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This report covers the FHI AIDS Control and Prevention (AIDSCAP) Project (1991-1997). Volume 1 covers regional program overviews, technical strategies, and program support strategies.
Volume 1 |
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| . | Cumulative |
| Total People Educated: | 14,527,377 |
| Total People Trained: | 97,283 |
| Total Condoms Distributed: | 86,629,096 |
| Free: | 14,720,555 |
| Sold: | 71,908,541 |
| Total Materials Distributed: | 7,923,451 |
| Process indicators are used to track measurable data in a subproject. People educated includes number of people attending educational sessions or contacted through AIDSCAP interventions. People trained includes number of people attending training of trainers sessions. Condoms distributed indicates condoms sold through condom social marketing programs and condoms distributed for free. Materials distributed includes behavior change, condom promotion, and HIV/STI educational materials such as posters, pamphlets, handbooks, tapes, newsletters, and comic books. | |
Community Strengthening
To strengthen communities' ability to prevent HIV/AIDS, AIDSCAP/FHI implemented activities like those in Tanzania, where sustainable nongovernmental organization (NGO) networks were established, and in Ethiopia, where focus site intervention teams of NGO, community, business, and governmental leaders coordinated their HIV/AIDS interventions.
In Tanzania, AIDSCAP/FHI stimulated and facilitated the formation of clusters of small, indigenous, community-based organizations in 9 of Tanzania's 20 far-flung administrative regions, covering more than half of Tanzania's population of 27 million. By binding together under an umbrella organization, the individual groups -- each with a prior, specialized interest in AIDS-related issues -- were able to design integrated, synergistic activities that more effectively delivered HIV/AIDS prevention and care services to their constituencies. The nine clusters have more than 100 NGO members. Each cluster has decentralized into at least two districts within its region, and together all the clusters cover a total of 20 out of 132 districts in Tanzania.
The participation of the clusters in national policy dialogue served to strengthen advocacy for policy changes in HIV/AIDS nationwide. Through regional policy sensitization workshops, senior government officials, including members of parliament and cabinet ministers, community and religious leaders, private sector entrepreneurs, and other key decision makers, were informed of the dangers of the HIV/AIDS epidemic and the need for community responsibility in effecting policy changes. More than 450 policymakers, government ministers, elected government officials, religious and community leaders, private sector business managers, and trade unionists were educated in STI/HIV/AIDS prevention and care needs to ensure their involvement in policymaking.
AIDSCAP interventions such as those described in the Tanzania example and the similar focus site project conducted with the Department of Health in Ethiopia helped reduce duplication of efforts, eliminate competition for support and clients, enhance the stature of participating organizations in their communities, and provide mutual support that reduced the burnout experienced by many programs that rely on volunteers.
Institutional Capacity Building
To strengthen institutional capacity to develop and mobilize prevention activities, AIDSCAP/FHI funded projects in five countries to foster and strengthen networking and resource-sharing among nascent STI/HIV/AIDS prevention groups, such as the Kenya AIDS NGO Consortium (KANCO).
KANCO established a national resource center for use by members and by other persons and organizations in Kenya with an interest in HIV/AIDS. The center provided prompt access to accurate AIDS-related information and fielded approximately 350 inquiries a month. The consortium also sponsored four regional workshops and one national workshop for representatives from a broad spectrum of community-based groups to identify HIV/AIDS-related issues of concern to their constituents. Three policy papers -- "Discrimination of Persons Infected with or Affected by HIV/AIDS," "Removing Stigma and Developing Appropriate IEC Strategies for STI Prevention and Control," and "HIV/AIDS Education for Kenyan Youth" -- were prepared and submitted to national policymakers. These papers were used by the Government of Kenya in developing a sessional paper on AIDS, which was approved by Parliament in September 1997. KANCO now has a membership of 360 NGOs and 8 individuals.
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Fassil Nebyeleul was a 21-year-old university student when AIDS claimed one of his best friends. The death shocked Fassil and his mates. They had never imagined that HIV could hit so close to home. But they knew the behavior that had led to their friend's death was no different from their own. "We decided that we were all HIV-positive and calculated out time of death as 4 or 5 years," Fassil said. "So we said, let us do something before our lives are gone." What they did was organize a group called Save Your Generation Association (SYGA) to warn others about HIV/AIDS. Each of the five founding members invited five friends to the first meeting, where they discussed preventing HIV transmission and urged new members to spread the word. From that original group, SYGA has grown into a registered Ethiopian NGO, with a paid staff of 14 and more than 6,000 dues-paying members. The founding members (who later learned that they were not HIV-positive) have expanded the organization's activities well beyond the university community. Most of their efforts are aimed at saving Ethiopia's lost youth -- the tens of thousands of school dropouts and other unemployed young people who are particularly vulnerable to HIV/AIDS. SYGA is one of the seven NGOs that received support from AIDSCAP/FHI over 3 years to bring HIV/AIDS prevention education to out-of-school youth in six urban areas. These projects enlisted the help of young volunteers and community organizations to inform and motivate a segment of the Ethiopian population that is difficult to reach and very much at risk. By the end of the AIDSCAP program in Ethiopia, SYGA had received grants from several other donors. Fassil remembers when donors shied away from supporting the group because they thought they were too young and inexperienced to manage grants. Now, because of the technical assistance the group received from AIDSCAP and other organizations, he believes SYGA is in a good position to attract additional funding to sustain its programs. |
Peer Education
To inform individuals about transmission, their personal risks, and strategies for prevention, AIDSCAP/FHI funded 45 peer education interventions in nine countries to promote AIDS information and behavior change. Typical interventions included the following:
- In Calabar, Nigeria, a group of CSWs (275) trained as peer health educators (PHEs), together with two senior PHEs, provided prevention information and advice to peers on condom use and recognizing their own STIs, as well as those of potential clients. STI rates plummeted as a result of the intervention. In addition, some women sold socially marketed condoms to their peers and others, retaining the profits as alternative income to commercial sex work. The network of PHEs has provided one-on-one HIV prevention sessions to 6,330 women and 7,609 men. Furthermore, the PHEs, working in pairs, conducted group educational sessions attended by 3,822 women and 1,054 men; an additional 10 people were educated by outreach workers.
- Employees of the National Railways of Zimbabwe formed peer educator groups throughout the railway network, which employs more than 12,000 persons and has potential access to 45,000 family members. The educators, at scheduled breaks during work hours, provided safer sex instruction, distributed free condoms, motivated peers to stay celibate during long absences from home, and, increasingly, provided home-based care to HIV-infected colleagues and grief and legal counseling to partners and families of deceased colleagues.
- In South Africa, AIDSCAP/FHI funded the national association of traditional healers to train members -- the first, and sometimes only, point of health care advice for most South Africans -- in providing HIV-transmission knowledge, counseling in prevention measures, recognizing signs and symptoms of possible HIV infection, and determining when to refer suspected HIV/AIDS cases to government health care facilities.
- A pilot project in Soweto, South Africa, assisted secondary school youth in developing information materials and safer sex brochures by using expressions and language appropriate to their peers. The trained peer educators made presentations, with the encouragement of school authorities, in schools throughout the community, and also served as informal information resources for their colleagues after school.
- Military personnel in Africa, as elsewhere, often have a high incidence of STIs, including HIV infection. AIDSCAP/FHI funded local agencies in Cameroon, Rwanda, and Zimbabwe to train military personnel to dispense HIV transmission and prevention information to peers, to promote STI treatment-seeking behavior, and to promote condom use among those unable to remain abstinent or monogamous.
- During of the 3-year AIDSCAP program in Cameroon, 2 military coordinators and 400 military officers were trained as volunteer health educators to teach and encourage appropriate risk-reduction behaviors among members of the units to which they were assigned. These officer-educators conducted 2,300 educational sessions attended by more than 60,000 male and female military personnel. Approximately 16,000 posters and flyers, 250 training manuals, and 100 albums were distributed; two radio spots directed at military personnel were aired during regular radio programs. More than 7,000 condoms were distributed free-of-charge as a promotion. In Rwanda, a similar subproject with the military resulted in the training of 384 PHEs and 84 health care service providers in the syndromic approach to STI management, the development of two posters and one comic book targeting the military, and the establishment of 40 condom distribution points. In addition, 16,600 behavior change communication (BCC) materials and 887,480 free-of-charge condoms were distributed.
- In Ngara, Tanzania, AIDSCAP/FHI funded CARE, Population Services International (PSI), and John Snow International (JSI) to establish a peer education and condom distribution network in the vast Rwandan refugee camps using AIDS community educators. Despite the turbulent camp life, the intervention conclusively demonstrated that if behavior change and STI prevention messages are carefully crafted and delivered by educators with their peers in mind and if condoms are widely available and accessible, a significant number of people will still embrace life-affirming measures to protect themselves and others. During the project, 4,550,000 condoms were distributed, more than 10,000 persons were counseled about STI/HIV, and more than 70,152 persons were reached with prevention messages. More than 1,900 existing health care workers were trained in new STI/HIV prevention skills and more than 1,000 community volunteers, scouts, and peer educators joined project activities. Prompted by CARE, HIV/AIDS strategy meetings with representatives of the United Nations High Commission on Refugees and the various NGOs working in the camps encouraged a common approach to implementing prevention activities across five camps.
Promoted Condom Use and Improved Access
In the absence of a vaccine for HIV or of affordable and accessible treatment in Africa for AIDS, prevention of infection was the major focus of AIDSCAP/FHI interventions in the region. In conjunction with BCC interventions that encouraged delayed start of sexual activity or fidelity and monogamy for those already sexually active, most AIDSCAP/FHI programs also made condoms more available, accessible, and affordable. As a result of the increasingly visible ravages of HIV/AIDS infections spread, as well as enhanced awareness (promoted, in part, by other AIDSCAP/FHI support interventions), impressive numbers of populations in many countries across the region adopted condom use as a prevention measure.
As the following examples illustrate, AIDSCAP/FHI programs used a wide range of innovative approaches to make condoms more accessible, affordable, and acceptable to target audiences.
- In Ethiopia, Nigeria, Senegal, and Tanzania, AIDSCAP provided technical assistance through JSI by conducting condom logistics needs assessments and recommending to national governmental agencies improvements in the procurement, storage, and distribution of free-of-charge condoms at government clinics and health care facilities.
- Many AIDSCAP/FHI projects in Africa included condom distribution components linked to public supply systems. This kind of promotion and distribution added an alternative, personal dimension (peer educators often delivered the condoms) and a greater credibility (the prevention message was seen as coming from friends) to the condom instruction delivered with clinic-based distribution. As a result, condoms became more popular, and the demand for free-of-charge condoms dramatically increased. In Kenya, for example, free-of-charge condom distribution through public sector channels increased from 6 million units in 1988 to more than 100 million in 1996.
- AIDSCAP/FHI also funded projects to promote the sale of subsidized, affordable condoms distributed through private sector retail networks. By offering attractive profit margins to participating retailers, these social marketing projects were able to establish sales points in a wide range of commercial outlets where condoms had never been available before. Accessibility was also enhanced through these retail networks since many shops were open on days and at hours when (government-run free) distribution locations were closed. Some sales points are also located near or in bars, night clubs, hotels, and rest houses where high-risk sexual activities may take place.
- The PSI social marketing project in the Kingdom of Lesotho offered prevention information, counseling, and condom use negotiating skills and sold condoms to the Lesotho-based wives of men who worked most of the year as migrant labor in South Africa's distant goldfields. The goal was to inform women about HIV/AIDS and to encourage condom use when their absentee partners-who often partner with other women during their prolonged absence-return home on leave.
- Demand for socially marketed condoms was created and strengthened by the implementing agencies through aggressive and innovative commercial marketing techniques, including prime time radio and TV advertising; production of radio and TV soap operas on HIV/AIDS themes; mobile video shows in rural areas; press and outdoor billboard ads; and dance, drama, puppet show, and rap music competitions addressing HIV/AIDS-related issues.
- In South Africa, the AIDSCAP-funded PSI social marketing project developed prime time public service TV spots that featured the revered Bishop Desmond Tutu plugging condom use "for those unable to remain monogamous."
- Social Marketing of Condoms in Senegal, as part of a social marketing project supported by AIDSCAP, trained 292 pharmacists in condom use demonstration techniques, enhancing their willingness and capacity to advise and counsel their customers on effective condom use to prevent HIV infection.
- In rural Rwanda, a PSI mobile video van toured the countryside, stopping at large regional open air markets to explain and demonstrate condom use, with awareness-raising videos (some filmed by the project in Rwanda and using local languages), question-and-answer sessions with the crowd that were taped and shown live on a 10 x 20 foot screen. Condoms were sold at a nearby stand.
- AIDSCAP-supported condom social marketing projects achieved remarkable increases in sales. In Ethiopia, for example, more than 6 million condoms were sold in the first year of the AIDSCAP program. This meant that 800,000 condoms per month were being sold. By the end of the AIDSCAP program, monthly sales had risen to 2 million. Over 33 months, 43 million condoms were sold through 10,000 sales outlets. AIDSCAP partners distributed more than 830,000 condoms.
- AIDSCAP-funded countries in Africa promoting the sale of low-priced condoms saw annual condom purchases increase from a few million (including all for-profit brands) prior to the introduction of social marketing to 100 million socially marketed brands alone by the end of the project 6 years later. This dramatic increase in sales indicates one of the most successful -- and quickest -- new product introductions in history.
Improved STI Diagnosis, Treatment, and Prevention
As the connection between infection with other STIs and increased risk of HIV infection became more evident, AIDSCAP/FHI took the lead across Africa in promoting and facilitating the adoption of WHO's simpler, faster, more cost-effective algorithmic methods -- using patient interviews and checklists rather than slow and costly lab tests -- to diagnose other STIs.
In South Africa and Tanzania, AIDSCAP/FHI funded local entities to encourage and facilitate the process of changing both public national medical policies and traditional, lab-oriented private medical practitioners to embrace the new diagnostic methods. The syndromic approach was also successfully tested in one medical region of Rwanda. The Government of Rwanda now plans to expand the use of this approach nationwide.
With the adoption of the new diagnostic techniques by national medical bodies and governments, AIDSCAP/FHI then confronted the huge task of training and retraining thousands of field practitioners in accepting and understanding the new diagnostic methods and applying them and related treatment approaches effectively in their daily clinical practices.
In Tanzania, for example, the Institute of Tropical Medicine, an AIDSCAP/FHI subcontractor, provided technical assistance to three local health/medical training institutions, which by the end of the project had trained 657 health care providers (HCPs) representing health care facilities in 7 of the country's 20 regions, in the use of the new diagnostic methods. The quality of posttraining STI case management was assessed by evaluating correct (syndromic) diagnosis and appropriate treatment and the provision of prevention advice, including information about condom use and the importance of partner treatment. The findings indicate that more than 93 percent of patients with complaints or signs consistent with common STI syndromes were correctly diagnosed. Correct treatment of STIs assumes that HCPs have access to nationally recommended drugs. Supplies of medications were good in the private sector clinics. Supervisors verified greater than 90 percent availability of recommended drugs for the main STIs, with the exception of candidal vaginitis (70 percent). Seventy percent of the patients received either the first-line recommended drugs for the diagnosed syndrome or approved alternative treatments; 97 percent of patients who returned to the clinics for follow-up reported either cure or improvement.
In Senegal, under implementation agreements with both the public and private sector (including Catholic Church- run clinics), over 1,200 lab personnel, health care providers, and clinic staff were trained by specially recruited medical students in the application of syndromic diagnosis and STI prevention and counseling. An evaluation was carried out to measure baseline levels of the WHO prevention indicators (PIs) related to STI case management (PIs 6&7) and to measure any changes that took place in the short term after training. Ninety-seven percent of health workers in 6 of the 10 regions were trained in the use of STI treatment algorithms (PI6) and prevention education and counseling (PI7). Two methods of obtaining data on PIs 6 &7 were used: (1) direct observations of providers interacting with their patients, and (2) interviews with providers. Results obtained from the two methods are summarized in Tables 7 and 8.
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| Correct | No | Percent | Correct | No | Percent | P-Value | ||||
| History | 16 | 35 | 45.7 | 24 | 41 | 58.5 | 0.3 | |||
| Examination | 15 | 35 | 42.9 | 26 | 41 | 63.4 | 0.07 | |||
| Treatment | 4 | 35 | 11.4 | 16 | 41 | 39.0 | 0.0006 | |||
| PI6 | 4 | 35 | 11.4 | 5 | 41 | 12.2 | 0.6 | |||
| Condom advice | 4 | 35 | 11.4 | 10 | 41 | 24.4 | 0.2 | |||
| Partner advice | 12 | 35 | 34.3 | 30 | 41 | 73.2 | 0.0007 | |||
| PI7 | 1 | 35 | 2.9 | 9 | 41 | 22.0 | 0.01 | |||
| Risk assessment | 0 | 35 | 0.0 | 2 | 41 | 4.9 | 0.2 | |||
As illustrated in Table 7, using the strict WHO criteria during observations, the baseline level of PI6 was 11 percent, and there was little improvement at follow-up (12 percent). However, a significant improvement in HCP performance occurred in two of the three areas that are components of PI6 (examination and treatment). For PI7, the baseline level was 2.9 percent, and the follow-up level was 22 percent. Therefore, there was a significant improvement in HCP performance.
Providers reported better case management practices. The baseline PI6 reported during interviews was 4.6 percent, with an increase to 19.2 percent at follow-up. The already high levels for PI7 at a baseline of 83.1 percent increased significantly to 94.3 percent at follow-up. It should be noted that the time between training and the survey was only 3 months.
Training in STI case management also improved HCP performance in Kenya, where AIDSCAP/FHI funded the Family Planning Private Sector Project run by JSI to train 402 staff from 147 clinics in the new diagnostic methods. After training, more than 90 percent of patients with STI symptoms were correctly diagnosed without recourse to clinical tests.
Africa was also the site of the first pilot project to test marketing of prepackaged STI therapy, an innovative approach to improving access to effective treatment. In Cameroon, the AIDSCAP-funded PSI social marketing project worked with national authorities and the pharmaceutical establishment to package and promote the sale of an STI home treatment kit at clinics and pharmacies. The product included appropriate drugs, awareness information, a referral card to notify partners of potential infection, and a pack of condoms to prevent reinfection. Although sales of the kit were lower than expected for a variety of reasons, those who did buy them reported high levels of satisfaction and compliance with the treatment.
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| Correct | No | Percent | Correct | No | Percent | P-Value | |
| History | 55 | 65 | 84.6 | 180 | 193 | 93.3 | 0.03 |
| Examination | 14 | 65 | 21.5 | 148 | 193 | 76.7 | 0.00 |
| Treatment | 6 | 65 | 9.2 | 40 | 193 | 20.7 | 0.04 |
| PI6 | 3 | 65 | 4.6 | 37 | 193 | 19.2 | 0.005 |
| Condom advice | 56 | 65 | 86.2 | 186 | 193 | 96.4 | 0.003 |
| Partner advice | 63 | 65 | 96.9 | 189 | 193 | 97.9 | 0.5 |
| PI7 | 54 | 65 | 83.1 | 182 | 193 | 94.3 | 0.005 |
| Risk assessment | 0 | 65 | 0.0 | 11 | 193 | 5.7 | 0.04 |
Influenced Policy to Support HIV/AIDS Prevention
Without the support of governments -- at both national and local levels -- prevention interventions may not be as effective as they might be. Throughout the Africa region, AIDSCAP/FHI funded and provided technical assistance to a broad array of policy initiatives designed to increase the awareness of political, religious, and economic leaders about the dimensions of the problems posed by the HIV/AIDS epidemic and to build support for effective prevention programs, including controversial ones. Some examples follow.
Political Initiatives
- In Senegal, AIDSCAP supported a sensitization seminar for members of the National Assembly. The seminar included the basics of HIV transmission; facts and figures on the reality of HIV/AIDS in Senegal (and projections of future impact); and participatory, thought-provoking activities, such as role-plays on gender and the experiences of people living with HIV/AIDS.
- KANCO, with support from AIDSCAP, provided input to the Government of Kenya in the drafting of major legislation that presented the government's position on HIV/AIDS. KANCO was also invited by the Joint United Nations Programme on HIV/AIDS (UNAIDS) to sit on the committee advising on the HIV/AIDS components for the national Medium-Term Plan 3 development document and was asked by the National AIDS and STI Control Program to review proposals for World Bank funding through its STI project.
Religious Initiatives
- Also in Senegal, AIDSCAP promoted symposia for both Christian and Islamic leaders to inform them about the HIV/AIDS situation in their country and to allow them to debate and propose roles and responsibilities for religious leaders in combating the epidemic.
- Medical Assistance Program (MAP) International in Kenya mobilized volunteers from Christian churches across the country and trained them as trainers of community-based religious personnel in HIV/AIDS prevention and counseling. MAP also produced an HIV/AIDS module for use in the curriculum of theological schools in the country.
Economic Initiatives
- The AIDSCAP office in Kenya mobilized a group of Kenyan governmental agencies, NGOs, and private sector representatives to produce and promote the book AIDS in Kenya: Socio-Economic Impact and Policy Implications in Kenya and to distribute it to opinion leaders and policymakers. The book was launched by Kenyan Vice President George Saitoti and received front-page coverage and editorial comment in all the national newspapers, raising awareness about the current and projected impact of HIV/AIDS on Kenyan society and the country's economy.
- In Tanzania, the Africa Medical Research and Education Foundation, with AIDSCAP support, managed an intervention to inform private businesses of the threat HIV/AIDS poses to their investments and to establish peer education programs in the workplace to inform workers about HIV/AIDS, discuss prevention alternatives, and distribute or sell condoms. By the end of the project, businesses were contributing 25 percent of the cost of the programs (with AIDSCAP/FHI funds paying the balance), and they planned to assume all costs within 3 years.
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In April 1994, hundreds of thousands of Rwandan refugees fled from ethnic violence into northern Tanzania. Emergency camps, created overnight, were overwhelmed with as many as 4,000 new refugees each day. As conditions in the camps grew desperate, relief agencies struggled to take care of basic needs -- food, clean water, shelter, sanitation, and first aid. But even as camp life stabilized, another crisis loomed: the threat of HIV spreading through the refugee population. Before the exodus, Rwanda had estimated urban HIV infection rates as high as 33 percent, based on seroprevalence studies among selected groups of antenatal clinic attendees in Kigali. Overcrowding, days full of idle time, a flourishing commercial sex trade, and severe strains on traditional social structures and family life left camp residents acutely vulnerable to infection. In August 1994, AIDSCAP/FHI initiated a 1-year HIV education and prevention pilot project in the huge Benaco Camp, which had a population of about 250,000 refugees. AIDSCAP/FHI contracted with CARE, the NGO that has worked in Benaco since the camp's inception, for peer education training and other HIV prevention services, and with PSI for a condom social marketing and distribution program. Another AIDSCAP/FHI subcontractor, JSI, conducted a baseline knowledge, attitudes, and practices survey among camp residents, discovering high levels of HIV/AIDS awareness and understanding of the importance of condom use but a much lower level of safer sex behavior. Such early HIV/AIDS interventions in a refugee setting had never before been attempted on this scale. |
Identified and Addressed Emerging Needs
Throughout the Africa region, as the epidemic expanded and needs at all levels changed, AIDSCAP/FHI was in the forefront of sponsoring new approaches and testing new methods of addressing the epidemic and the needs of those affected by it.
HIV Counseling and Testing
In the Kariobangi slums of Nairobi, Kenya, and in the Tanzanian capital, Dar es Salaam, AIDSCAP/FHI, UNAIDS, and the Center for AIDS Prevention Studies worked with the Kenya Association of Professional Counselors and Muhimbili University in a field study of the effectiveness of HIV counseling and testing compared with health education alone as an inducement to changing personal behavior. Among many positive outcomes, it was found that participants maintained a high level of participation during follow-up visits (retention rates were 87 and 80 percent respectively, in the Kenya and Tanzania study centers). Study participants were overwhelmingly motivated to participate and remain in the study because of the opportunity to know their HIV status as a prelude to changing their sexual practices.
AIDS Orphans
In some of the harder hit areas of eastern Africa, HIV/AIDS has already killed a significant number of adults, leaving large numbers of orphans and elderly parents of the deceased to fend for themselves without adequate skills or resources. AIDSCAP/FHI worked with community-based organizations in Tanzania to help some of these families cope with their loss and earn a livelihood.
In the Moshi area of northern Tanzania, for example, the AIDSCAP/FHI-funded Kilimanjaro community cluster provided skills training to orphaned children and grandparents to enable them to support themselves. Children cultivated their own vegetable gardens and sold the produce at local markets or apprenticed -- through cost sharing between the cluster and local businesses -- in occupations such as brick-making, carpentry, and auto repair. Teenage children, and sometimes their aging grandparents, were trained in selling skills, dispensing prevention advice, and selling subsidized, socially marketed condoms to friends and neighbors in the community, along with dispensing the personal and powerful message: "Protect yourself and your family; don't let what happened to me happen to you."
Profits from the condom sales were retained by the individual sellers to meet their personal needs. The cluster also allocated profits from the income-generating projects it sponsored, such as the sale of traditional crafts bearing HIV/AIDS prevention messages, to providing school uniforms and books to scholastically qualified orphans who otherwise might have had to drop out of school for lack of the few dollars required for these supplies.
Care and Management Support for People Living with HIV/AIDS
Although AIDSCAP/FHI's mandate was to build local capacity for HIV/AIDS prevention rather than care, the project was able to conduct short-term pilot projects to test models of care and prevention. One AIDSCAP program, the Tanzania AIDS Project, provided integrated prevention, care, and support services through local NGOs and other community-based organizations.
STI Treatment Innovations
With increasing evidence of the link between untreated STIs and HIV, AIDSCAP/FHI undertook a field trial in South Africa to test the effectiveness of periodic presumptive treatment of persons known to be at high risk of STIs. With this approach, persons in high-risk populations are periodically treated, free-of-charge, with an array of drugs effective against the most common STIs, minus expensive and time-consuming traditional lab exams, on the presumption that they are likely to be infected with one or more of the STIs because of their life-styles.
The trial in South Africa treated the CSW partners of miners working in the goldfields region. Initial follow-ups with both the women and their untreated possible partners showed that STI levels in both groups had declined. If the decline was sustainable, the lower STI levels would lead to declines in HIV infection rates as well. The management of the mine where the trials were conducted was impressed with the results and agreed to continue the program with private funds after the end of the trials.
Gender and HIV/AIDS
As the impact of the HIV epidemic on women became more evident, AIDSCAP/FHI established a worldwide AIDSCAP Women's Initiative (AWI) to ensure that gender issues were considered in field project design and implementation and to fund studies on issues related to the female condom. AWI used untapped channels to reach women and girls, build awareness, and promote capacity building at the grassroots level. Examples of these initiatives include the following:
- Sponsoring a gender and AIDS conference in Mombasa, Kenya, for senior policymakers and program managers from Kenya, Zimbabwe, Tanzania, South Africa, and Ethiopia. AWI funded pilot interventions developed at the conference in each of the five countries and produced a manual based on the workshop.
- Working in Kenya with the Collaborative Center for Gender and Development on a study to identify the factors and rationale determining use and non-use of the female condom. The study concluded that almost all women (93 percent) were satisfied with the condoms and, most were interested in continuing to use it; women's organizations and groups provided useful structures for promoting and sustaining its use.
Strengthened Local Capacity to Respond to HIV/AIDS
Overall, the AIDSCAP/FHI Africa Regional Office worked in 19 of 44 countries in Africa to build the capacity of government national AIDS control programs and indigenous nongovernmental organizations to design, manage, and evaluate STI/HIV/AIDS programs in their communities. This was largely done through training in project design and management, financial management, monitoring and supervision, BCC materials production, peer education, local and community-based theater, and drama and song. This kind of training has left the NGO members with skills to develop STI/HIV/AIDS programs that will respond to the needs of their communities from grassroots to urban societies and has also contributed to their preparedness to respond to any future epidemics.
In some countries, to support the community-based efforts, resource centers were established at regional, district, ward, and village levels and staffed with people who source and maintain all documentation and information on HIV/AIDS and STIs; this material is accessible to everyone. The staff have also been trained as peer educators and counselors and are, therefore, able to assist individuals seeking help with particular sexual issues. Alongside the resource centers, networks were established within certain countries so that experiences were shared, and the best practices were adopted whenever possible.
| Country | Target Population | Percentage Able to State Two or More HIV/AIDS Prevention Methods | |
| Baseline | Follow-up | ||
| Cameroon | CSWs | 40% (1994) | 87% (1996) |
| Clients | 50% (1994) | 86% (1996) | |
| Students: Male | 79% (1993) | 95% (1996) | |
| Students: Female | 84% (1993) | 96% (1996 | |
| Military | N/A | 90% (1996) | |
| Youth (Project CARE) | 37% (1993) | 70% (1996) | |
| Ethiopia | MPSCs 1 | 62.6% (1995) | 94% (1996) |
| Youth | 78% (1995) | 99% (1996) | |
| Nigeria | CSW | 88% (1994) | 90% (1996) |
| Youth: Cross River | 7% (1993) | Not Calculated | |
| Youth: Jigawa State | 9% (1995) | Not Calculated | |
| Youth: Lagos State | 61% (1994) | Not Calculated | |
| LDDs Overall 2 | 45% (1995) | 92% (1997) | |
| Dock Workers | 60% (1995) | 85% (1997) | |
2 Long-distance drivers (LDDs).
Reduced Risk Behaviors Among Target Populations
AIDSCAP/FHI prevention interventions focused on populations that are a cross section of those at risk. Men, women, girls, and boys from all walks of life have been addressed: people living with AIDS, CSWs, youth in and out of school, market women, teachers, HCPs, traditional healers, traditional birth attendants, religious leaders (both Christian and Islamic), business and community leaders, uniformed army and air force personnel, and intransit populations at locations where they can be reached between moves.
These prevention interventions helped increase awareness, reduce stigmatization, and encourage appropriate treatment-seeking behavior and safer sex practices. Traditional healers and traditional birth attendants are now observing safer practices in their healing and birth-delivery methods. Although working with army and air force personnel proved difficult, AIDSCAP/FHI succeeded in sensitizing the military leadership in a number of countries to the importance of educating their personnel, along with their families, on the potential consequences of high-risk behavior and the danger of remaining ignorant about HIV/AIDS.
Evaluation surveys found evidence that knowledge of two or more effective methods of preventing HIV transmission had increased significantly in nearly all target populations in AIDSCAP/FHI's major countries in the region. Table 9 shows changes in knowledge of HIV prevention methods among various target groups in selected countries.
These dramatic changes in knowledge levels in nearly all AIDSCAP/FHI programs in the region have also resulted in the decline of incorrect beliefs in means of transmission which include the use of public toilets, shaking hands with persons infected with HIV, and mosquito and other insect bites. In Senegal, for example, the proportion of respondents who cited handshaking, sharing of food with persons infected with HIV, and mosquito and other insect bites as ways of contracting HIV declined from 31 percent, 27 percent, and 44 percent in 1995 to 13-32 percent, 3-13 percent and 18-37 percent, respectively. As these results suggests, however, misconceptions about HIV transmission are still present. Improvements in levels of HIV knowledge have resulted in increases in the proportions of people using condoms with casual sex partners across all projects in the region. These increases are only moderate in the general population of men and women, but condom use is becoming almost universally accepted by CSWs. Table 10 presents results from a few countries in the region.
Most of the AIDSCAP/FHI programs in the region have demonstrated some limited behavior change regarding sexual risk taking. For example, in Cameroon, the percentage of male students reporting more than one sexual partner in the last 3 months dropped from 53 percent in 1993 to 36 percent in 1996; there was no significant change among female students (14 percent in 1993 and 17 percent in 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; the 1996 figure decreased significantly to 9.4 percent.
Among Cameroon's military population, the percentage of male members reporting more than two sexual partners in the past 3 months dropped significantly from 47 percent in 1993 to 37 percent in 1996.
To improve the treatment of STIs, AIDSCAP/FHI established networks between private and public sector clinicians, pharmacists, traditional healers, and other HCPs in the syndromic management of STIs and cross-referrals of complicated cases. These established networks brought services closer to patients so that they no longer have to wait weeks to have a simple STI properly treated. Availability of condoms-both distributed free-of-charge and socially marketed-has complemented all activities and ensured that simple protection was readily accessible when needed.
The policy environment has been the most difficult to change, but nonetheless, major support for HIV/AIDS interventions has been gained from the national AIDS control programs and ministries of health in the various countries. Special success was recorded in Kenya, where policy interventions culminated in the publication AIDS in Kenya, a book that was launched by the vice president of the country with the participation of the U.S. ambassador and eventually led to passage of landmark national HIV/AIDS legislation by Parliament. With the support of the policymakers, it becomes easier to garner the support of the business community, as has been illustrated by the increased interest of business entities in AIDSCAP/FHI's private sector policy package.
Emerging needs in the region are care and support, testing and counseling, and support for AIDS orphans. These new demands on HIV/AIDS programs are the result of high levels of awareness and the general public's acceptance that HIV/AIDS is real. The issue now is how to contain and stop an epidemic that has already killed at least 8 million people in Africa.
| Country | Target Population |
| |
| Baseline | Follow-up | ||
| Cameroon | CSWs with Nonregular Clients | 52% (1994) | 75% (1996) |
| CSWs with Regular Clients | N/A | 63% (1996) | |
| Clients with Nonregular Partners | 54% (1992) | 97% (1996) | |
| Students: Male | 75% (1993) | 75% (1996) | |
| Military: Consistent Condom Use With CSWs | 48% (1993) | 59% (1996) | |
| Youth | 54% (1993) | 55% (1996) | |
| Ethiopia | MPSCs1 | 62.6% (1995) | 94% (1996) |
| Youth | 78% (1995) | 99% (1996) | |
| Nigeria | CSWs (Consistent Use) | 23% (1990) | 64% (1996) |
| Youth: Cross River | 21% (1993) | 80.3% (1996) | |
| Youth: Jigawa State | 20.4% (1995) | 67% (1996) | |
| Youth: Lagos State | 18% (1994) | 75% (1996) | |
| LDDs: Cross River 2 | 32.3% (1995) | Not Yet Reported | |
| LDDs: Jigawa State | 23% (1995) | Not Yet Reported | |
1 People with multiple sexual contacts.
2 Long-distance drivers.
