reform efforts to be fair, which the authors define as “what people are owed as a matter of justice” (Daniels et al., 2005). An example of items measured is the MPH’s policy to provide free care to mothers and children under 5 years old. After analyzing this, 4 of 6 districts were found to be charging up to $4 for treatment. Another example is an analysis of service quality improvements in various healthcare facilities. A ratio of administrative staff to medical staff indicated public staffing issues, and as a result, the team notified provincial authorities (Daniels et al., 2005). These examples show the benchmarks approach is working somewhat as a checks-and-balances system for Ecuador’s health-sector reform. Continued efforts with this system will be beneficial for Ecuadorian healthcare. Structure of Medical Practice The process of becoming a physician and practicing medicine in Ecuador is different than the process in the United States. Dr. Lucy Candib explains this, as well as how this affects patients, in her analysis of family medicine in Ecuador. Unlike the positive connotation “general practitioner” has in the United States, the same term in Ecuador is attached to a lack of experience or mistrust among the general public. Reasons for this begin with the method of education. Candib says that in Ecuador, medical schools and medical practices are highly specialized. Medical schools require graduates to serve one year of rural service, which has a reputation of negatively impacting health in these areas. After this year, graduates compete for further specialized training or for prestigious training outside of Ecuador. If a graduate is denied both of these, he or she will often leave the medical field or begin practicing “general medicine” (Candib, 2004). Therefore, “general practice” seems to be a last resort and the public knows this. Candib claims that this is a problem, because general practice, also known as family medicine, should be the key to giving primary care

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and preventive care to Ecuadorians. To combat this problem, the Andean Pact of 1980 agreed to create a “family medicine” specialty and in 1987 a 3-year family medicine program began. The establishment of the Ecuadorian Society of Family Medicine followed, and some of the negative ideas towards “general practitioners” among medical students improved. Candib is quick to note, however, that despite advancements, medical students are still unprepared to deal with the health needs of Ecuadorians. She says the focus is misplaced among the practice: care is based on illness and disease rather than on what causes suffering. It should use a holistic, continuous approach with emphasis on prevention. The practice also generally “looks at health in terms of cost-benefit…and at quality in terms of technology, pharmaceuticals, and high return on investment,” which overshadows the basic needs of patients. Knowing these shortcomings, Candib suggests that “the quality of care should be measured by the extent of its fulfillment of the principals of continuity, comprehensiveness, and integration of care” (Candib, 2004, p. 281). However, integrating such family medicine services into the health care system takes time and is a political decision. Poverty impacts Ecuador’s family medicine in many ways. Preventative health is seen as a luxury in developing nations and most Ecuadorians cannot afford to lose a day’s wages to visit a doctor for just a “check-up” (Candib, 2004). Family physicians also struggle, because their incomes are “inadequate to maintain a modest standard of living.” Perhaps this is one reason why Ecuador is having a hard time keeping its doctors from leaving the country (Candib, 2004). Ecuador’s poor economic state causes the medical sector to be dependent on external sources such as the World Bank and the International Monetary Fund (IMF). Candib notes this dependence limits the growth potential of healthcare in Ecuador. Efforts to promote change however, such as Dr. Candib’s analysis of family medicine, can positively impact the future of healthcare. In summary, Ecuador’s health sector is broad and dynamic. It has organizational and funding problems, but these are known and are in the process of being worked out through governmental reforms and individual efforts. This information is vital in our understanding of the HIV/AIDS situation in Ecuador simply because HIV/AIDS work is directly tied to the health sector. Basic legislation knowledge is also important, and will be discussed next. HIV/AIDS & the Legislature Many issues arise with HIV/AIDS that must be addressed by legal systems. It is from this sector that laws and regulations are borne and issues such as discrimination are fought. In an article examining responses to HIV/AIDS epidemics, Paget determined that there is a general global legislative pattern (Paget, 1998). More over, this 3-stage pattern is consistent with responses to other disease epidemics. I will describe the pattern and apply this to Ecuador’s legislature. The first stage of this response is when the legislature denies the presence of the epidemic in its country. At this stage, no regulatory measures exist. Second, the legislature recognizes the epidemic and will take necessary measures to discover its scope. The last stage is

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mobilization, where a legislature gets active to hinder the epidemic (Paget, 1998). At the time Paget wrote this article, I would argue Ecuador was beginning stage 2. Efforts, such as creating the National AIDS Institute exemplify recognition of the epidemic. Eight years later, I believe Ecuador is closer to stage 3, because of the many examples of HIV/AIDS work that have begun recently and because of the efforts to bring international attention to their epidemic. These efforts will soon be discussed. Identifying that legislatures worldwide have a patterned response to AIDS is important because it helps us predict the future. Fortunately, Ecuador is already in the mobilization stage, but being in the last stage of this pattern does not mean there is no work to be done. On the contrary, reaching this stage means the legislature is open to doing what it can to combat this epidemic. At the same time, representatives of Ecuador’s legislature are not immune to societal biases and always need the encouragement of lobbyists to keep HIV/AIDS a significant issue. Now that I have explained many aspects of Ecuador’s HIV/AIDS epidemic, from social situations to the legislature, I can describe domestic and international efforts in response to it and can analyze the strengths and weaknesses of this assistance. DOMESTIC EFFORTS IN RESPONSE TO EPIDEMIC Ecuador is one of Latin America’s poorest countries, yet it is one with a strong will. It is a nation facing a rapidly spreading HIV/AIDS epidemic and in light of its economic status, is doing what it can to fight back. In this section I will explain some of the key efforts, relating to HIV/AIDS, of governmental and non-governmental organizations. We at Mercy Corps can use this information to formulate program or partnership ideas. Governmental Response According to a 2001 Ecuadorian case study done by UNAIDS (2001), the history of Ecuador’s HIV/AIDS response dates back to 1987, 3 years after the first cases were reported. It was then that Ecuador established a national AIDS program, with the help of WHO/PAHO. Although this may seem highly proactive, the program mainly focused on getting HIVtesting materials (Reaching out, 2001, p. 34). It made little progress over 7 years and in 1994, funding was cut. As of 2001, funding was still not restored. The MPH’s funding also declined during the 1990s and therefore had trouble getting treatments for people living with HIV/AIDS. These struggles prompted the government to create a National AIDS Council in 1995, hoping that joining forces would increase resources and the capacity to deal with HIV/AIDS (Reaching out, 2001). The council remains intact, including “representatives from MPH, Ministry of Government, [and] Ministry of Public Welfare.” It also includes a representative of people living with HIV/AIDS and a representative of NGOs (Reaching out, 2001). Despite funding concerns, the MPH remains the main governmental organization working with the HIV/AIDS epidemic. In the last few years, they launched a section specifically for HIV/AIDS work, called “Programa Nacional de Control y Prevencion del VIH-SIDA-ITS”

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or “National HIV-AIDS-STDs Control and Prevention Program.” According to its website, this program strives to be the reference-point for all other HIV/AIDS work in the country (MPH, 2005). In 2005, it published a manual titled “Manual Nacional de Consejeria en VIHSIDA-ITS” providing extensive information on the subject of HIV/AIDS care. I will describe some specific objectives and activities of this program and then mention specific aspects of the manual. The National HIV/AIDS Control and Prevention Program’s main objective is to establish HIV/AIDS services, with the support and participation of the society, in order to decrease the psychosocial impact of HIV (MPH, 2005). The program has many specific objectives as well. For example, it strives to increase the access to voluntary HIV-testing, especially in rural areas. It wants to establish at least one counseling and anonymous blood-status center in every province. It tries to defend the human rights of people living with AIDS and encourages attendance at AIDS support meetings (MPH, 2005). The program’s website also listed several activities, including training personnel for all levels of HIV/AIDS assistance, reference system and data-collection work, external evaluations of the quality of laboratories and blood bank networks, and increasing access of counseling services to the general population. These objectives and activities are clearly in coordination with NGOs and other communitybased organizations. The government realizes the importance of community-level empowerment, as is seen with its efforts of decentralization, and wants to promote and guide these community services. One way the National HIV/AIDS Control and Prevention Program is doing this is through its manual on various aspects of HIV/AIDS care. The manual is a reference guide to HIV/AIDS workers, people living with HIV/AIDS, people affected in other ways by this disease, and for anyone wanting to educate themselves on implications of this disease and other sexual transmitted diseases (STDs). It is easy to read and very well-organized. The entire manual is available online, but because most Ecuadorians do not have access to the internet, the program has made it available in other ways. The manual begins by declaring STD infections, including HIV, a problem in Ecuador. It acknowledges that in order to have effective care of these diseases, a team approach is necessary, drawing from all sectors of society (MPH, 2005, p. 6). Some specific aspects of the manual are a code of conduct for counseling people with HIV/AIDS, a guide to establishing voluntary HIV-testing and counseling services, and a discussion of high-risk population groups, such as men who have sex with men. One of the most important sections of this manual, in my opinion, is the discussion of human rights associated with these diseases. The manual says that the respect of human rights is indispensable for the effectiveness of prevention programs and the fight against HIV/AIDS (MPH, 2005, p. 51). It lists many human rights and provides sections of legal documents declaring those rights, including the Constitucion Politica del Ecuador (1998) and the Ley de Prevencion y Asistencia Integral del VIH/SIDA (2000). These documents declare the right to no discrimination, equality before the law, privacy and confidentiality, health, education, work, legal protection, full medical attention, and the right to information, such as personal

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health status, for people living with HIV/AIDS. This section of the manual, in particular, is empowering for people living with HIV/AIDS, as it clearly defends their rights to live as normal and productive of a life as they feel possible. In light of the social discrimination and stigmatization, it is encouraging that Ecuador’s government has such defined respect for these individuals. In summary, Ecuador’s government has responded well to the HIV/AIDS epidemic, but has been limited financially since the beginning of its efforts. It encourages community, nongovernmental work and defends the human rights of people living with HIV/AIDS. The work of NGOs is thus vitally important in Ecuador’s fight against HIV/AIDS and an overview of its response follows. Non-Governmental Response The first main NGO working with HIV/AIDS was Comunidec, which among its other activities, developed its Program for AIDS Initiatives in 1995 that was a “means of linking and supporting community HIV prevention and care programs throughout the country” (Reaching out, 2001, p. 35). Comunidec had a partner from England, the International HIV/AIDS Alliance, who helped “establish and improve HIV-related NGOs’ relationships with business, media, government, and local health services” (p. 35). In 2000, a new organization, Kimirina, replaced Comunidec as the International HIV/AIDS Alliance’s partner to “help reduce both the advance and the impact of the epidemic” (p. 35). This brief history of NGO involvement shows that Ecuador acted early to address HIV/AIDS and used a head NGO with an international partnership as a guiding force for smaller NGOs to meet the needs of people living with HIV/AIDS. Current NGOs: Structures & Services Kimirina Corporation, partnered with the International HIV/AIDS Alliance, continues to be the leading NGO supporting several other HIV/AIDS organizations nationwide. Kimirina focuses on empowering over 100 organizations and communities to take active roles in prevention and support services for target groups of people (Reaching out, 2001). (See appendix B for a partial list of these organizations). These groups are diverse, but the main emphasis is on people living with HIV/AIDS, men who have sex with men, and sex workers. Kimirina empowers organizations by providing grants, recommendations, technical tools and organization methods. With this support, these organizations can set up activities or improve current services (Reaching out, 2001). Before I get more specific on these services, I need to explain NGO structure dealing with HIV/AIDS. There are two main types of NGOs that deal with HIV/AIDS, according to reports from Horizons, which is an HIV/AIDS research operation for the International HIV/AIDS Alliance (2000, 2002), and according to the UNAIDS case study (2001). They are self-help organizations and semi-self-help organizations. The degree of involvement from people living with HIV/AIDS determines the type of organization. People living with HIV/AIDS implement, run, and benefit from services in self-help organizations, whereas health/social workers are in charge of most services and people living with HIV/AIDS take less prominent

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roles in semi-self-help organizations. According to Horizons’ research, there are advantages and disadvantages of each type, regarding the effectiveness of meeting the needs of its participants. Each structure is valuable, but the greater the involvement from people living with HIV/AIDS, the more effective that NGO will be. Examining every NGO in Ecuador dealing with HIV/AIDS is beyond the scope of this report, but many organizations are listed in appendices C and D. The following 4 examples, however, will provide a better understanding of NGOs dealing with HIV/AIDS in Ecuador and what they do to meet people’s needs. First, the Dios, Vida y Esperanza Foundation is a NGO based in Guayaquil. It was founded in 1992 and started as a self-help group. It has since incorporated health workers who run the organization, turning it into a semi-self-help organization (Cornu, Herrera, & Velasco, 2000). The Esperanza Foundation also formed in 1992, and health workers focused on providing HIV prevention services to sex workers in Quito. People living with HIV/AIDS have mainly been service users, but the organization is working to incorporate them in service-providing. Vivir Foundation is another NGO based in Quito, and it started in 1990 as a self-help group. Like Dios, over time, health workers have taken charge and as of 2000, there was little involvement from people living with HIV/AIDS. The last NGO that Horizon researched was the Siempre Vida Foundation, which was formed in 1994 in Guayaquil and has a history of high involvement of HIV-positive people in all aspects of the organization (Cornu et al., 2000). These NGOs provide numerous services, and I will mention these services by focusing on the needs of people living with HIV/AIDS. HIV/AIDS Needs Addressed by NGOs First, NGOs address social, emotional, and mental needs of people living with HIV/AIDS. NGOs offer group meetings and counseling that provide people an outlet from the social stigmatization surrounding them. They can feel accepted, loved, and safe in an environment where others around them, often including service providers, have similar conditions. In fact, Horizons’ research of these organizations (2000) states that participants feel more supported and comfortable when more HIV-positive people are providing these services. This could be from the ability to share experiences or from not having to worry about possible discrimination from an HIV-negative worker. Another social need met by NGOs is the importance of having human rights protected. Ecuadorian NGOs are educating people of their rights and are advocating further legislation protecting the rights of people living with HIV/AIDS. An example of a key achievement through advocacy efforts is in 2004, sex workers became included in the national “free maternity program” mentioned earlier. This achievement means sex workers will have access to free HIV and STD testing (“Ecuador,” 2004). Second, NGOs can meet many physical needs. The organizations I mentioned provide medical care and refer participants to clinical laboratories that can provide further assistance, such as specialized care and free or discounted medicines (Cornu et al., 2000). These services depend on the availability of trained health workers, thus the greater the amount of trained NGO workers, the greater the organization can provide for the physical needs of its participants.

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Finally, NGOs provide educational services to increase HIV/AIDS awareness and understanding. HIV-positive people can learn about their condition and find answers to questions they may have. NGOs also work with the general population on prevention and awareness-raising activities, showing they understand that Ecuadorian’s HIV/AIDS knowledge and correct assumptions are important in controlling the epidemic (Cornu et al., 2000). Ecuadorian NGOs try to meet all these needs dealing with HIV/AIDS, but certain nationwide issues often inhibit that goal. I will point out some NGO weaknesses and describe how they need international assistance next. NGOs’ Weaknesses The UNAIDS case study (2001) and Horizons’ research (2000, 2002) mention several times that Ecuador’s NGOs need to have greater involvement from people living with HIV/AIDS, meaning that they would “take part in management, policymaking, and strategic planning…and may represent the organization externally” (Greater Involvement, 2002, p. 5). They have this need in part because many people living with HIV/AIDS are afraid to face Ecuadorian society. The research suggests that NGOs need sufficient training programs in order for there to be an increase in people living with HIV/AIDS’ involvement. Training HIV-positive people so they can provide services involves personnel and media aids that build on their practical knowledge and instill technical and theoretical knowledge (Horizons, 2000, p. 5). Kimirina Corporation works to provide this, but is financially limited. This reminds us that NGOs are also affected by Ecuador’s poor economic state. Every program and AIDS initiative requires money, which is difficult to obtain. International efforts to provide funding and additional services will be described in the next section. It is in this area where Mercy Corps could be helpful. In summary, the domestic response to this HIV/AIDS epidemic has been strong, but Ecuador has many limitations and must also rely on international efforts. INTERNATIONAL EFFORTS IN RESPONSE TO EPIDEMIC International organizations have had a role in Ecuador’s HIV/AIDS response since the beginning. As I mentioned, the WHO/PAHO helped establish a national AIDS program in 1987. Since then, international organizations, ranging from various non-profit organizations to world AIDS initiatives, have continued to support Ecuadorians. Due to Ecuador’s levels of poverty, however, Dr. Jose Prado, director of the governmental AIDS program, says these efforts are only part of what is needed to stop widespread devastation (as cited in Dudley, 2005). This is also compounded with far more advanced epidemics in other regions of the world, namely sub-Saharan Africa, which naturally receive more assistance. Ecuador can use all the help and attention it can get, and having Mercy Corps join and/or expand current HIV/AIDS care would make a positive difference in their fight against HIV/AIDS. It would be focusing on preventing Ecuador’s epidemic from reaching the widespread status seen in Africa. In this section I will provide examples of global support, showing how they benefit Ecuador’s HIV/AIDS work.

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Funding I have already indicated Ecuador’s economic dependence on external sources. It receives grants and loans from the World Bank and the IMF. Naturally, Ecuador would seek financial assistance for their HIV/AIDS efforts as well. The most recent grant began in March 2005 and was awarded by The Global Fund to Fight AIDS, Tuberculosis, and Malaria (The Global Fund, 2004). The MPH requested slightly over $14 million for its efforts to fight HIV/AIDS in Ecuador, and is in round 2 of the process. The Global Fund approved about $7.5 million, and dispersed funds to Ecuador are so far around $1 million (The Global Fund, 2004). The MPH plans to use this money to help accomplish its HIV/AIDS objectives, which I mentioned earlier. As is evident, although this grant will be monumental, the process is slow and much more assistance will be needed. The United States has greatly responded to the HIV/AIDS pandemic as well, and in October 2005, “The President’s Emergency Plan for AIDS Relief” newsletter described the Bush Administration’s commitment to specifically helping Latin America and the Caribbean. According to this newsletter, the U.S. government has given over $100 million to various regional programs, in the current fiscal year, which represents a 115% over the past two years. It also mentions Bush’s pledge of “a 50% increase in funding of the Small Grants Program for HIV/AIDS for the upcoming year.” Ecuador benefited from this Small Grants Program with a grant for Corporacion Kimirina in 2002. This Grants Program is from the U.S. Agency for International Development (USAID), and more specifically, is part of an initiative called Communities Responding to the HIV/AIDS Epidemic [CORE] (Bhuyan, Deng, & Clark, 2002). USAID launched the CORE initiative in 2001, after realizing the potential and urgent need for “faith- and community-based organizations to contribute to the fight against HIV/AIDS.” Kimirina has focused on reducing societal stigmas by targeting media and reporting on HIV/AIDS issues. The grant supports “one-on-one visits with influential print and broadcast journalists, AIDS awareness workshops for journalists, and ongoing advocacy activites” (Bhuyan et al., 2002). These examples of external funding show the world is concerned with the HIV/AIDS pandemic and for the most part, Ecuador is not being ignored. HIV/AIDS Programs of International Organizations Many of Ecuador’s HIV/AIDS care programs have been organized, staffed, and funded by international organizations. One such organization is World Vision International. In 2002, World Vision Ecuador launched 3 pilot HIV/AIDS prevention projects, hoping to slow the spread of HIV/AIDS (Utreras, 2002). It also collaborated with Medical Assistance Programs (MAP) International to start a long-term training program that educates people on HIV causes and effects. MAP International is an organization dedicated to promoting the total health of impoverished people worldwide and has been working in Ecuador for over 15 years (MAP, 2005). Its main focuses are training community health promoters, youth-to-youth HIV/AIDS education and prevention, and working with government agencies. Because of its success in these efforts, “MAP has the respect of local churches and credibility with the

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Ecuadorian Ministry of Education” (MAP, 2005). This cooperation goes a long way in HIV/AIDS care. Another organization, Family Care International (FCI), is helping a different aspect of the HIV/AIDS epidemic. Its mission is to “ensure that women and adolescents have access to the high quality information and services they need to…experience safe pregnancy and childbirth and avoid unwanted pregnancy and HIV infection” (FCI, 2005). In Ecuador, maternal health services are partly underutilized because they are often seen as culturally unacceptable, so FCI is working to reverse this. It is developing programs that find common ground between traditional and western medicine, giving more respect to indigenous women (FCI, 2005). I will mention one other HIV/AIDS program, run by an international organization called Aid for AIDS. This organization provides free treatment, education, and recycled medication to HIV-positive individuals (Aid for AIDS, 2003). One of its main programs is the AIDS Treatment Access Program (ATAP) which collects un-expired medications, specifically antiretrovirals, from donors and then sends them to “ATAP clients in their native countries in collaboration with and direct supervision of their health care providers” (Aid for AIDS, 2003). Because antiretroviral therapy is scarce and expensive in Ecuador, this is an important program to have available. There are certain criteria that patients must meet before they can begin and renew treatments, which can cause low participation, but it is a start. These examples are some key HIV/AIDS programs in Ecuador supported by international organizations similar to Mercy Corps. Coalitions As we know, fighting the spread of HIV/AIDS is not a simple task, and therefore the more organizations that join together in a united effort, the stronger the impact will be. Fortunately, Ecuador has one such project, called “United in the fight against HIV/AIDS in Ecuador” (UNIVIDA). The project aims to reach over 1 million people in Ecuador’s most affected provinces, significantly slowing the spread of HIV/AIDS by 2009 (CARE, 2004). Its coalition was formed from efforts of UNIVIDA’s parent organization (CARE) and consists of government officials, the UN, multilateral donors, and domestic and international NGOs. The coalition is working to promote HIV/AIDS as a sense of urgency on the national agenda and to have all HIV/AIDS efforts fighting the epidemic together (CARE, 2004). Another coalition of sorts is UNAIDS. This program is comprised of many UN agencies: the UN Children’s Fund, the UN Development Program, the UN Fund for Population Activities, the UN Educational, Scientific and Cultural Organization, the WHO, and the World Bank. The coalition sponsors a regional AIDS initiative for Latin America and the Caribbean called SIDALAC. This coalition has numerous roles in fighting HIV/AIDS epidemics. In fact, it is partly because of UNAIDS’ case study of Ecuador that I had enough statistically information to compile this report. This demonstrates one of SIDALAC’s main objectives: “To develop research projects that provide useful information for strategic planning in the prevention of

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HIV/AIDS/STD and the provision of adequate health care for those affected” (“About SIDALAC,” n.d.). These examples of funding, various organizations and their programs, and coalitions give us at Mercy Corps a framework of understanding as to what the international community is doing in Ecuador. Knowing this will save us time when designing and planning our assistance. CONCLUSION Throughout this report, I described and analyzed Ecuador’s HIV/AIDS situation to prove that Ecuador should be the site of Mercy Corps’ first South American HIV/AIDS assistance. I defined Ecuador’s need for assistance by mentioning various statistics and situations. I further defined Ecuador’s need by explaining its epidemic, and I showed how it is on the verge of becoming widespread. I contextualized this epidemic with the rest of Latin American and also within various aspects of Ecuador’s culture and structure. From there, I began discussing the domestic and international responses to HIV/AIDS in Ecuador. I gave brief historical information, pointed out key organizations, and discussed structures of various programs. All of this information and analysis is meant to be a starting point for our future investigation and planning of HIV/AIDS assistance in Ecuador. With that objective in mind, I would like to mention a few conclusions and recommendations to guide our planning.       

Ecuador’s government has fortunately recognized its HIV/AIDS epidemic and is in the mobilization response phase. Governmental and non-governmental organizations, for the most part, have a positive relationship and are trying to fight this epidemic together. Partnerships among organizations are common and encouraged. A strong base of HIV/AIDS work has been laid, but further assistance would enable them to prevent a generalized epidemic. As we known, “small, specialized projects, suited to the local context are often more effective than large, generic programs” (Bhuyan et al., 2002), so we should focus on strengthening and enabling existing programs. Many NGOs lack trained personnel and/or beneficial levels of involvement from people living with HIV/AIDS, and this hinders them from reaching their full potential. Cultural aspects affect every part of HIV/AIDS care and need to be remembered during planning.

In conclusion, let us remember there are many South American countries in need, and hopefully we can reach them eventually, but because of Ecuador’s unique and particularly volatile HIV/AIDS situation, we should being our assistance with it. A UNAIDS executive director recently said “A rapid and substantial boost in national, regional and international support for the Latin America and Caribbean region on AIDS is essential to enable the region to get ahead of its diverse epidemics” (“Latin America,” 2005). Let us do our part.

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REFERENCES

Aid for AIDS. (2003). Programs & Services. Retrieved October 19, 2005, from http://www.aidroaids.org/programs/index.php America Latina. (2004). Joint United Nations Programme on HIV/AIDS (UNAIDS). Retrieved October 1, 2005, from http://www.unaids.org/wad2004/EPIupdate2004_html_sp/epi04_08_sp.htm#TopOfPage Anonymous. (2000). HIV in Latin American and the Caribbean. The Lancet, 355(9221), 2087. Retrieved September 27, 2005, from the ProQuest database (55742880). Bhuyan, A., Deng, A., & Clark, B. (2002, May 1). Local efforts make a world of difference [Electronic version]. AIDSLink 73. Retrieved October 1, 2005, from http://www.arches.uga.edu/~benclark/aidslink.html Candib, L. (2004). Family medicine in Ecuador: At risk in a developing nation. Families Systems & Health, 22(3), 277. Retrieved on September 26, 2005 from the Proquest database (730275811). Central Intelligence Agency (CIA). (2005). The World Factbook – Ecuador. Retrieved September 26, 2005, from http://www.odci.gov/cia/publications/factbook/print/ec.html CARE International. Project Information. Retrieved October 19, 2005, from http://careusa.org/careswork/projects/ECU86.asp Cornu, C., Herrera, D., Maldonado, A., & Velasco, N. (2002). Greater involvement of PLHA in NGO service delivery: Findings from a four-country study (Research Summary). Washington D.C.: Horizons-Population Council and the International HIV/AIDS Alliance. Retrieved September 20, 2005, from http://www.popcouncil.org/horizons/ Cornu, C., Herrera, D., & Velasco, N. (2000). The involvement of people living with HIV/AIDS in the delivery of community-based prevention, care and support services in Ecuador (Research Summary). Washington D.C.: Horizons-Population Council and the International HIV/AIDS Alliance. Retrieved September 16, 2005, from http://www.popcouncil.org/horizons/ Country Profiles: Ecuador (2004). Pan American Health Organization. Epidemiological Bulletin, 25(2). Retrieved September 26, 2005, from http://www.paho.org/english/dd/ais/be_v25n2-perfil-ecuador.htm Daniels, N., Flores, W., Pannarunothai, S., Ndumbe, P.N., & Al, E. (2005). An evidencebased approach to benchmarking the fairness of health-sector reform in developing countries. World Health Organization. Bulletin of the World Health Organization, 83(7), 534. Retrieved on September 27, 2005, from the ProQuest database (877012191).

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Dudley, S. (2005, February 2). Ecuadoreans cry for help in a region prone to HIV. Knight Ridder Tribune Business News, 1. Retrieved September 27, 2005, from ProQuest database (788974581). Family Care International. (2005). Ecuador. Retrieved October 19, 2005, from http://www.familycareintl.org/countries/pl_LA_Ecuador.php Green, E. (2004). U.N. says Ecuador at “appropriate moment” to act against HIV/AIDS. Wahsington, D.C. Retrieved on October 19, 2005, from http://usinfo.state.gov/utils.html HIV/AIDS epidemiology; U.N. warns of out-of-control AIDS problem in Ecuador's Pacific coast (2004, November 14). Medical Letter on the CDC & FDA, 50. Retrieved on September 26, 2005, from ProQuest database (729830811). HIV/AIDS response differs among Latin American countries. (2000). AIDSAlert, 15(5), S1. Retrieved on October 2, 2005, from the Expanded Academic ASAP Plus database. Latin America and the Caribbean AIDS conference opens in El Salvador. (2005, November). Joint United Nations Programme on HIV/AIDS (UNAIDS). Retrieved on November 10, 2005, from http://www.unaids.org/en/media/feature+stories.asp Lewis, S. (2005). The need to scale up HIV/AIDS programmes for gay men and other MSM in Latin America and the Caribbean. (Policy notes). Sexual Health Exchange, 2005(1), 2(3). Retrieved on October 2, 2005 from the Expanded Academic ASAP Plus database. Manual nacional de consejeria en VIH-SIDA-ITS. (2005). Ecuador: Ministry of Public Health and the National Control and Prevention Program of HIV-AIDS-STDS. Retrieved on September 27, 2005, from http://www.msp.gov.ec/ MAP International. (2005). Ecuador. Brunswick, GA: Author. Retrieved October 19, 2005, from http://map.org/site/pp.asp?c=fsJRK2PGJpH&b=837949 Mercy Corps International. (2005). About us. Retrieved October 16, 2005, from http://www.mercycorps.org/aboutus/overview Meydani, A., Ahmed, T., & Meydani, S. N. (2005). Aging, nutritional status, and infection in the developing world. Nutrition Reviews, 63(7), 233. Retrieved on September 27, 2005, from the ProQuest database (871292561). Paget, D. Z. (1998). HIV/AIDS and the legislature: An international comparison. AIDS Care, 10, S65. Retrieved on September 27, 2005, from the ProQuest database (29119748). Park, I. U., Sneed, C. D., Morisky, D. E., Alvear, S., & Hearst, N. (2002). Correlates of HIV risk among Ecuadorian adolescents. AIDS Education and Prevention, 14(1), 73. Retrieved on September 27, 2005, from the ProQuest database (110692187).

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Programa Nacional de Control y Prevention del VIH/SIDA/ITS. (2005). IntroductionObjectivos-Actividades-Datos VIH/SIDA. Ecuador: Ministerio de Salud Publica. Retrieved September 27, 2005, from http://www.msp.gov.ec/sida.html Quevedo, M. (2001). A reluctant response to HIV/AIDS in Ecuador. (Programme feature). Sexual Health Exchange, 2001(2), 9(2). Retrieved on September 27, 2005, from the Expanded Academic ASAP Plus database. Reaching out, scaling up: Eight case studies of home and community care for and by people with HIV/AIDS (2001). (Case Study. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS (UNAIDS)). 34-45. SIDALEC. About SIDALEC. Retrieved November 9, 2005, from http://www.sidalac.org.mx/english/quees_english.htm Snell, J. (1999, October 2). The looming threat of AIDS and HIV in Latin America. The Lancet, 354(9185), 1187. Retrieved on September 26, 2005 from the LexisNexis Academic database. The Global Fund to Fight AIDS, Tuberculosis, and Malaria. (2004). Portfolio of grants in Ecuador. Retrieved on October 19, 2005 from http://www.theglobalfund.org/search/portfolio.aspx?lang=en&countryID=ECU#HIV/A IDS The President’s emergency plan for AIDS relief. (2005, October). Washington, D.C.: Office of the U.S. Global AIDS Coordinator. Utreras, E. (2002). Ecuador. World Vision International. Retrieved October 19, 2005, from http://www.wvi.org/wvi/aids/latin%20america_aids.htm

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APPENDIX A: MAPS OF ECUADOR Map 1: South America

Adapted from: Columbus Guides. November 30, 2005. South America.

Map 2: Landscape of Ecuador

Taken from: MetaMorf S.A. Retrieved November 4, 2005. Basic Map of Ecuador.

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Map 3: Ecuador’s Provinces

Taken from: University of California, Santa Barbara. Retrieved November 4, 2005. Map of Various Provinces of Ecuador.

Map 4: Population Density

Adapted from: Joint United Nations Programme on HIV/AIDS (UNAIDS). Retrieved November 4, 2005. UNAIDS/WHO Epidemiological Fact Sheet on HIV/AIDS and Sexually Transmitted Infections-2004 Update. P 5.

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APPENDIX B: KIMIRINA PROJECTS Projects Supported by Corporacion Kimirina in 1999-2000 Organization Fundacion Esperanza Fundacion Guazhalan Centro Cultural Pajara Pinta Habitierra Clinica de Nar Asociacion Ninos Pichincha Fundacion Dios, Vida, y Esperanza Fundacion Maria Guare

Population Served Clandestine sex workers School teachers and parents of school children Peasant women and young people Peasant and indigenous women Peasant women Young people in Felices

City and Province Quito, Pichincha Gualaceo, Azuay Deleg, Canar Canar, Canar Canar, Canar Quito, poor urban areas Guayaquil, Guayas

Fundacion Siempre Vida Club social J. Forever

Women (both HIV-positive and HIVnegative) in poor urban areas Women and their partners in poor urban areas People living with HIV/AIDS Young people in poor urban areas

Fundacion SOGA Manabi

Young people in secondary school

CEMOPLAF- Riobamba

Young people in school

CEMOPLAH- Lago Agrio

Sex workers and their clients

Cruz Roa de Loja Fundacion Vivir CEDIME Colective de Alternativas Humanas Grupo de Mujeres Despertando CEPAM Guayaquil Fundacion Nuestros Jovenes Fundacion Jose de Arimatea Concinelle Foro Permanente de la Mujer en Esmeraldas

Young people in school People living with HIV/AIDS Peasant and indigenous women Young people in school

Guayaquil, Guayas Esmeraldas, Esmeraldas 14 cantons in Province Riobamba, Chimborazo Lago Agrio, Sucumbios Vilcabamba, Loja Quito, Pichincha Puyo, Pastaza Guayaquil, Guayas

Women and men in poor urban areas Health workers Young people in jail People living with HIV/AIDS Transvestites and sex workers Young people and women in poor urban areas

Guayaquil, Guayas Guayaquil, Guayas Quito, Pichincha Guayaquil, Guayas Quito, Pichincha Esmeraldas, Esmeraldas

Guayaquil, Guayas

Taken from: Joint United Nations Programme on HIV/AIDS (UNAIDS). September 2001. Reaching Out, Scaling Up. UNAIDS Best Practice Collection. P. 42-43.

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APPENDIX C: LIST OF REFERENCE INSTITUTIONS FOR HIV TESTING1 QUITO:          

Instituto Nacional de Higiene Leopoldo Izquieta Pérez Cruz Roja Hospital de las FF.AA Hospital Metropolitano Hospital Voz Andes CAISS 1 Área de Salud # 5 Áreas de Salud del MSP Centros de Consejería Dirección Provincial de Salud

GUAYAQUIL: o o o o o o o o o o

Instituto Nacional de Higiene y Medicina Tropical Leopoldo Izquieta Pérez Cruz Roja Hospital Luis Vernaza Hospital de Infectología Hospital Abel Gilbert Pontón Maternidad Sotomayor Hospital del IESS SOLCA Áreas de Salud Dirección Provincial de Salud

CUENCA:     

Instituto Nacional de Higiene y Medicina Tropical Leopoldo Izquieta Pérez Banco de Sangre de la Cruz Roja Cruz Roja Áreas de Salud Dirección Provincial de Salud

ESMERALDAS:    

Instituto Nacional de Higiene y Medicina Tropical Leopoldo Izquieta Pérez Banco de Sangre de la Cruz Roja Áreas de Salud Dirección Provincial de Salud

1

Adapted from: Ministerio de Salud Publica. December 4, 2005. Manual Nacional de Consejeria en VIHSIDA-ITS. p. 69-71.

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MANTA:  

Banco de Sangre de la Cruz Roja Áreas de Salud

PORTOVIEJO:    

Instituto Nacional de Higiene y Medicina Tropical Leopoldo Izquieta Pérez SOLCA Áreas de Salud Dirección Provincial de Salud

MACHALA:     

Instituto Nacional de Higiene y Medicina Tropical Leopoldo Izquieta Pérez Banco de Sangre de la Cruz Roja Dirección Provincial de Salud Áreas de Salud Centros de Consejería

MILAGRO:  

Banco de Sangre de la Cruz Roja Área de Salud

IMBABURA:   

Instituto Nacional de Higiene y Medicina Tropical Leopoldo Izquieta Pérez Banco de Sangre de la Cruz Roja Dirección Provincial de Salud

AMBATO:   

Instituto Nacional de Higiene y Medicina Tropical Leopoldo Izquieta Pérez Banco de Sangre de la Cruz Roja Dirección Provincial de Salud

AZOGUEZ:   

Instituto Nacional de Higiene y Medicina Tropical Leopoldo Izquieta Pérez Banco de Sangre de la Cruz Roja Dirección Provincial de Salud

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LOJA:     

Instituto Nacional de Higiene y Medicina Tropical Leopoldo Izquieta Pérez Banco de Sangre de la Cruz Roja Dirección Provincial de Salud Áreas de Salud Centro de Consejería

NOTA: Las pruebas confirmatorias se realizan en Quito, Guayaquil, y Cuenca, en el Instituto Leopoldo Izquieta Pérez.

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APPENDIX D: REFERENCE LIST OF ORGANIZATIONS FOR PEOPLE LIVING WITH HIV/AIDS2

NOMBRE DE LA ORGANIZACION

PERSONA DE REFERENCIA

TELEFONO

ACJ

Mario Rivas

05-635724

APROFE

Paolo Marangoni

04-2400-888 04-2419-667

APROFE IEC

Miriam Becerra

04-2400-888 042419-667

Aso. 5 de junio

Jenny López

05 758 755

Aso. TS. Por una Vida Nueva Asociación ALFIL

Sra. Pilar Pallares

CORREO ELECTRONICO

[email protected]

Esmeraldas [email protected] [email protected]

Julio Grijalva

097067563

Asociación de P.V. Manantial

Ab. Mauri López Medardo Silva

04-2569410 04-2862204

[email protected]

Asociación Ecuatoriana de Gays y Transgénero-ASOEGT

Ronald Estévez (Estrellita)

[email protected] [email protected]

Asociación Niños Felices

Alicia Carrasco

2778070 2288497 3410228 2597118 (fax)

Asociación Prodefensa de la Mujer

Elizabeth Molina

098371614

CEFOCINE

Rafael Carriel / Maribel Ruiz

04-2252864 04-2260255 04-2260256

CEMOPLAF

Dra. Marcia Arciniegas

06 712 536

CEMOPLAF

Lcda. Bélgica Betancourt

Quevedo

CEMOPLAF – Santo Domingo de los Colorados

Dra. Lourdes Tapia Lic. Nora

[email protected]

Cemoplaf - Quito

Lcda. Teresa de Vargas Dra. Rosario Naranjo

2230519 2547144

CEMOPLAF -Esmeraldas

Dra. Marcia Arciniegas

06 712 536

Centro Cultural Pájara Pinta

Ana Cordero

03 288 5478

CEPAM - Guayaquil

Lcda. Hanne Holts / Dra. Tatiana Ortiz

04-2401-740 04-2412-275 04-2403-252

CEPVVS

Ricardo Herrera

[email protected] [email protected] [email protected]

[email protected] [email protected]

[email protected] [email protected] cepam@ gye.satnet.net

[email protected]

2

Adapted from: Ministerio de Salud Publica. December 4, 2005. Manual Nacional de Consejeria en VIHSIDA-ITS. p. 72-76.

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Coalición Ecuatoriana de Personas que viven con VIH/SIDA

Ricardo Herrera y Walter Gómez

COLECTIVO DE TRABAJO PARA ALTERNATIVAS HUMANAS

Lcda. Peggi Ricuarte

04-2512-019 04-2524-214 04-2526-837

Cooperativa Agricola Cafetalera Cabo de Hacha

Alejandro Victores García Melchora Figueroa

05-2526837

Coordinadora de ONG de SIDA de Guayas

Dra. Lily Marquez

Coordinadora Política Juvenil

Viviana Maldonado

Corporación Kimirina

Ruth Ayarza o Jeannette Calvachi

Cruz Roja

Sr. Jorge Mujica M.

Cruz Roja – Quito

Marcelo Erazo

2582479

Cruz Roja de Loja

Dr. Patricio Aguirre

07 570 200

FAES

Antonio Ube

05 754 355

Quevedo

FEDAEPS

Manuel León/Edwin Ariza

2223298 2556964

[email protected]

FEMIS

José Urriola Pérez (Alberto Cabral)

2549919

Foro Permanente de la Mujer – Esmeraldas

Lcda. Lady Ballesteros / Sra. Amanda Arroyo

06 721 447 ext. 5569

Fundación Amigos por la Vida

Neptalí Arias

04-2390598

Fundación Causana

Patricio Bravomalo

FUNDACION DIOS VIDA Y ESPERANZA

Dra. Rosa Barba Lcda. Acela Trujillo

(04-303170) 04-208-388 04-245 072

Fundación Equidad

Orlando Montoya

2529008 2268563

Fundación Esperanza

Mariana Sandoval

Fundación EUDES

Galo Robalino

Fundación Guazhalàn

Byron Villacis Dra. Verónica Camaniero Jessica Jácome

Fundación Hogar, Ilusión y Vida

[email protected]

[email protected]

[email protected]

[email protected] 2556432 2556750 2543246 06 726 961 06 726 963

[email protected] [email protected] Esmeraldas [email protected]

femisgai@hotmailcom [email protected] [email protected] [email protected]

2556432

2512002 2287081

[email protected]

[email protected] [email protected] [email protected] [email protected]

255667 2240391

[email protected] [email protected]

Fundación Niñez y Vida

Guillermo Ordóñez

2227419

Fundación Nuestros Jóvenes

Silvia Barragán

2394490 2394491

[email protected]

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Fundación Nuestros Jóvenes

Diana Barragan / Hilda de Petersen / Eva Cevallos

04-2389285 04-2389285 04-2385819

FUNDACION SIEMPRE VIDA

Carmen Almeida, Luis Argudo

04-2435870 / 09-421623

FUNDACIÓN SOGA

Jayro Vinces

05-639-328 05-651467

[email protected]

Fundación VIDA LIBRE

Walter Gómez

04-2321735 09 7197319 09 7426796

fundacionvidalibre@interactive. net.ec

Fundación Vivir

Yolanda Gaón

2545105

[email protected] yolandaqGaón805@hotmail. com

FUVES (Fundación Verde Esperanza)

Sr. Alirio Mendoza / Sr. Fernando Murillo

09 826 3171 09 766 4992

[email protected]

GRUPO APASHA

Ricardo Jiménez

2468746

Grupo GLBTT de Cuenca

Patricio Coellar Maggy Martínez

07 283 3081

MAP

2476524

[email protected]

[email protected]

[email protected]

Médicos Sin Fronteras

Anna Cavali/Marc Bosch

2465458 2242864

[email protected]

Proyecto ESPOIR

Mayra Avellán/ Betty Moreira

05-632-650 05-630-235 05-630179

[email protected]

Proyecto Hope

Myriam Aguirre

2257919

Proyecto HOPE

Francisco Moreno

05-632-650

Red de Personas VVIH/SIDA

Luis Argudo

04-201-228

[email protected]

[email protected]

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