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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
MSTOP : Social Marketing of Prepackaged STD Treatment for Urethritis
Background and Scope of the Intervention Results from the 1991 baseline study for social marketing of STD treatment commissioned by AIDSTECH, confirmed anecdotal evidence that when Cameroon men suffer from STDs 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. Management 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. The treatment kit contained 1 gram of cefuroxime-axetil (C-A) as a single dose and a 10-day course of doxycycline (Doxy), 200 mg/day. 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. PSI was responsible for supplying kits and monitoring sales. 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 STD 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.. 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 STD 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. Accomplishments In 10 months 1,421 kits were sold at 21 health settings and 3 private pharmacies serving primarily the military and student communities. 81 health care providers were trained in syndromic management. Results of end of project interviews with patients showed that 86 percent of patients receiving MSTOP were pleased with the product's presentation. 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 and a total of 44 percent used the referral cards to notify their partners. Lessons Learned 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 STD 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. Condom Social Marketing
Background and Scope of the Intervention Condom programming, a major strategy of the Cameroon Program, was implemented by AIDSCAP subcontractor, Population Services International (PSI). The PSI/Cameroon Social Marketing Program launched an affordable condom under the brand name "Prudence" in October 1989 with funding from US-based private foundations. During the first two years of operation, the CSM project received additional support from Family Health International's AIDSTECH project and the World Health Organization. AIDSTECH funding allowed PSI/Cameroon to purchase condom promotion and advertising materials, employ and train marketing and distribution staff, and expand their sales territory. WHO funding was used to expand drama performances by CSWs, and to support a second CSW theater group called: "Les Amies de Prudence". The strategy under the AIDSCAP-funded project was to expand the condom social marketing program to additional target group populations and expand the number of distributors and outlets to increase demand, increase sales and ultimately effectively prevent the transmission of HIV. As part of their strategy, PSI would establish officially recognized and supervised distributors in all major urban centers using specific marketing techniques and advertising in order to cover all of Cameroon's ten provinces. The purpose of the Cameroon Condom Social Marketing Project under AIDSCAP was to achieve a sustainable increase in condom use among high-risk groups in Cameroon. To achieve this purpose, the Cameroon CSM program was aimed at 1) increase sales of project condoms throughout the country; and 2) implement effective AIDS education and "Prudence" promotion campaigns directed at selected target groups. Principal Accomplishments With total "Prudence" sales exceeding thirty two million condoms since the project's inception in 1989, PSI's condom social marketing program is considered one of the more successful components of the USAID AIDS program in Cameroon. PSI's condom distribution program was at the center of the AIDSCAP program in Cameroon with over 24 million condoms sold over the life of AIDSCAP. Given the severe economic constraints of the average Cameroonian consumer, it is highly probable that "a condom bought is a condom used". This implies that the risk of STI/HIV infection was effectively reduced by the use of condoms in as many as twenty-four million sexual encounters. In addition to the condoms sold through the CSM program, over 800,000 "Prudence" condoms were given away during promotional campaigns and educational programs. In addition to the "Prudence" condom, PSI also sold a more "upscale" expensive condom under the brand name of PROMESSE through pharmacies. The highest proportion of all condom sales occurred in the major urban and commercial centers of the Littoral, Central and West Provinces. PSI/Cameroon created over 9,000 new outlets for condom distribution, 105 commercial wholesalers and 26 distributors (direct dealers), five each in the Central and Littoral province and two each in the remaining eight provinces. In addition to commercial distributors, PSI/Cameroon also distributed condoms through ten local and international NGOs who served as wholesalers. Both AIDSCAP and GTZ sold condoms through their projects. Sex workers served as condom sales agents to peers and clients, and became very adept at their new trade, selling over three million condoms in Yaoundé alone. To heighten public awareness of "Prudence Plus" (the condom was renamed in the 1994 promotional campaign) and PROMESSE condoms, PSI/Cameroon produced and distributed over one million promotional articles. These items included mugs, T-shirts, pens, caps, bags, condom samplers, stickers and inserts. The condom samplers, in particular, were an extremely successful promotional item. First produced in collaboration with the National AIDS Control Unit, the samplers contained, besides a condom, informational answers to some of the most frequently asked questions about AIDS. Due to high public demand, an additional 457,000 "Prudence Plus" samplers were produced with financial contributions from AIDSCAP, CARE, GTZ and the French Cooperation. Condom samplers were used throughout the AIDSCAP intervention projects to promote condom usage. PSI launched a major promotional campaign in 1994 called "Dix bonnes raisons" or "Ten Good Reasons". The basic educational objective was to encourage condom users to actually look at the condom use insert and improve condom negotiation skills. Special inserts were printed, each with one of ten reasons for using a condom. Consumers collected the inserts and presented them to local distributors for prizes. The insert also contained a coupon to be filled out by the user and entered into a prize drawing that was held on the national TV's "Tam-Tam Week-end" show. Special posters, TV spots and an adolescent call-in radio show were developed to support the campaign. PSI/Cameroon consistently and actively participated in planning and implementing activities for World AIDS Day, and the Cameroon National AIDS Week. For example, they assisted the NACS to have the video "Marriage with the condom" by the CSW theater group aired on national television on World AIDS Day in 1993. French television subsequently requested a copy of the video tape to be aired in France. In 1994, with funds from GTZ, they purchased the rights to air "More Time" on national TV and worked with the Ministry of Education to prepare and present a roundtable discussion following a showing at the Goethe Institute on World AIDS Day in 1994. In 1995, PSI/Cameroon and members from other subprojects participated in the World AIDS Day parades in Yaoundé and Douala. Capacity Building PSI/Cameroon trained its entire distribution network consisting of 26 distributors, 10 NGO wholesalers and 105 commercial wholesalers in proper condom storage, client follow-up, outlet creation and communication activities on HIV/AIDS and STIs. During promotional campaigns retailers were also trained in the correct use of condoms and on how to effectively handle frequently asked questions by consumers. Project Management During the AIDSCAP period PSI/C worked with a new legal advisor as well as tax and labor authorities to revise the project's structure in conformity with Cameroonian law. In addition, PSI/C systematized procurement management, undertook measures to reduce project costs, improved the accountability system, and reinforced the MIS tracking system. Formal job descriptions were created to enable local staff to become more accountable for their responsibilities. Staff received training in their respective fields: accounting, quality control and stock management, and warehouse procedures. The Commercial Director was given additional responsibilities over the course of the project and after the departure of the American Resident Advisor in 1995, became interim RA and was appointed PSI Country Representative in March 1996. PSI/Cameroon encountered major constraints in two areas: the funding and the legal environment. Prospects for additional funding remained bleak due to donor concerns about GOC accountability, and the closure of USAID. As a result, PSI/Cameroon was forced to lay off six staff members and increase the workload of the remaining staff. With respect to the legal environment, PSI/Cameroon was involved in a lawsuit with Groupe Santé, who sealed PSI's warehouse in late June 1994. Unable to access its commodities, the project experienced product stock-out which hurt sales and threatened the project's reputation. Eventually, with the help of a legal advisor and the Ministry of Public Health, the seal was removed and the case dismissed. Lessons Learned and Recommendations The number one lesson learned was that even a social marketing project must legally protect itself. The best protection, in addition to a government agreement, is strong governmental relations and good legal counsel. The subsidizing of condoms is critical and will remain so until there is significant improvement in the social-economic well-being of Cameroonians. Because of poor buying power of the average Cameroonian, sales revenues cannot fully support the supply of condoms and the necessary advertising and promotion. Social marketing is an extremely effective tool in promoting behavior change and condom use. Even if most Cameroonians are attracted by the low price of "Prudence Plus" condoms, 10 - 20 US cents, attractive packaging and promotion are also contributing to high sales. IEC and promotion campaigns remain the key to success in achieving behavior change and condom use.
*This number also includes all free condoms distributed by other AIDSCAP projects. Interventions with Commercial Sex Workers, Their Clients and STD Patients
Background and Scope of the Intervention The National AIDS Control Service has made significant strides to monitor and combat the AIDS epidemic through epidemiological surveillance, mass-media campaigns, and education and condom distribution interventions with high risk groups. FHI's AIDSTECH project and other international organizations collaborated with NACS to develop a model AIDS prevention program for high-risk groups in Cameroon in 1988-1992. The AIDSCAP project provided continuing support to the project and expanded it to six urban cities in Cameroon. A survey conducted in 1992 by AIDSTECH among CSWs in Yaoundé and Douala found that about half of the sex workers reported consistent condom use with their clients, and that three out of five clients reported using condoms in high risk situations in the 30 days prior to the survey. Half of the clients and about 40 percent of the CSWs could cite at least two correct ways of preventing HIV. Self-reported STI in the past three months was 10 and 12 percent, respectively, among CSWs and clients, and eight out of ten CSWs, and three out of four clients went to a medical facility for treatment. A 1992 seroprevalence survey conducted by the NACS and WHO found increased levels of HIV infection among CSWs in Yaoundé and Douala, respectively 25 and 45 percent, up significantly from 1989 rates of seven and ten percent, respectively. Chlamydia and HIV infection rates among a group of 168 CSWs in Yaoundé were respectively 38 and 7.1 percent. The purpose of the project was to change high-risk sexual behaviors that lead to HIV and STIs among CSWs, their clients and STI patients. Principal Accomplishments The sex worker community is not easy to identify especially since prostitution is not legal in the country. Nor is it easy to define who is and who is not a sex worker. CSWs in this project were identified at their meeting points: hotels, brothels, bars, streets and night clubs, in so called "hot neighborhoods;" and the men hanging around these places were presumed to be potential "clients." With assistance from AIDSCAP, the NACS assessed its current Peer Education program, including IEC materials, drama, educational presentations, and peer group networking components. Based on the needs identified in the assessment, existing materials were reproduced and new IEC materials and training curricula developed. Trainers and Field Coordinators were identified and trained. Over the four years, the project trained 200 peer educators and coordinators who conducted more than 5,000 formal educational sessions in community- and clinic-based settings to reach CSWs, their clients, bar patrons and STI patients in the six target cities: Douala, Yaoundé, Ebolowa, Kribi, Garoua and Maroua. In pairs of two, these women would hold weekly educational sessions in STI clinics and neighborhoods, bars, brothels, and "chicken houses", and other sites frequented by persons whose behavior puts them at a higher risk for HIV transmission. Close to 500,000 contacts were made by the CSWs through formal and informal education. CSWs also conducted educational sessions by special request:; for example, they were invited to conduct STI/HIV education sessions for prisoners, and conducted a total of 52 sessions at the Central Prison in Yaoundé. Sex workers sold condoms to peers and clients alike. Numerous sex workers became "expert" condom sales persons, and some did so well at selling condoms that they left the profession altogether. In Yaoundé alone, sex workers sold over three million condoms. Another 59,469 were distributed free as promotion. The other remarkable achievement of the project was the theatrical group, composed entirely of sex workers, putting a bit of "vaudeville art" into AIDS education. The scene: a bar frequented by CSWs and interested men: Dialogue between commercial sex workers and clients (all played by women) carries the play's messages: "marriage avec le condom" helps convince audiences to adopt safer sexual practices by playing out the issues that arise when condoms use is negotiated between a sex worker and client. The issues address individuals' self-interest and concern for family, friends, and partners. The audience of 150 to 200 persons listen to the humorous, explicit dialogue and use of props desensitizes the audience making it easier for peer educators to begin their work. After each performance, Les Amies work the audience, going from table to table, answering questions, and showing correct condom use on penis models. In addition the women sell "Prudence" condoms, the brand sold through PSI's social marketing program. To evaluate the results and impact of the activities, baseline and follow-up data was collected on knowledge, attitudes, beliefs and practices among the CSWs and their clients. Both quantitative and qualitative data was collected at each project site. At baseline 800 CSWs, 800 clients and 200 STI patients were interviewed, whereas at follow-up data was collected from 818 CSWs and 661 clients. Some of the results are summarized in the following table: Table 8: Summary of principal results
The follow-up survey has shown the impact of the project on certain behaviors and practices of CSWs and their clients. For example, the proportion of CSWs who reported ever having used a condom rose steadily from 28.3 percent in 1988 to 56 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 to 63 percent with regular clients. However, only 13 percent report condom use with their regular (non-client partners). Thus the degree of condom use seems to decline with sex partners the more they are known and "trusted". Obviously future interventions will need to focus more on condom use with regular partners. 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, but those reporting consistent condom use did not change. Project Management The project was managed jointly by the Director of Community Medicine, the head of the National AIDS Control Services, and the project manager. The project manager was assisted by 6 field coordinators and the AIDSCAP/Cameroon Office. During the implementation of the project, several constraints were encountered, notably the mobility and consequent high turnover of trained peer educators, who would leave either periodically or permanently for other cities. Another impediment was the level of education of CSWs, which was generally low, and therefore required more frequent and direct supervision of the activities by the field coordinators, which was not always possible given their caseload. Capacity Building The Peer Educator Guide developed under the project and the TOT manual developed in concert with the other projects are lasting educational training materials for future use. The CSW project worked very closely with the Condom Social Marketing Project implemented by PSI. Leaders became first class condom sales ladies and a few even became wholesalers. They were able to make a livelihood by selling condoms which enabled them to leave their previous profession. The theater group, "Les Amies de Rose et Douglas", started in the late eighties with the initial cast of peer educators, has seen many new faces under AIDSCAP,and continues to perform and is known all over Cameroon. The group benefited from repeated professional assistance to refine their acting. Lessons Learned and Recommendations Drama is an effective way for communication. Project managers and field coordinators agreed that drama is one of the better ways for reaching people in otherwise noisy and loud places such as bars and beer houses. Everybody is having a good time and no one wants to be bothered by formal education sessions in these places. It requires that the music be turned down and conversations have to stop. However, when the same messages are presented in a skit format with music, and at times supported by a DJ, people's attention naturally turns to the stage. Although consistent condom use with clients has risen significantly, condom use with "regular" partners is still low or nonexistent. Future interventions with CSWs will need to focus on the importance of using condoms with "regular" partners as well as with clients. Regular partners may be a source of STI and HIV infections and could account for repeat STIs in CSWs. Future projects would also benefit from research to determine who is and who is not considered a "regular" partner. Other Recommendations
Prevention of HIV/AIDS Among University Students in Cameroon
Background and Scope of the Intervention Seventy percent of Cameroon's AIDS cases are among the population aged 20 to 39. University students tend to be sexually active and engage in risk-inducing behavior including sexual experimentation and alcohol use. In 1992, STIs ranked first among the reasons students sought medical attention at the university health clinics, and HIV seroprevalence among student blood donors was 4 percent. Given a nationwide university population of 50,000 students aged 18 to 28, the National AIDS Control Program recognized the need to initiate AIDS prevention programs among this group and worked with the Ministry of Higher Education to implement a three year intervention within the University system, using the model AIDS prevention program developed under AIDSTECH. This three-year long project was designed to reduce STI/HIV risk-associated sexual behaviors among university students in Cameroon. The strategy included awareness and behavior change through peer education, better STI treatment seeking behavior to control STIs, and condom use and promotion. Principal Accomplishments A total of 278 students were trained and retrained to conduct health education sessions in basic sexuality, risk assessment, and risk reduction among their peers, emphasizing skills for negotiating condom use as well as proper use of condoms. Six coordinators were also trained. They worked in teams of two and conducted 3,621 educational sessions that reached over 55,000 students. The project developed four posters, one calendar and one brochure. A total of 66,418 pieces were distributed over the life of the project. In addition three radio and two TV spots were produced and broadcast on national radio and TV. Numerous special activities were held each year to commemorate World AIDS Day and the Cameroon AIDS week These activities included AIDS awareness marches, concerts, festivals, theater presentations and exhibits. Five resource centers were set up, one in each university city, staffed by a field coordinator, where students could go for additional information and documentation. The project also assisted the university system to improve basic STI services in its health centers by training 56 health care providers in Yaoundé and Douala (MSTOP) in the syndromic approach for diagnosis and treatment of urethritis. Project staff collaborated with PSI and established 115 condom sales outlets for students in and around campuses. Over 17,000 condoms were distributed free for promotion. Close to 500,000 condoms were sold through the project. Sales of condoms, in the opinion of field coordinators and program manager alike, was the most tangible indicator of behavior change. Other formal and informal indicators of behavior change suggest that the intervention has made progress among the students. STIs went from first to third place as the reason students sought medical treatment at the university health clinics. Other evidence provided through focus groups as project progress and success was summarized as follows: "There are unmistakable signs. For example, at the end of the academic year, student association leaders ask for brochures and other teaching materials to be taken and used in their villages over the holidays." Table 9: Evolution of behavior changes among university students.
Project Management During its execution the project was confronted with financial and technical constraints. The financial constraint was directly linked to the economic status of the country: student grants and stipends were cut drastically, therefore recruiting volunteers as peer educators was difficult without the benefit of some financial assistance. On the technical side, because of the delayed approval of the national treatment guidelines, the second STI training component for university medical staff was not conducted. Lessons Learned and Recommendations
Interventions with the Cameroon Armed Forces
Background and Scope of the Intervention The project was initiated in June 1993 by the Ministry of Public Health and the Ministry of Defense and National Security with funding from FHI/AIDSCAP. The project was executed in the context of the National AIDS Control Program, which, in collaboration with several international organizations, had developed several strategies to fight the spread of AIDS by conducting sentinel surveillance, awareness campaigns and specific interventions targeting high risk groups. A nationwide seroprevalence study conducted among military personnel in Cameroon in 1990 indicated 3.4 percent HIV and 30 percent syphilis seroprevalence levels. By June 1993, seroprevalence levels in the military had increased to over 6 percent. The purpose of the project was to change high-risk sexual behaviors that lead to HIV and STIs The outcomes of the project were to develop a core of "officers/health educators", improve STI case management, and to promote condoms in high-risk sexual situations. Principal Accomplishments Table 10: Evolution of behavior change and health seeking behavior.
The target population was the 50,000 men and women in uniform, respectively 80 and 20 percent of the armed forces, at 11 military bases in Cameroon. Results from the baseline survey conducted in the Spring of 1993 indicated that only 40 percent of the forces could explain adequately what the acronym "AIDS" stood for. Sixty three percent of the respondents cited condoms, and almost 50 percent cited abstinence as a prevention method, however, condoms were not used consistently in high risk situations. As for STI treatment, the preferred facility was the military health clinic located on the base. Seroprevalence in the same cohort was just over six percent and syphilis was five percent. Over the course of the three-year project, two military coordinators and 400 military officers were trained as volunteer health educators to teach and encourage appropriate risk-reduction behaviors among members of their assigned units. The military did not use the "true " Peer Educator Approach, but preferred the more hierarchical training system of the military, whereby the officer in charge of the unit was the health educator. An Educator Guide, specifically targeting military personnel, was developed for use by the officer-educators. These officer-educators conducted over 2,300 educational sessions attended by over 60,000 men and women in uniform. In addition 13,000 persons were reached, through small, informal "chats" and one-on-one discussions about HIV/AIDS, behavior change and condom use, in and around the military bases. Close to 16,000 poster and flyers, 250 training manuals, and 100 albums were distributed and two radio spots were aired during regular radio programs directed at military personnel. Although the military programs had a captive audience for AIDS prevention messages, comments made by military program managers raise concerns about the impact of these messages on behavior change. While educational efforts have increased the knowledge of the target audience, they may lack the ability to effectively move the target audiences beyond knowledge and into the higher levels of the behavior change continuum. Interventions with this group focused more on the delivery of information through classroom-type settings where participants are required to pass an exam at the end of the class, effectively reflecting the hierarchical nature of the military and also its approach to a problem, as stated by one: "... We don't need tricks. We are the military, we give orders- if you are chosen, no two ways about it." Despite these approaches, program managers doubted that the information given to the military in the class room would ever influence the military men to make positive changes in their behavior. "Will they ever change? Their behavior will never change completely. The military men seldom yields to influence: to be a good military man he has to be tough, resistant... " Over 7,000 condoms were distributed free as promotion, however, condom sales by health-educators were less than originally expected. There were several reasons for the limited sales of condoms: 1) Military men preferred to buy their condoms outside the garrisons, at outlets created by PSI. Again, soldiers may have been reluctant to buy condoms from their health educators, who were often their commanding officers. 2) Condom logistics and management were problematic, and military stores' staff were not properly trained in condom sales and marketing. The problem was exacerbated by the fact that bases are off-limits to civilians thereby prohibiting PSI staff and wholesalers to assist with logistics During focus groups with project managers and coordinators, condom sales and demand were cited as a reliable and accessible indicator of behavior change: "That people will pay 5 or 10 francs for a condom is a tangible means of assessing the impact of the project" -- Military/Garoua "as for practices, it is a bit tricky because you need to look at individual behavior. Although it cannot be stated categorically whether there has been some behavior change, there are means by which one can attempt it such as increased demand for condoms.... This is a behavior change indicator" -- Military/Ebolowa. STI training focused on the syndromic approach. As part of the MSTOP project, 25 military providers at the Yaoundé and Douala bases were trained in syndromic management of urethritis. In June 1996, after the adoption of the STI treatment guidelines, military physicians participated in the Training of Trainers workshop, and consequently trained 40 military providers in Bafoussam as part of the first decentralized training in STI case management. An important outcome of the project was the institutionalization of STI/HIV prevention training within the military training system. Through a "Note de Service No. 94000014/FC/MINDEF/025" (a decree) of March 7, 1994, the Ministry of Defense made teaching STI/HIV prevention an obligatory discipline in training courses and part of the exam for promotion in the Armed Forces. To measure the impact of the project on knowledge, attitudes and beliefs and practices of the target population, baseline and follow-up quantitative and qualitative research was conducted on a random sample of about one thousand military staff in 11 garrisons. Results from these surveys indicate that 90 percent of the military can identify two correct means to prevent AIDS. The proportion of the target population that had more than two partners in the previous three months had decreased from 47 percent in 1993 to 37 percent in 1996, and the proportion of the target population using self-medication for their last episode of an STI decreased from 8 to 6 percent. There was a notable increase in partner notification in case of STI, from 49 to 60 percent and treatment seeking behavior increased from 81 to 92 percent over the course of the three years. Almost everyone interviewed was sexually active (99 percent). The average number of sexual partners during the last six months was 2.6 versus three partners during the three months prior to the baseline survey. Project Management The project was executed under the leadership of the Director of the Department of Community Medicine representing the Ministry of Public Health, the Director of Military Health, representing the Ministry of Defense and National Security, and the Director of the National AIDS Control Program. The day to day activities were coordinated and implemented by the Field Coordinators with assistance from the AIDSCAP/Cameroon office. Management constraints included the frequent reassignment of trained Officer-Educators and insufficient coordination of activities at the respective sites/bases. Field coordinators often blamed insufficient coordination on financial constraints, such as lack of transport for the coordinators. On the technical side, the delayed approval of the national treatment guidelines influenced the training schedule, and only one training at the decentralized level in the use of treatment guidelines was conducted. Institutional strengthening To reinforce the capacity of the National AIDS control service and military health services, the Chief of the Military STD Services, participated in a two-week STD Managers Course held in Dakar, Senegal. Four military physicians were part of the TOT training in the use of standard treatment guidelines. In turn, they trained 40 first-level providers in Bafoussam. A training manual for health educators specifically targeting military personnel was developed during the project and available at the 11 military bases. This manual is also part of the regular military training curricula for initial and advanced training of military personnel. Lessons Learned and Recommendations Early involvement of military authorities is crucial for the sustainability of the project The early and continued involvement of military authorities paved the way for the institutionalization of the STI/HIV prevention training into the official training program for the military. By signing the official decree, the Ministry of Defense gave credibility to the intervention program, an action not lost on the average man and woman in uniform. In order to ensure continuation of the activities and to avoid overburdening "volunteer" staff, the project recommends:
Continue awareness raising through the use of radio messages developed under the project. This can be achieved at no cost and aired during the regular military radio programs.
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