Final Report for the AIDSCAP Program in Cameroon: Executive Summary

Table of Contents

Executive Summary (See Below)

I. Background and Country Context

II. Country Program Description

• Part 1
• Part 2

III. Lessons Learned

IV. Subproject Highlights

• Part 1
• Part 2

V. Attachments

Glossary of Acronyms

Executive Summary

The AIDSCAP program in Cameroon was designed in October 1992 to address unmet needs in HIV prevention. Available HIV prevalence information in 1992 indicated that Cameroon still had a relatively low HIV prevalence rate, estimated between 0.5 percent and one percent of the general population. However, surveillance studies suggested that the epidemic was increasing rapidly among specific populations within Cameroon, specifically, urban youth, commercial sex workers, STI patients, and the military. Building on the experience of two previous centrally funded USAID projects FHI/AIDSTECH and HAPA projects, the AIDSCAP program sought to expand the reach of prevention efforts to include additional target populations and geographic regions than were being reached through the National AIDS control program. Project activities started in 1993 and the program officially closed on September 30, 1996.

The program focused on improving behavior change communication for select targeted groups at higher risk of HIV and STIs, expanding condom availability and affordability through condom social marketing, and assisting the Ministry of Public Health to establish a national sexually transmitted disease (STD) control service. It was funded by the United States Agency for International Development (USAID) through a cooperative agreement with Family Health International (FHI).

AIDSCAP/Cameroon was housed within the National AIDS Control Program of the Ministry of Health and headed by a Resident Advisor. Its primary responsibility was to build the capacity of the National AIDS Control Service (NACS) to design, implement, evaluate, and sustain programs that prevent sexual transmission of HIV and STIs. The AIDSCAP program was implemented by government and nongovernmental agencies and operated at the national level and in geographically focused areas, and addressed specific components of the Medium Term Plan of the National AIDS Control Program. The AIDSCAP/Cameroon program actively collaborated with the World Health Organization (WHO) and the German Technical Cooperation (GTZ) on sentinel surveillance, and with GTZ on the development of national STI treatment guidelines and peer education activities. AIDSCAP's subcontractors, Population Services International (PSI) and the Institute of Tropical Medicine (ITM), Antwerp, were instrumental in implementing the Condom and STI strategies in Cameroon.

National interventions included the condom social marketing program implemented by PSI, and support to the Ministry of Public Health for the national sentinel surveillance program and the development of national STI treatment guidelines. Geographically focused activities included interventions with sex workers and their clients, STI patients, university students, military, youth, and truck drivers.

The AIDSCAP/Cameroon program focused on building capacity through three complementary and mutually reinforcing strategies: behavior change communication, condom promotion and STI prevention.

The following provides an overview of these strategic approaches:

BCC strategy

The AIDSCAP/Cameroon BCC strategy included peer health education, community-based outreach programs, the development and distribution of educational materials, and alternative media such as theater. The heart of the Cameroon Program was its pioneering behavior change interventions that have inspired the peer education models currently used around the world. Interventions with the military, university students, STI patients, sex workers and their clients were implemented by the NACS in collaboration with the ministries of defense, higher education and health. CARE/Canada and Save the Children, USA, two international NGOs, respectively implemented the in and out-of-school youth project and a community-based intervention project in the East and Far North Provinces of the country. The focus of the BCC interventions was on sustained adoption of risk reduction behavior, including promotion of abstinence for young adults, fidelity for couples, partner reduction, condom use, and treatment for STIs. The projects used multiple, reinforcing communication channels and IEC activities. Specific approaches included interpersonal counseling and educational techniques, such as formal education sessions, drama, informal chats and one-on-one counseling, and mass and traditional media. The projects also focused on building capacity for sustainability through training, and the development and production of peer health educator manuals for CSWs, the armed forces, youth and university students. Over the course of the four years, AIDSCAP/Cameroon trained over 2,000 peer educators and leaders, who in turn educated more than 700,000 women, men and youth about HIV/AIDS prevention. Over 1,180,000 educational materials that reinforced communication activities and behavior change were produced and distributed as well as radio and television spots.

Condom promotion

The BCC strategy was complemented and reinforced by the condom social marketing program. Condom programming, was implemented by AIDSCAP subcontractor, Population Services International (PSI). Under AIDSCAP, the condom social marketing program expanded countrywide to reach additional target group populations. As part of their strategy PSI established officially recognized and supervised distributors in all major urban centers using specific marketing techniques and advertising to cover all of Cameroon's ten provinces. Over 9,500 condom sales locations were established for Prudence condoms. The program also used peer educators, especially CSWs, to serve as condom sales agents in nontraditional venues while CSM sales staff supplied the more traditional commercial outlets. In Yaoundé alone, CSWs sold over three million condoms. A number of CSWs were so successful as condom sales agents, that they were able to leave the sex work profession. Over the life of the AIDSCAP project, the social marketing program sold over 24 million condoms and distributed close to a million for free.

STI prevention

At the initiation of the AIDSCAP/Cameroon project, no national STI control program existed. AIDSCAP/Cameroon efforts led by an AIDSCAP subcontractor, the Institute of Tropical Medicine (ITM), concentrated on supporting the NACP in the development of national STI guidelines. As a result of these efforts, a national STI control plan and standard diagnosis and treatment guidelines were adopted by the Ministry of Health. These guidelines were essential for effective and appropriate treatment of STIs as well as for promoting rational, cost-effective use of antibiotics. As part of this initiative, AIDSCAP supported a collaborative study with the Centre Pasteur du Cameroun to investigate the sensitivity of N. Gonorrhoeae to ten antibiotics commonly used in Cameroon. The results of the study were used to validate the proposed treatment guidelines and to assist care givers in efficacious treatment of gonorrhea. In the final year of the project, the treatment guidelines were adopted and approved by the Ministry of Health for use in their decentralized training program. At the central level, a core group of ten physicians/trainers were trained in their use, followed by a decentralized training for 40 military prescribers. In addition, a pilot study on prepackaged urethritis treatment (MSTOP) to improve access to STI treatment was completed and evaluated.

Capacity building

Over the four years, with assistance from AIDSCAP, governmental and nongovernmental agencies have strengthened their capacity to mobilize communities and individuals towards positive action in the fight against AIDS. Significant progress has been made in raising awareness about STIs and HIV/AIDS and creating a positive environment to support behavior change. Important technical and financial management skills for HIV prevention programming and implementation were transferred to the MOH and local NGOs. Over the life of the project significant accomplishments were achieved including:

• The capacity of the Ministry of Health to plan, manage, and evaluate comprehensive STI/HIV/AIDS programs was substantially increased;
• More than 700,000 men, women, and youth were educated about how to protect themselves from HIV/AIDS and STIs;
• Over 2 000 individuals working in professional and/or volunteer capacities were trained in the skills they need to sustain HIV prevention activities in their communities;
• Close to 25 million condoms were distributed, all but a million were sold through the condom social marketing system;
• Over 1 million educational and promotional materials that reinforce behavior change communication efforts and condom use were distributed; and
• National guidelines for STI diagnosis and treatment were developed and adopted by the Ministry of Health.

The final country program evaluation was completed under a grant with IRESCO, a local research institute. IRESCO conducted the end-of-project knowledge, attitudes, beliefs, and practices surveys among all the target groups. Analysis of baseline and post intervention quantitative surveys data suggests that knowledge about HIV/AIDS increased significantly in all target groups and many of the target groups have adopted safer sexual behaviors such as increased condom use with a non regular partner, reduced number of partners and/or seeking treatment for STIs. Specific documented outcomes include:

• Knowledge of two correct methods of preventing HIV has increased among all the target groups. One of the most dramatic increases was evidenced among youth in the Eastern Province. In 1993 only 37 percent were able to cite two correct ways of AIDS prevention. By 1996, this had increased to 70 percent. In both male and female university students, the proportion of respondents able to cite two correct ways of preventing HIV increased from 79 and 84, respectively to 95 and 96 percent. Among clients of sex workers, knowledge of two correct HIV prevention methods increased from 50 percent in 1994 (unprompted) to 86 percent (prompted) in 1996. Knowledge about prevention methods also increased among sex workers from 40 percent (unprompted) in 1994 to 87 percent (prompted) in 1996.
• Reported safer sexual behavior related to condom use increased among several target groups. Of CSWs who report having ever used a condom, the proportion has risen steadily from 28.3 percent in 1988 to 65 percent in 1990, to 68 percent in 1994 and finally to 88 percent in 1996. The proportion of clients who report ever having used a condom also rose significantly from 55.5 percent in 1990 to 81 percent in 1996. Consistent condom use by CSWs with non-regular clients increased from 52 percent in 1994 to 75 percent in 1996 and 63 percent with regular clients. The proportion of CSW clients who report using condoms during their last sexual encounter with a non-regular partner increased from 54 percent in 1992 to 97 percent in 1996. Among female students the percent reporting having ever used a condom increased significantly from 56 percent in 1993 to 85 percent in 1996. The percentage of men in the military reporting consistent condom use during the past 30 days with CSWs increased from 48 percent in 1993 to 59 percent in 1996.
• Other risk reduction behaviors such as reduced number of partners were also evidenced in several target populations. The percent of male students reporting more than one sexual partner in the last three months dropped from 53 percent to 36 percent between 1993 and 1996. In 1993, 18.6 percent of male university students reported having had sexual relations with an occasional partner during the 30 days preceding the survey, and by 1996 this figure had decreased significantly to 9.4 percent. Between 1993 and 1996 the percentage of male members of the military reporting more than two sex partners in the past three months dropped significantly from 47 percent to 37 percent.
• STI treatment seeking behavior increased among several target groups. For example, the proportion of CSWs seeking STI care at a health care clinic went up from 34 percent in 1992 to 86 percent in 1996 and among their clients from 65 percent in 1992 to 84 percent in 1996. Among male university students in 1993, 72.6 percent reported seeking treatment for their most recent STI either at a health center, with a nurse, doctor or pharmacist and in 1996 this rose significantly to 85.7 percent.

There were many lessons learned from the AIDSCAP interventions. Specific lessons learned and recommendations are described in detail under the Lessons Learned and Project Highlights' sections. Seven lessons learned are highlighted as major lessons learned from the overall project.

• Informal educational "chats" about relevant sexual issues and personal experiences with HIV/AIDS were an effective way to support behavior change among CSWs.
• Drama is a practical and accepted medium to reach people in bars and beer houses with educational messages.
• Prevention efforts should include "regular" partners of sex workers.
• Peer education projects need to explore innovative ways to motivate their volunteers.
• Involvement of political and religious leaders in decision-making is crucial in breaking cultural and religious barriers to AIDS prevention.
• Continued subsidizing of condoms is critical to achieve sustainable behavior change, ..... and
• Serious consideration should be given to subsidizing STI drugs as well.