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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 II. Country Program Description A. Introduction The AIDSCAP program was implemented in January 1993 and funded by the United States Agency for International Development (USAID) through a cooperative agreement with Family Health International. The long-term goal of the program was to stabilize the rate of sexually transmitted HIV infection in Cameroon. To reach the long-term goal, the program aimed to strengthen the capacity of Cameroonian institutions to improve STI/HIV risk reduction behavior in targeted populations in selected urban areas. (The LogFrame, which summarizes the AIDSCAP/Cameroon project design, is in Attachment D.) The AIDSCAP/Cameroon program built on the experiences and lessons learned from the centrally-funded AIDSTECH and HAPA programs. These two programs provided management and technical assistance in the implementation of education and counseling programs, condom promotion and distribution, STI treatment targeted at high risk groups, sentinel surveillance, and technical and financial assistance to ensure the safety and quality of the blood supply. Information available at the time of the project design indicated that Cameroon had a relative low HIV prevalence, estimated between 0.5 and one percent of the adult population. Surveillance studies indicated however that the epidemic was steadily increasing among many different populations within Cameroon, particularly among the urban young, commercial sex workers, STI patients, and the military. The AIDSCAP/Cameroon Strategic Plan was designed in collaboration with the AIDS Control Unit of the Ministry of Health specifically to address the unmet prevention needs within the country. The program targeted commercial sex workers and their clients, STI patients, the military, students and youth with a multifaceted, mutually reinforcing approach, focusing on the three major AIDSCAP strategies of communication for behavior change, condom programming, and upgrading of STI services. These three primary strategies were supported by AIDSCAP's efforts in sentinel surveillance, policy development, capacity building, behavioral research and evaluation. The program was designed to operate both at the national level and in geographically focused areas, and addressed in large part the components of the medium term plan of the national AIDS control program. The program designed for four years, from January 1993 through September 1996, was implemented by the National AIDS Control Service of the Ministry of Public Health, in collaboration with the ministries of Higher Education and Defense, as well as international and local NGOs. In addition, CARE International was awarded a three-year grant under the AIDSCAP competitive PVO Grants Program funded under the core cooperative agreement to work with in- and out-of-school youth in the East Province. National interventions included the condom social marketing program implemented by PSI, support to the National AIDS Control Service for the sentinel surveillance program and the development of national STI treatment guidelines. Local activities focused on urban and commercial sites in the francophone provinces (support to the anglophone provinces was provided by GTZ) of Cameroon. Projects in these sites focused on behavior change through peer education on university campuses, military bases, hotel, bars, brothels, and STI clinics. The Far North and East Provinces also targeted youth. The program collaborated with other international donors including GTZ and WHO. Implementation of activities as planned was constrained by the closure of the USAID/Cameroon Mission in the summer of 1994. This untimely closure jeopardized the continuation of the AIDSCAP program. However, with funding from the Africa Bureau, projects which were initiated prior to January 1994 were allowed and able to continue, albeit with somewhat reduced levels of funding. The subsequent sections of this report provide a summary of the accomplishments, results and lessons learned from the project interventions collectively and individually. In addition the report reviews the capacities strengthened of local institutions to implement and evaluate HIV prevention projects. The Minister of Public Health during his opening speech at the Lessons Learned and Information Dissemination Workshop held in Kribi in September 1996, confirmed that AIDSCAP/Cameroon has played a significant role in slowing the transmission of HIV through its behavior change interventions: "considering the evolution of the AIDS epidemic in our country, I can positively assure you here, that the epidemiological situation of this scourge would be disastrous in Cameroon if it had not been for the multifaceted interventions by AIDSCAP." During its 4-year program, ten subprojects were completed, four with the Ministry of Public Health in collaboration with the Ministries of Education and Defense, and six in concert with international and local NGOs or institutions. AIDSCAP contributed to the strengthening of local capacity and institution building through training and seminars; and through technical support and financial contributions to the NACP, indigenous NGOs involved in care and support of HIV infected persons; evaluation and research. The AIDSCAP Cameroon program, using a three-pronged strategy of behavior change communications, condom promotion and STI control, implemented multidimensional, multilevel interventions both targeting specific high-risk groups and the population at large. To bring effective behavior change messages to members of groups at high-risk for infection, the program relied heavily on the time-tested model of the "peer education". Interventions with high-risk groups used a combination of mutually reinforcing messages and approaches to encourage individual adoption of safer sexual behaviors and at the same time building within the community a supportive environment to reinforce behavior changes. The AIDSCAP program also constituted the larger part of the Ministry of Health's national AIDS control program and was physically housed within the National AIDS Control Service. 1. Behavior Change Communication The behavior change and communication strategy in Cameroon was designed to change behavioral norms that support the adoption of low risk behaviors. It focused on promoting risk reducing behaviors, including promotion of abstinence for young adults, fidelity for couples, partner reduction, condom use, and promotion of health care seeking behavior for STIs to reduce the risk of HIV infection. Interventions programs among youth, students, military, CSWs, their clients and bar patrons, were carefully planned using multiple, reinforcing communication channels and IEC activities to reach the target populations in selected geographic areas. The behavior change communication strategy in Cameroon focused on:
Training Training was the first step in the comprehensive behavior change approach in each one of the subprojects. In July 1993, with technical assistance from PATH, an AIDSCAP subcontractor, a Training of Trainers workshop was held for Ministry of Health and NGO trainers, and AIDSCAP/Cameroon staff resulting in a core group of 10 master trainers. A Training of Trainers Manual, especially developed for the AIDSCAP Cameroon Program provided support to the core group of trainers. The core group of master trainers in turn designed and delivered training for project staff and peer educators through out the four years of the project. Peer educators and leaders were identified and recruited from among each of the target populations -- students, CSWs, military and youth. Peer educators and leaders were trained together with MOH project supervisors, field coordinators and medical staff. Furthermore, on the job and retraining was a regular feature of the program. Week-long training sessions were held for peer educators and leaders, using the locally adapted -- specific for each target group -- peer educator manuals (i.e. CSW, students, and military). Peer educators and leaders participated in refresher training courses every six months. All training sessions were participatory and experiential and based on adult learning theory. Role plays and case studies were frequently used in the training to provide peer educators with "real life situations" in order to practice skills and apply knowledge and attitudes in a safe learning environment. The project trained more peer educators and leaders than required in order to account for "dropouts". There was little turnover among the field coordinators, however, peer educator burnout and turnover was relatively high over the life of the project. For example 400 military leaders were trained to ensure that the required 220 were available for the regular scheduled educational sessions. Among the CSWs, 200 leaders were trained to ensure that 144 were always available to provide the weekly formal education sessions in addition to informal contacts with their peers. Health personnel in the military, university health clinics and STI clinics were trained in STI treatment, referral and condom promotion: eighty-one university and military physicians and nurses in Yaoundé and Douala received training in syndromic management of urethritis in the context of the MSTOP project. After the official adoption of the national STI treatment guidelines in March 1996, ten physicians were trained as master trainers. In July 1996, these master trainers conducted the first decentralized training of 40 military providers in Bafoussam. Table 2 : Number of peer educators/leaders trained.
Interpersonal Communications
Peer education and community-based outreach programs were the foundation for the behavioral change component. The program identified and trained peer leaders who worked with their peers and in their communities to encourage and support changes in high risk behavior. Recruitment criteria for peer educators included: being able and willing to talk freely in front of peers during formal and informal sessions; being available at odd hours; being well accepted by their peers, and willing to work for few incentives. Once trained, pairs of peer leaders and community outreach workers held regular educational sessions among their peers or in their community following a pre-established workplan. Depending on the target group, sessions were held in hotels, bars, beer houses, STI and health clinics, at university campus gatherings, schools, youth clubs and military bases. Peer educators were provided with specially designed and culturally appropriate materials for use in their educational sessions. Each pair of peer educators, after successfully completing the training course, was supplied with a bag containing the peer educator manual, condoms, artificial penis, leaflets, flipchart and a photo album. Peer educators used the Peer Educator Manual as a reference when confronted with difficult questions, or when in need of additional information. All sessions included a demonstration of correct condom use using the artificial penis. The flipchart "Emma Says" modeled "safer sex" conversations women could have with their partners and STI treatment seeking behavior. The photo album was very popular, developed under AIDSTECH, it is a collection of pictures of people with venereal diseases, Karposi Sarcoma, and AIDS. Each educational session dealt with a specific topic: STIs, the difference between HIV and AIDS, abstinence and fidelity, condom use and negotiation etc. Educational sessions were participatory, the audience was invited to ask questions and share their experiences. Field Coordinators and Program Managers attended selected educational sessions to provide additional support, supervision and feed back to the peer educators. Peer Educators maintained a log of the number of participants present at each session. They also recorded any questions they felt they could not answer for referral to their supervisor or a medical authority. Peer educators met monthly with their supervisors and/or project coordinators to discuss and share problems and solutions. They also discussed how to answer difficult questions and respond to complex situations. These group sessions provided peer educators and leaders an opportunity to share ideas and assist their fellow educators in finding solutions. Table no. 3 summarizes the number of educational sessions held and number of people reached over the life of the projects. Table 3 : Number of Educational Sessions held and people reached by target group
* These numbers do not include people reached through one-on-one counseling or mass media.
Although group educational sessions constituted the main venue for educational activities, individual contacts were equally, if not more important, for actual behavior change in most target groups. Informal educational sessions also known as one-on-one and small group sessions or "chats" were held in addition to formal sessions. This gave members of each target population a chance to discuss or ask questions they may have felt uncomfortable raising in a public setting. For example, these chats might include personal experiences with STIs and HIV/AIDS. The chats also gave peers an opportunity to provide additional information about STIs and their symptoms, where to go for treatment, testing, and how to cope with anxiety about HIV infection or AIDS. For example in the month of June (1996), over 10,000 informal contacts were made, respectively 8,593, 1,824 and 845, for CSWs, students and military. From key informant interviews conducted for the study, BCC experiences from the field in Cameroon, we learned that informal educational "chats" about relevant sexual issues and personal experiences with HIV/AIDS were an effective way to support behavior change among CSWs. The projects included a variety of interpersonal peer education and discussion techniques. According to the program managers, the most successful interventions involved "chats". "We decided to base our communication action on educative chats. The reason is that they enable us to have some feedback each time we have contact with the client. In so doing, we are able to determine each time whether our message went across." -- CSW/Maroua. "They have learned a lot to protect themselves and to know all of the situations that may expose them to risk and how to deal with such situations. There was even a time when we talked, had chats about the way a CSW should act in bed with her client. They were very enriching experiences for the CSWs. After such chats, we felt that there was really good reason to believe that CSWs could change." -- CSW/Yaoundé. CSWs, with a higher overall HIV/AIDS prevalence than other population groups, had more frequent personal encounters with death and illness caused by HIV infection. This close personal association served as a strong motivation for sustained behavior change. The chats offered opportunities to discuss these personal experiences, risk perception and to reinforce behavior change messages. Several project managers reported a direct relationship between personal experience and behavior change. "What helped us is that many CSWs who refused to understand our message at first, who said we should go to hell with our messages got infected with AIDS a little while later and died in front of their friends and these friends who are our leaders with whom we work came and told us... they have also seen many of their friends die of AIDS before their eyes. That is why many of them have changed." -- CSW/Yaoundé.
Drama and Mass Media Drama and theater, radio, TV, and video played an important role and were seen as highly successful in the university community, youth, and commercial sex workers projects. Furthermore when asked to comment on the most influential and successful media, program managers consistently mentioned photo albums, and folk and mass media such as theater performances and radio programs. Traditionally, oral communication and expression is highly regarded in Africa and Cameroon is no exception. Drama performances and skits grew naturally during the eight years of interventions with the CSWs. Starting with the original intervention by FHI in 1987 with private funds and expanded under the AIDSTECH project, role playing during training for peer educators gradually was transformed into the spontaneous creation of skits and performances by the CSWs. Project managers quickly capitalized on these natural talents to create several theater groups in Yaoundé and Douala. Two of these groups, one called "Les amies de Prudence" supported by PSI and WHO and the other "Les amies de Rose et Douglas" supported by AIDSTECH/AIDSCAP and GTZ, went on to tour the country giving performances from beer houses to urban theaters and international audiences at conferences on HIV/AIDS and STIs. In 1995, Editions Clé, Cameroon, with support from GTZ and AIDSCAP, published a collection of short skits in book form called "Le Sida au Village" for the 1995 World AIDS Day, featuring such famous skits as "Marriage avec le condom", "le Sida au village", and "Adieu l'ignorance." "Marriage with the condom" was also produced on video cassette with funds from USAID and WHO. The video was broadcast on National TV for World AIDS Day in 1993 with support from PSI. Finally, in 1995, with funding from WHO, Population Services International documented most of the repertoire of "Les amies de Rose et Douglas" on video.
Radio and to a lesser extent, television were used to reach both specific target groups and the population at large. Educational messages targeting the armed forces were aired through a regular military radio program, while university students were reached through slightly provocative and appealing TV spots with lively background music, but invariably ending on a more sobering note about the dangers of STIs or HIV. One of the Lessons Learned over the years was that theater is a more effective way of communicating messages and getting patrons attention in otherwise noisy and loud bars and beer houses, than the more formal education sessions. After each skit, the actors and other CSWs would mingle with the public, talk to individuals, answer questions and sell "Prudence" condoms. Educational Messages and Materials Culturally appropriate educational messages and materials played a large part in the comprehensive behavior change approach used in the Cameroon program. In the early stages of the AIDSCAP program, international and local IEC experts provided technical assistance in the development of educational messages and materials. Information provided by the initial KAP surveys and Focus Group Discussions helped to define the content of appropriate messages and type of communication channel or media to be used for delivering such messages. Through use and strengthening of local communication, assessment and evaluation skills, a variety of messages were developed and diffused through appropriate communications channels for each target group.
Creative approaches were used to penetrate the student population and maintain their interest over time. The cyclical transience of the student population required that program managers use a variety of approaches to reach out to students who are at different stages along a continuum of behavior change. From the start of the program, students were involved in designing messages and slogans. For example, a contest was held for the best drawings and slogans expressing the way they perceived the STI/AIDS problem. Winning drawings and slogans were used for posters and messages. One of the more original and better received ideas was when students were asked to write slogans for campus bus tickets. When a student bought his ticket there was a prevention message on it that changed according to the color of the ticket and the day it was bought. The most frequently used materials during the educational sessions were print materials, which may reflect the relatively low cost and ease of using these tools. Video and drama, which are more interesting to the audiences, were logistically more complex and required transportation and equipment. Interestingly, while brochures and strip cartoons were used most often, they were also cited by some as the least effective materials. One informant suggests, these methods may not be very effective with this population because of low literacy rates. " ....at times after an explanation session you find that the same handout you used has been crumpled and thrown aside. Maybe they thought handouts were not worth the pain in comparison to photo albums and condoms" -- Military/Ebolowa. However, another informant looked from a different angle at the usefulness of brochures: "we use (brochures) because they related the history of the disease...in simple and straightforward language. They are distributed and the message is clear" -- Military/Garoua. Program managers recommended that future projects include more radio programs to reach more people, explore more theater and drama opportunities, provide more outreach to remote areas and improve staff access to scientific literature. In addition, Program managers working with the CSWs, students and military audiences identified photo albums, containing graphic photographs of people with AIDS and people's genitals with STIs, as the most successful communication tool at their disposal. These albums, which were designed to arouse an emotional response from the various target audiences, used fear-inducing images to give rise to self-protective behaviors. After the albums were shared with the target audience, usually in small groups or one-on-one, the images were discussed with the peer educators. The use of graphic fear-based messages were reported to be the most influential and successful way to make an impact on behavior and attitude change in Cameroon. This contradicts the conventional wisdom which postulates that to use fear can be a detrimental and inappropriate approach.
Table 4 : Production and distribution of educational materials.
At the design phase of the AIDSCAP Program in Cameroon, epidemiological data indicated that STIs were a serious health problem in the country. Limited data on the extent of STI morbidity is gleaned from a selection of studies conducted in Yaoundé by local researchers and co-funded by USAID through FHI. In a study conducted among 200 women attending an antenatal clinic in Yaoundé in 1991/1992 the prevalence of STIs in low risk women was 16.2 percent. No ulcerations were reported in this study, but 10 percent of the women were seropositive for syphilis. In a study of 303 female sex workers in Yaoundé, 36 percent were TPHA positive, indicating past or present syphilis. Respectively 15 percent and 27 percent had Trichomoniasis and Candidiasis and three percent were diagnosed with endocervical gonorrhea upon admission. More than one third (39 percent) of the women had one or more gonococcal infections during 12 months of follow-up. The most common STIs diagnosed among 1,161 male and female patients attending the main STI clinic in Yaoundé, were urethritis (41 percent), secondary syphilis (28 percent) and genital ulcers (9 percent). HIV infection among this group was still low (2.41 percent) in 1990 compared to findings from other countries in the region. At the time of the design of the AIDSCAP/Cameroon Program, there was no national STI control program in Cameroon and many of the existing health structures were weak in STI case management. Therefore standardized STI case management, including diagnosis and treatment guidelines, was a priority for the successful implementation of the program. The AIDSCAP STI control and prevention program in Cameroon had four components: (1) the development of a national STI plan and standard diagnosis and treatment guidelines, (2) an assessment of gonococcal resistance to antibiotics, (3) the completion and evaluation of the pilot project of prepackaged STI treatment, and (4) training of health care personnel in standard treatment guidelines. Development of National STI treatment guidelines The development of national STI treatment guidelines consisted of two main components: (1) the development and adoption of standard treatment guidelines, and (2) a sensitivity study of commonly used antibiotics. Under the STI component, AIDSCAP/Cameroon efforts were led by an AIDSCAP subcontractor, the Institute of Tropical Medicine (ITM), and concentrated on supporting the National AIDS Control Unit, and later the newly created STI unit, in the development of national STI guidelines. Such guidelines are essential for effective, appropriate treatment of STIs as well as for promoting rational, cost-effective use of antibiotics. A series of meetings and workshops were organized with STI specialists, medical authorities, decision makers, and other medical personnel in ongoing efforts to improve STI case management. In July 1993, a first meeting was held in Kribi to start the work on the development of national STI guidelines. This was followed by a consensus meeting in February 1994 and the pretesting of the proposed algorithms in six cities of Cameroon. The pretesting of the algorithms was completed in December 1994, but it was not until March 1996 that the national algorithms were officially adopted by the Ministry of Public Health. In June of 1996, the training of trainers workshop was held to train a core group of physicians at the central level. The first and only decentralized training for providers prior to the end of the AIDSCAP program was held in Bafoussam in July 1996 for 40 military health care staff. Unfortunately, with the long process to have the national treatment guidelines adapted, the decentralized trainings scheduled which were to be held in each intervention site/city of the AIDSCAP program did not take place before the end of the AIDSCAP Program. Because the trainings did not take place within the scheduled timeframe, PI6 & PI7 evaluation could not be carried out. Nonetheless, by the end of the AIDSCAP program, despite the obstacles and constraints, a national STI unit had been created, national treatment guidelines were approved by the Ministry of Public Health and a core group of trainers is available within the existing health infrastructure. The integration of the project in the Ministry of Health and the continued funding by GTZ in Cameroon should ensure the sustainability of the efforts achieved so far. Additionally, the country program worked successfully to facilitate the introduction of the antibiotic Rocephine on the list of essential drugs in Cameroon.
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. MSTOP : Sales of Prepackaged STD Treatment for Urethritis Results from the 1991 baseline study for social marketing of STI treatment commissioned by AIDSTECH, confirmed anecdotal evidence that when Cameroon men suffer from STIs the level of self-treatment is very high (close to half). Researchers from OCEAC (Organization for the Coordination for the control of endemic Diseases in Central Africa) and the Institut Pasteur interviewed men as they left pharmacies in Yaoundé and Douala. Of those that had urethritis during the past month, 43 percent had not consulted a physician, or other health provider. "Everybody is a prescriber, from the older brother to the friend passing along his own experience to non-medical personnel in medical institutions", the authors wrote. The researchers' findings also pointed to the need for standardized treatment. Therefore, Cameroon seemed an ideal site for a pilot project, which would offer over-the-counter prepackaged therapy for male urethritis, a common complaint with recognizable, annoying symptoms that prompt patients to seek treatment. In collaboration with the Ministry of Public Health, AIDSCAP and PSI launched an innovative STI prevention program to increase the availability of effective STI treatment regimens. The objective of the project was to improve case management of men (and their partners) presenting with urethritis. In addition to the treatment regimens, the kit contained an educational brochure, detailed instructions on how to take the medication, two referral cards for diagnosis and treatment of sexual partners, and eight "Prudence" condoms. The launch of the MSTOP kit was preceded by pretesting of various packages and logos, the selection of the most appropriate antibiotics for the treatment of Chlamydia and gonorrhea and a three-month trial to assess the effectiveness and appropriateness of the MSTOP kit at two health centers. By the time all the necessary preliminary studies and consultations had been completed, officials at the Ministry of Health had changed, and the original plan of selling MSTOP without prescription in pharmacies and health centers had to be revised. Instead, in March 1993 government officials approved the sale of kits by prescription only in 21 health facilities in Yaoundé and Douala that primarily served university students and the military and in three private pharmacies near the university campus. Just over 1,400 kits were sold during the 10-month pilot intervention. Lower than expected sales were caused by 1) the relatively high price of the kit, 2) low acceptance of the product by health care providers, 3) lack of public awareness of the existence of the intervention, and 4) constraints such as the unexpected closure of some of the participating health centers. Over half of the 81 health care providers who had received training in syndromic management of urethritis and the methodology of the project did not prescribe MSTOP to their patients. The reasons given for not prescribing MSTOP included a lack of confidence in the efficacy of the antibiotics in the kit and the belief that STI drugs should not be prescribed without laboratory diagnosis. Providers also complained that they did not receive the kind of incentives for prescribing MSTOP, such as wall calendars, posters, pens, that pharmaceutical companies give with other drugs. In contrast with the prescribes' attitude, more than 86 percent of the patients who bought the kit said they were satisfied with it. Reported treatment compliance was 96 percent for the single dose cefuroxine axetil and 82 percent for the 10-day course of doxycyline. Over half of the users notified sexual partners, and 84 percent of those who had sex during treatment used some or all of the condoms in the kit. Unfortunately an expansion of the project was not supported by the MOH. The MSTOP project encountered many difficulties including a change in the Ministry of Health leadership, resistance from physicians and pharmacy associations, and the country's drug registration law, which precluded use of the cheapest and most effective drug. Project implementation obstacles included: the low acceptance of syndromic management by health care providers who are trained to make etiologic diagnosis and are reluctant to give it up; the lack of national STI treatment guidelines at the time of the pilot phase; no consensus on treatment of choice by participating parties; Cameroonian regulations not permitting the use of generic drugs, resulting in the relative high cost of the kit; and providers who were not associated with the research and development of the kit and therefore alienated from the start. Although the Cameroon project did not achieve the anticipated level of success, the rationale for marketing syndrome-elective kits for treatment and prevention remains valid. The various lessons learned from the MSTOP project include:
Despite the discontinuation of MSTOP in Cameroon after the pilot phase, the approach has generated a lot of interest in other countries and they can now find benefit by not repeating the same mistakes. The potential for socially marketed STI treatment and prevention delivery system remains good if (1) the kit is introduced in a country with a tradition of providing health care, including prescribing drugs, by non-physicians; (2) has a less heavily regulated pharmaceutical market, (3) gatekeepers feel an ownership of the project, and (4) national treatment guidelines and standard drug regimens have been approved and implemented. Improving health seeking behavior and STI referral was advocated throughout the AIDSCAP subprojects. In addition to training selected health care staff, the AIDSCAP subprojects reinforced health seeking behavior, STI referral and partner notification through its formal and informal educational programs held within its target groups. KABP data collected at the end of the project shows improved treatment seeking behavior, which means that the accent put on referral of STI cases to health care facilities was successful. During focus group discussions with project managers, several reported that health seeking behavior had improved as a result of project interventions: "[This project...] enabled everybody to go to the hospital to see a specialist and have him diagnose and prescribe tests, and complete treatment that should be taken following the advice of the specialist." CSW/Y Other focus group discussions indicated that STI rates had decreased with increased knowledge and condom use: "Behavior change can only be measured indirectly through condom use and through rates of STDs measured in the university dispensaries. STDs fell from first on the list of diseases seen in dispensaries to now third." -- Students/N Less than 10 years ago, it was almost impossible to find a condom after hours in Yaoundé, and if they were available they were prohibitively expensive. Only a few highly paid sex workers could afford to buy them in the pharmacies. The standard of living for the average Cameroonian has gone down year after year, and it would have been very difficult to pay 500 to 1000 francs (1 to 2 dollars) and even more to buy a few condoms, a novelty at that time not known for its usage or usefulness. In 1989, with the AIDS epidemic on its front door, the government of Cameroon agreed to a pilot condom social marketing program. Population Services International (PSI), with assistance of AIDSTECH and other international donors, started one of its more successful CSM programs on the continent. They increased access to condoms by creating a network of regional condom wholesalers and teaming up with international nongovernmental organizations to distribute and sell condoms. The CSM project continued to be supported by AIDSCAP and expanded its services population and countrywide. Campaign activities included a targeted AIDS education and condom promotion campaign, including promotional activities, assistance to local wholesalers to put up advertising and point-of-purchase displays, and sponsorship of theater and AIDS discussion talk shows on six regional radio stations. The success of the CSM program can be measured by the increasing monthly and yearly condom sales figures. In Cameroon, "Prudence" is a household name. In all AIDSCAP/C intervention projects the promotion and correct use of condoms was an essential part of the behavior change strategy. Educational sessions always included the demonstration of correct condom use, using a locally made wooden penis. Condoms were promoted and sold by peer educators at a price of 50 francs for a packet of 4 "Prudence"condoms. Promotion of condoms at educational sessions throughout the AIDSCAP projects was responsible for the rapid growth of point-of-purchase outlets in localities where educational activities were implemented. For example, the university student project created 115 outlets that sold close to 500,000 condoms over the life of the project. The CSW peer educators became adept condom sales ladies, and a total of just over three million condoms were sold by CSWs in Yaoundé alone. A concerted effort between PSI and the AIDSCAP offices in Cameroon made this collaboration a real success. By August of 1996, PSI had sold over 32 million condoms in Cameroon. Condom sales increased steadily over the years and by 1996, more condoms were sold per month than in the first year of the program. The target of selling over 7.5 million condoms per year (.6 per capita) by the end of the project was reached by the end of 1995. The CSM distribution network consisted of 26 official distributors, working through 105 commercial wholesalers, supplying over 9,000 distribution outlets, ten NGOs wholesalers selling condoms within their projects, and six authorized pharmaceutical distributors serving pharmacies nationally. In several AIDSCAP intervention projects, a significant number of peer educators became effective condom sales persons. PSI worked in collaboration with the Youth project implemented by CARE International, an NGO wholesaler, to make condoms more accessible and affordable in the East Province, a large province with high infection rates and extreme poverty. Despite the success of the CSM program, there remain pockets of resistance to condom sales and utilization. If people are not using a condom for occasional sex acts, one of the reasons can probably be attributed to the price of the condom itself, which even at the subsidized price, is rather high for people in poor rural areas. In addition, it has been observed that the price of condoms increases in remote areas of the country, and a packet of 50 francs is being sold for 200 francs. Even in large urban cities, it has been found that the price of condoms increases with the hours of the night, and one hears statements such as "if I have to pay 150 to 200 francs for a packet of 4 condoms, then I rather drown my sorrows in alcohol, and as for the rest, we'll see". Quality of condoms is another problem often related to poor storage at the outlet-level, especially by street vendors, where condoms are exposed to heat, humidity and sun. Street vendors have been instructed to display an empty condom dispenser while keeping the actual condoms away from the elements. Poor quality condoms increase the risk of breakage and tearing, thereby discrediting the credibility and efficiency of the condom. |
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