In 1992 the Jamaica Red Cross Society, in cooperation with the American Red Cross and funding from AIDSCAP, began an island-wide programme to develop a training system to prepare youth peer educators knowledgeable about the prevention of HIV/STDs. Its aims were to involve young people in acquiring knowledge, attitudes and skills to prevent the spread of HIV/STDs and to minimize discrimination towards persons living with HIV/AIDS. A major concern was guaranteeing the programme's sustainability, i.e., ensuring that the training system would be replicated on a large scale and continue over time.

Jamaica is the third largest Caribbean island, with a population projected to double to 4.8 million by the year 2026. Adolescents 12-18 years old account for 22% of the total population. The estimated Gross National Product per capita is US$ 1260. The literacy level for young women aged 15-29 years is 78%, and for men it is 66%.

More than 1500 people have been diagnosed with AIDS and an estimated 20,000 people are HIV-infected. The predominant mode of transmission is heterosexual. Young adults, under the age of 24 years, account for 40% of all reported syphilis cases and nearly 50% of reported gonorrhoea cases. Nearly 15% of girls and 47% of boys are reported to be sexually active by the age of 14 years. Jamaica's sexually active adolescents are therefore considered at risk of becoming infected with HIV.

Between 10-21 trainees attend a workshop for a total of 27 hours. The classes are designed to be held over three weekends in five sessions or in a one-week residential setting. The workshop emphasizes games and activities that make learning fun as a good way for young people to learn.

During training the PEs learn how to reach other youth with appropriate information on how to protect themselves against HIV/STDs. They are also taught how to facilitate 14 specific activities outlined in a handbook, including use of a model to demonstrate the correct way to use a condom. Work is further done with them to develop non-judgemental attitudes towards persons living with HIV/AIDS (PHAs).

After training, working in twos or threes, the PEs are able to organize and facilitate a minimum of three HIV/STD peer education programmes. These programmes usually involve small groups of 10-15 young people about their own age. The PEs learn to consult with adult leaders when they have problems they cannot solve themselves, or to refer young people with other questions or serious personal problems to their adult leader or other community services. Maintaining confidentiality is stressed throughout the training.

The people who train the peer educators must also be trained and meet knowledge and skills criteria to be certified as Red Cross "instructor trainers". They receive their special training in two weekend sessions. Additional adult leaders are recruited to support and back up the PEs. A radio serial drama, Andrew's Story, was also developed to support key messages related to myths about HIV/AIDS, stigmatization and prejudice.

The training design allows for, and indeed depends upon, role change - peers can become PEs, adult leaders and PEs can become instructor trainers and so on. Roles at each level and standards of performance are spelled out and used among the criteria necessary for certifying people at different levels.

The PEs were also involved in evaluation: they gave feedback on the questionnaires and collected and processed course records. The evaluation plan was further designed to elicit information about the 14 activities from the young people reached. The evaluation methods used here may carry over to other programmes.

The project grew substantially in the third year. By that time most of the systems and materials were in place. Instructor trainer and PE workshops had been held. In one parish, comprising five districts, the local Red Cross had established a PE club and secured funding from the local bauxite company to fund PE workshops.

Eight schools had adopted the programme and the Ministry of Education used the PE workshop design and materials in another district comprising three parishes. Peer-to-peer sessions were held in a variety of urban and rural settings, involving young people in school and not in school, through youth clubs such as the JRC "Links" and other community organizations. In this way, young people of all socio-economic and literacy levels were reached.

The high per student costs in the first two years is a reflection of development and testing of methods and materials used in training peers, PEs and instructor trainers. Fewer people are reached during the development stages: in year one, 570 young people were reached by PEs; in year two, 1304 were reached and in year three 4187 were reached. A critical mass of PEs and instructor trainers was forming.

Printed materials are used in this programme, including a manual, teaching posters, handouts and other teaching materials. Economy of scale is important in this regard since the more that is printed, the less the per unit costs. The overall unit costs for the programme will continue to go down as it expands. The high start-up costs will not continue once the programme is sustainable. By the fifth year the costs will probably be a fraction of those initially incurred.

Long-term project sustainability was ensured at the start of the programme because this project has integrated an educational philosophy and technology into a pre-existing, well-established NGO, the JRC. Many benefits accrued, among these were:

• The transfer of important skills between the JRC and ARC. The JRC adapted the American training system and learned important computer and project management skills. The ARC adapted techniques from the "Together We Can" Programme for its own HIV/AIDS youth programmes.
• Young people benefited from the training activities as these had an impact on their  risk attitudes and behaviours; their attitudes towards PHAs greatly improved.
• Other community organizations integrated this programme into their own activities.
• Participants and potential participants continue to be motivated.

In order to maintain the training system core staff, continued project management, ongoing programme evaluation, financial record-keeping, inventory control, continued technology transfer and creation of political alliances are needed. What truly influences sustainable programmes, beyond the afore-mentioned components, are the priorities of the NGOs involved (e.g., the two Red Cross Societies), Ministries of Health and Education, donors and funding cycles.

Our plans for this programme to recover all of the ongoing operational costs did not come to fruition. Individuals and organizations are not willing, or do not have funds, to pay for HIV/STD prevention training programmes. In a world of stop/start funding, it is very difficult, if not impossible, to sustain programmes in developing countries. Two contributing reasons are:

Not enough instructor trainers and PEs are trained to allow for continued replication. Attrition (i.e., drop-outs) will assure that the project doesn't reach a sufficient critical mass to keep moving on its own. 

Stop/start funding is much more expensive per person reached than a steady flow of funds. Investment in human capital and institutional capacity-building can be lost, only to be recreated at great cost when new funding cycles and systems are put in place, often with a different focus.

Since the three-year funding for the development and implementation of the programme came to an end, the programme has continued through a patchwork of funds and delivery systems. Funding has been obtained for core staff (from the Norwegian Red Cross). Fortunately, we were able to use funds from the project to print a large number of materials for use on a continuing basis.

A local bauxite company that had supported community development efforts was approached for support of the project; having seen what the young people were doing, the company funded several PE workshops. Ten schools have incorporated the programme on an ongoing basis and many youth leaders in the JRC youth programme, Links, were trained as instructor trainers.

The "Together We Can" PE project will be incorporated into a separately funded three-year programme whose primary emphasis is not STD prevention. Pre- and post-workshop KAB tests continue to be collected for newly-trained PEs and the University of Maryland may eventually analyse these data. We also have plans to further analyse the data previously collected on the PEs. And the ARC continues to maintain contact with the JRC on an ongoing basis, sharing information and providing technical assistance as needed.

We recommend that others who try programmes of this nature involve youth at every stage of programme development. It is also important to enlist a wide variety of organizations to recruit instructor trainers, seek a variety of funds from the start of the programme, and carefully plan the growth and expansion of the programme.

Calculating the "true" costs of workshops may help obtain sponsorship for individual workshops. Further studies are needed to compare the costs and results of different approaches of reaching young people. In order to do this we not only need formulas to calculate costs per person reached but something beyond numbers reached. At a minimum, the formula should account for varying levels of intervention intensity, contact hours and movement towards behaviour change. Most important, we need operational definitions of sustainability in HIV/AIDS prevention education and sustainability benchmarks for youth peer education.

In any event, core staff are needed to continue to support the programme, schedule the training workshops and secure funds on an ongoing basis. We certainly recommend a minimum of a stable five-year funding period.

Carole Kauffman, Health and Safety Services, American Red Cross Society, National Headquarters, 8111 Gatehouse Road, 6th Floor, Falls Church, VA 22042, USA, Tel. 1-703-206-7637, Fax: 1-703-206-7765; e-mail: kauffmanc@usa.redcross.org; Lois Hue, Jamaica Red Cross Society, National Headquarters, Spanish Town, St. Catherine, Jamaica, Tel. 1-809-984-7860, Fax: 1-809-984-8272; e-mail: jres@infochan.com

Instructor trainers                      Direct observation protocols
                                               KAB pre- and post-tests
                                               Focus groups
Peer educators                         Standards of performance debriefing
                                               Course records/numbers reached and
                                               demographics
                                               3-month follow-up: KAB and focus groups
Peer to peer sessions               Observation of peer sessions
Radio serial drama                    Focus groups and radio call-in questions