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Final Report for the AIDSCAP Program in Cameroon: Country Program Description |
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Table of Contents I. Background and Country Context II. Country Program Description IV. Subproject Highlights
IV. Subproject Highlights (continued) STD/HIV Prevention Project Among Youth in the East Province
Background and Scope of the Intervention The STI/AIDS Prevention Project among Youth in the East Province aimed at influencing youth to adopt low risk behavior for STI/AIDS Prevention through Information, Education and Communication. Youth constitutes a high-risk group for HIV infection, and plays a large role in the spread of the infection. Survey data shows that many young people worldwide initiate sexual activity during their adolescent years. Every year millions of young people contract STIs and recent research indicates that up to 60 percent of all new HIV infections are among 15-24 year olds, with females outnumbering males by a ratio of two to one. Since it was reported that AIDS cases among youth were increasing at an alarming rate in the East Province, CARE decided to focus its efforts on in- and out-of-school youth in the province. The goal of the project was to reduce the spread of sexually transmitted infections and AIDS among youth in the East Province through behavior change, STI control and condom use. The methodology was to use the peer educator approach to reach both in- and out-of-school youth. The Project collaborated with the Provincial AIDS Country Committee/Delegation of Public Health, Education, Social Affairs, Youth and Sports and Agriculture. The Project also addressed parts of the Government of Cameroon's National AIDS Control Service (NACS) Medium Term plan which focuses on communication (IEC) for behavioral change and listed youth as one of its target groups. Principal Accomplishments This project targeted youth, because young people are in the early stages of developing their behavioral attitudes, intervening at this stage could have a great impact on slowing the course of HIV/AIDS. Youth are also very susceptible to be influenced by their peers. The Project reached youth at schools through teachers and peer educators, and out-of-school youth through animators and peer educators. The project increased AIDS and STI knowledge among a large majority of youth and the general population of the East Province. The project also influenced the sexual attitudes and behavior of the target group through information, education and communication (IEC) using the peer educator approach, which was effective in bringing about behavioral change conducive to reducing the spread of STI/AIDS. The project created a network of peer educators selected by teachers in secondary schools and animators from the Provincial Delegation of Agriculture, Social Affairs, Youth and Sports in the East Province. The project trained 777 peer educators, 5 coordinators, 53 teachers and 61 animators. Seven hundred active peer educators organized educational sessions and community activities on the prevention of STI and AIDS for more than 69,000 youth in the East Province. Another 64,000 peers were reached through individual one-on-one contacts by the PEs. Indirect project beneficiaries included related groups such as parents and school teachers not directly involved in the project. The project used awareness-raising campaigns to sensitize large numbers of people on AIDS and STI prevention, and publicized the existence and role of the peer educators during these campaigns. Most of these awareness-raising campaigns were organized during national days, such as Youth, Independence and Labor day, World AIDS Day and the Cameroon National AIDS Week. During these days, manifestations and marches were held throughout the country, and in the East Province in particular, these manifestations would gather large numbers of people throughout the province. The Project took advantage of these important days in Cameroon to organize activities and raise awareness about HIV/AIDS. T-shirts, caps and pens were among the materials given away during these campaigns. Over 40,000 educational and promotional materials were distributed through the project. The Project also worked closely with PSI and was one of their condom wholesalers. The Project facilitated the creation of new condom outlets in the East Province for PSI thereby increasing accessibility and affordability of condoms in this area. Over 50,000 condoms were distributed free for promotional purposes by the project. In addition, condoms were sold through PSI outlets. CARE developed a play "Le linge sale" or "Dirty Laundry" in collaboration with the British Council and the Canadian High Commission. A radio comedy "Dilemma" about STIs and AIDS was also developed and produced. These materials were subsequently duplicated and distributed. The baseline and follow-up surveys indicated that the Project had an impact on the target group Seventy-nine percent of the youth interviewed know that there is no cure for AIDS compared to 64 percent in 1993. The proportion of youth who can identify at least two means of AIDS transmission has increased by almost 16 percentage points. Behavior change was also observed, youth reporting having ever used a condom increased just over nine percentage points, although only three percent reported consistent condom use in every sexual encounter. The proportion of youth who have delayed their first sexual encounter increased by 13 percentage points. It needs to be noted that a majority of the youth interviewed did not yet engage in sexual activity. Project management The project was managed by the in-country director of CARE/Canada who implements CARE activities in Cameroon. During the first two years of project implementation, there were two consecutive part-time project managers and in the third year, a full-time project manager was appointed. The project manager was based in Yaoundé. This created management problems and lack of supervision at the field level. In the next phase of the project, CARE will base a full-time project manager in Bertoua, the site of the Project, to avoid lack of supervision and coordination of the Project. Five coordinators seconded from the Ministry of Public Health to the Project, with their cumulative function, could not be involved in the Project on a regular basis. The lack of involvement of the coordinators and the absence of a Project Manager based in Bertoua constituted a management obstacle manifested in the lack of supervision of peer educators' activities, and poor reporting. The Project worked closely with its local partners during the planning and implementation stages of the project, and provided the necessary technical and administrative back-up. CARE coordinated its activities with the National AIDS Control Service, and concerned ministries at the provincial and national level. As a result of this collaboration, CARE Cameroon filled a gap in the national program, by extending interventions to an important target group, youth, in a geographic area that was not currently covered by similar activities. Lessons Learned and Recommendations The Project has learned that behavior modification is a long term process that cannot be achieved in three years. Although substantial gains have been achieved by the project, a continuous effort should be made to avoid reversal of this progress. The Project also learned that not only the choice of peer educators is very important, but the peer educators need to be officially recognized to give them credibility with their peers. Also direct involvement of teachers and parents as supervisors was necessary to further increase the credibility of the young PEs.
Community-Based Integrated AIDS Education within Primary Health Care Services in the Far North Province
(FCO 53386)
Background and Scope of the Intervention
Save the Children, founded in 1932, works with communities to affect positive changes in the lives of people, youth in particular, and in their communities, as a whole. With the onset of AIDS, Save the Children played a key role in meetings that established the National AIDS Control Program in Cameroon. In 1989, Save the Children received USAID funds through the HIV/AIDS Prevention in Africa (HAPA) grant to include HIV/AIDS education in their community-based activities in the Far North Province of Cameroon. In 1993, Save The Children received a three year grant from FHI/AIDSCAP to implement a community-based integrated AIDS education project in four of the six administrative divisions of the Far North Province. The purpose of the Community-Based Integrated AIDS Education Intervention was to reduce risk-associated sexual behavior among the selected target populations through community-based and outreach activities in the urban cities of Yagoua and Maroua and the administrative divisions of Mayo Danay, Mayo Kani, and Diamare. The target populations were defined as youth, commercial sex workers, armed forces, and transport workers, mainly truck drivers. The project was designed to use cascade effect training and education to reach the target groups. The first component of the project concentrated on expanding the existing training of trainers program implemented by Save the Children, while the second component focused on operationalizing the project through community- outreach and education. Principal Accomplishments The project activities consisted of a series of participatory training and refresher workshops conducted every six months. Over the course of the 18-month project, Save the Children trained 350 individuals in STI/HIV counseling and prevention as well as IEC and outreach awareness activities. Peer educators and outreach workers were identified and selected from the target groups and trained as health educators using the training curricula developed by the AIDSCAP/Cameroon Project. The outreach workers and peer educators reached 18,655 students, 2,852 military, 1,612 CSWs and 2,704 transport workers through education activities. Over the life of the project, 8 types of educational materials and 9 educational messages were developed. The project distributed over 10,000 IEC materials and aired more than 8,000 educational messages over the radio. The project also reinforced the existing network for the sale of condoms in collaboration with PSI and 8 new outlets were created through the project. The predominantly Muslim North proved a challenge for condom promotion and distribution. PSI, at the request of the Ministry of Health, contributed to the printing of a booklet in Arabic on AIDS and STIs that targeted Muslim leaders. The Minister of Public Health then visited the Far North Province capital, Maroua, and met with religious leaders to explain the importance of condom use in AIDS prevention. He also paid a visit to PSI's principal distributor (Muslim), who is located in the center of the local market. The choice of the Far North was intentional because PSI's sales statistics showed that this province had the lowest per capita consumption of condoms in spite of several AIDSCAP funded activities targeting high-risk groups. Cultural barriers affected retailers' and wholesalers' willingness to distribute condoms. As a result of the visit by the Minister the number of wholesalers doubled within a week. Over 89,000 condoms were distributed free for promotion. The results of Focus Group Discussions held at the end of the project, show that respondents from the target population have an improved knowledge of STI and AIDS and know about the importance of using condoms to avoid infection. However, knowledge in these groups has not always led to significant behavior change. For example, CSWs, although very knowledgeable about the need to use condoms to protect themselves still engage in unprotected sex if the client was willing to pay extra. Furthermore they stated that condom use depended on the type of client, meaning if he is a "regular" client, they were less inclined to use condoms and leave the choice up to the man. After a long day on the road, the truck drivers wanted "a good massage, care and comfort" at their nightly stopping places, and the military men looked forward to sexual pleasure with multiple partners after completing a mission. Students on the other hand preferred faithfulness to one partner, however, boys reported to be less faithful than girls. Unfortunately, condom use in the highest risk sexual encounters still seems to be the exception rather than the rule. These results indicate that continued efforts in AIDS education are needed to affect sustainable behavior change. Project Management The project was managed by the Country Representative of Save the Children, assisted by a team of administrative and technical staff. Project activities were implemented in partnership with regional health authorities and collaborating National NGOs. These included the Ministries of Health, Defense, Education, Agriculture and Women and Social Affairs, and CEPARD (African pluridisciplinary centre for Development) and SALAMA (Health through Maternal Language). Originally the project was conceived to be implemented over a 36-month period, however, due to the closing of USAID/Cameroon, the project implementation was delayed and the actual project was only implemented over a 18-month period with reduced funding. Lessons Learned and Recommendations Student Peer Educators need adult supervisors to give them credibility. Using the Peer Educators approach worked much better with the adult target population than youth. Military, truckers and CSWs participated in sessions organized by their trained peers. Students, on the other hand, challenged the knowledge of their peers despite the training received by the latter. This problem was corrected by teaming up student peer educators with adult "animators" or outreach workers. The lesson learned in the North, as well as in the East Province under the CARE project, was that in order for the peer educator strategy to succeed in the school setting, trained student educators must work under the supervision of an adult person, be it a teacher or adult outsider. This gives credibility to the student-educator. Traditional Peer Educator approach may not be the most effective approach for a mobile target audience. Reaching truck drivers with educational messages is like trying to hit a moving target. Organizing formal training and retraining for peer educator/truck drivers was a difficult task given their mobility. Because of the transient nature of their job, the peer educators in turn had a hard time reaching their fellow transport workers. In future projects among mobile target groups, more innovative approaches should be designed. Also lessons could be learned from other projects on the continent such as Nigeria and Tanzania. Selecting health educators from among transport support workers is an option: peer educators could be selected from transport support workers at major truck stops along a transport route and at truck company headquarters. Truckers would not only receive the information before they leave on an extended trip, the same messages would be reinforced along the truck route at every overnight stop.
Sentinel Surveillance Introduction In 1989, the National AIDS Control Unit (ULS) began conducting HIV and syphilis surveillance in selected urban sites among STI and tuberculosis patients and pregnant women. At the beginning of the epidemic it was useful to sample STI and TB patients in addition to pregnant women, in order to monitor the entry of HIV into the population. But once it became clear that the virus had penetrated into the general population and that its prevalence was increasing, WHO recommended that only pregnant women be included in the surveillance system, so that scarce resources could be used for a group more representative of the general population. STI and TB patients do not represent any identifiable population in Cameroon. The sentinel surveillance system has monitored pregnant women in selected prenatal care facilities in selected sites since 1993. These women are easier to sample because of their accessibility and relative stability compared to other groups. In a 1993 report prepared in preparation for MTP II , analysis of the 1992 HIV data indicated that HIV had infected every part of urban society, but was higher among young, single women with secondary or higher education. Infection rates among ANC attendees ranged from 2 percent in Yaoundé to 7.9 per cent in Bertoua. The data also suggested that infection among the rural population and the illiterate population was not negligible. A seroprevalence study conducted in five rural villages near the Central African Republic found 2.2 per cent of the adult population was HIV positive. The sentinel surveillance project supported by AIDSCAP was a joint undertaking between the Ministry of Health, through the ULS, the World Health Organization and GTZ. While FHI was providing funding for logistics, supervision and data analysis, WHO assumed responsibility for providing HIV test kits for the AIDSCAP sites. GTZ was responsible for funding their sites in Limbé and Bamenda. Methodology Sampling method: Consecutive sampling: blood samples were collected during each session from every pregnant woman who was a first attendee , until the sample size was reached. Sample size: The sample size calculated for a simple random sample based on an estimated prevalence of 0.05 and precision of 0.025, was 292. Thus a sample of 300 was proposed for each sentinel site. Laboratory testing: Tests were anonymous and unlinked
Reporting: This was done through simplified anonymous forms containing the following variables on the participating pregnant women: age, nationality, residence, marital status, level of education and tests results. Results and outcomes Survey results allowed the government to follow the evolution of AIDS nationally and measure the impact of prevention activities aimed at stabilizing the rate of sexually transmitted STI/HIV infection. The HIV sentinel surveillance system also collected socio-demographic characteristics ( age distribution, residence, level of education and marital status) of the pregnant women from whom samples were collected, and monitored trends in HIV and syphilis seroprevalence levels among the women over time (1992-1996). Table 11: Sample sizes and syphilis prevalence levels among pregnant women per sentinel surveillance site, Cameroon, 1992-96.
Table 12: Sample sizes and HIV seroprevalence levels among pregnant women per sentinel surveillance site, Cameroon, 1992-96.
*1996 data was provided after the closure of the sentinel project by the AIDSCAP/Cameroon Office and is not reflected in the Final Report on Sentinel Surveillance. The HIV sentinel surveillance system has monitored trends indicating changes in the occurrence of HIV infection in Cameroon. The results of sentinel surveillance have permitted estimation of the level of infection in the general population. They also have permitted the National AIDS Control Program to reinforce control measures especially with respect to information, education and communication. In Cameroon, the HIV sentinel surveillance system provides regular data on the prevalence of HIV infection among pregnant women. Even though the six sentinel sites were not randomly selected, they provide very useful information, leading to estimation of the trend of HIV prevalence in the general population. Based on an unadjusted analysis, the surveillance data show an increase of HIV infection from 3.4 percent in 1992 to 5.9 percent in 1995 and 1996 in pregnant women in urban areas. The trends between 1992 and 1996 can also be looked at by city, excluding Bertoua for which there is no data from 1992 or 1993. By city, Douala and Garoua show relatively stable infection levels; Yaoundé and Bamenda show a slight increasing trend, and Limbé shows a clearly increasing trend. It is certainly encouraging that Yaoundé and Douala, Cameroon's two largest cities, remain at relatively low infection levels: 2.7 percent in Yaoundé, 1995, and 4.5 percent in Douala, 1996. These levels are lower than three of the other cities under surveillance in Cameroon. These data cannot prove that prevention programs have been effective in these two cities. However, these data are certainly consistent with the hypothesis that the research and intervention programs in Yaoundé and Douala have contributed to keeping HIV infection at relatively low levels. Based on these data and the following assumptions, one can estimate the number of HIV-infected adults aged 15-49 in Cameroon as follows:
Project Management The project was managed jointly by the Director of Community Medicine, the head of the National AIDS Control Services, and the Head of the Epidemiology Section at the Ministry of Public Health. Financial management of the project was provided by the AIDSCAP/Cameroon Office. The main constraint for the project was the periodic lack of reagents. When the WHO/GPA technical assistance was phased out, the timely procurement of reagents suffered. Due to the lack of WHO procured reagents, more often than not, GTZ was the provider of reagents for the AIDSCAP sites. Lack of reagents is the reason why collected sera from several sites was not tested. Lessons Learned and Recommendations The HIV SSS in Cameroon is not yet sustainable. One would therefore suggest some form of solidarity fund from the present cost recovery system of some high turnover drugs. This will require some initial stock of drugs or reagents to be earmarked for SSS yearly activity. Feedback mechanisms should be developed and maintained: i.e. a newsletter should be regularly provided to decision makers and sentinel sites. More data should be gathered on infection levels in rural areas, either based on a survey or through the use of additional sentinel sites. If resources can be found, it would be useful to resume testing of men and women attending STI clinics. Given that infection levels are relatively stable in the major cities, it may be important to know whether HIV is similarly stable in high risk groups. Antibiotic Sensitivity Study
AIDSCAP supported a collaboration with the Centre Pasteur du Cameroun to study the sensitivity of Neisseria Gonorrhoeae to ten antibiotics commonly used in Cameroon. The results of the study were used to refine the national treatment guidelines, collect data to update the essential drug list, and to assist care givers in efficacious treatment of gonorrhea. The project was a collaborative effort between the National STD Control Unit within the Ministry of Health and the Centre Pasteur of Yaoundé and Garoua, with technical assistance provided by ITM, Antwerp. The primary objective of the study was to determine the in-vitro susceptibility of gonococcal isolates obtained from male patients who consulted for urethritis at primary health care centers. A total of 200 isolates were tested for their in-vitro susceptibility to the following 10 antibiotics: penicillin, tetracycline, co-trimoxazole, thiamphenicol, erythromycin, kanamycin, gentamycin, ofloxacin, spectinomycin and ceftriaxone. Fifty-nine percent of the isolates produced penicillinase. A high level of resistance was also detected for tetracycline, co-trimoxazole, kanamycin and gentamycin. The isolates were highly susceptible to the remaining five antibiotics. Erythromycin, ofloxacin and ceftriaxone are presently recommended by the MOH for the treatment of uncomplicated gonococcal infection. From these results, it is important to note the necessity of evaluating drugs periodically to ensure that N. Gonorrhoeae has not developed a drug resistance. This is especially important for drugs recommended in national treatment guidelines to ensure that (1) recommended drugs are still effective, (2) treatment guidelines are updated and, (3) effective drugs are added to the essential drug list. GTZ is in the process of funding a similar study in their geographic target areas. Support to IRESCO Background and Scope of the Intervention In the early stages of AIDSCAP Program, operations research and evaluation were build into each subproject. Most programs or institutions, however, do not have the capability to conduct quantitative and qualitative research, and the subprojects had to rely heavily on outside consultants. In 1994, for the mid-term evaluations, IRESCO staff were hired as consultants to provide evaluation expertise to the AIDSCAP subprojects. In 1996, IRESCO as an institution was awarded a contract to conduct the End of Project evaluations and report writing. The Institut de Recherche et des Etudes de Comportement (IRESCO) is a nongovernmental organization (NGO) created in 1993 by a group of multidisciplinary researchers, with a combined experience in social sciences, demography, education and psychology. Its principal are as of research and expertise are: evaluation of intervention projects, qualitative and quantitative research, and marketing studies. Since its inception, IRESCO has conducted baseline studies, KABP surveys, evaluation of health projects, a study of the impact of interventions, and Focus Group Discussions for the development of BCC materials. The institute has provided in-country technical assistance to a number of international organizations in Cameroon: PSI, CARE, UNICEF, Save the Children, the French Cooperation, GTZ, AIDSCAP and the US Peace Corps. Staff members have also provided inter-regional technical assistance to other Francophone countries, among them Senegal, Burkina Faso, the Central African Republic and Rwanda. Results In March 1996, IRESCO, through a Letter of Agreement, was awarded a contract to conduct the End of Project evaluation and report writing for the AIDSCAP/Cameroon Program. Under this agreement IRESCO conducted quantitative and qualitative research among the selected target populations: military, CSW and students. After the analysis of the quantitative date, IRESCO developed focus group discussion guides for members of each target group. The focus of the FGDs was on changes in sexual behavior since the beginning of the AIDSCAP intervention. IRESCO also provided technical assistance to CARE and Save the Children with their end of project evaluations. Their survey and final reports on each target group summarize the findings of their research and compared the results with finding from the baseline studies. Parts of their findings can be found throughout this report. IRESCO also provided assistance in writing the French version of the Country Report and assisted with the Lessons Learned Workshop organized in September 1996 in Kribi. Capacity Building The AIDSCAP program contributed to the capacity building of IRESCO staff members through technical assistance and formal hands-on training for its research staff. In June 1996, a four-day workshop was held for IRESCO and Peace Corps staff in Ethnograph, a software program to analyze qualitative data. During the workshop participants learned the advantages and disadvantages of using computer software for qualitative data analysis, the Ethnograph program, and gained hands-on experience with the computer-assisted analysis of focus group discussions and key informant interviews. |
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