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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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| Original | Revised |
| Supergoal: None |
Supergoal: Reduced rate of sexually transmitted HIV infection in developing countries |
| Goal: To reduce the rate of sexually transmitted HIV infection in the developing world |
Goal: Improved HIV risk reduction strategies in selected populations and countries in the developing world |
| Purpose: To strengthen capacity of developing countries to increase condom use, decrease STIs, and decrease number of partners |
Purpose: Strengthened capacity of developing countries to design, implement and evaluate technically comprehensive HIV programs |
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Outputs:
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Outputs/results:
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Project Description
The AIDS Control and Prevention Project, a cooperative agreement between USAID and Family Health International (FHI), was launched in September 1991, with a budget of $168 million. In response to the recommendation to limit its focus, AIDSCAP/FHI was designed to prevent the spread of HIV through sexual transmission using three key strategies -- increased condom use, improved management and prevention of sexually transmitted infections (STIs), and the adoption of safer sexual practices, including partner reduction. This approach was chosen based on computer modeling that demonstrated the synergistic benefits of these strategies in achieving prevention results. These strategies were reinforced by commitments to policy support to create a positive environment for prevention, behavioral research as a means of improving the quality of interventions, and evaluation to measure the progress of individual efforts. As the project evolved, AIDSCAP/FHI broadened its areas of expertise to include special attention to the unique issues surrounding women and HIV, the connection between prevention and care, and the impact of the epidemic on women and children and its mitigation. This project became the flagship effort of the ATSP.
As originally designed, the goal of the AIDSCAP Project was to reduce the rate of sexually transmitted HIV infection in the developing world. The purpose -- to strengthen the capacity of developing countries to increase condom use, decrease STIs, and decrease the number of partners -- was to be achieved through three major outputs: (1) improved multidimensional programs designed, implemented, and evaluated; (2) findings from behavior research applied to interventions; and (3) critical policy issues resolved. This design was refined over the course of the project to reflect changing circumstances and the global evolution of the response to the epidemic. The refined objectives -- restated in the new USAID language of results -- are presented in Table 1. The revisions acknowledged that given the dynamics of the epidemic, measuring a reduced rate of sexually transmitted HIV in 5 years would be nearly impossible. In addition, the revisions acknowledged the need to address HIV/AIDS more comprehensively and recognized strengthened local capacity as the critical interim step to improving programs and eventually achieving reductions in sexually transmitted HIV.
The AIDSCAP Project was designed to facilitate comprehensive programming in as many as 15 countries and to support smaller scale efforts to a wider audience of associate countries. To ensure state-of-the-art technical cooperation, FHI teamed up with nine subcontractors: Population Services International for condom social marketing; John Snow, Inc. for condom logistics management; the Center for AIDS Prevention Studies at the University of California at San Francisco for behavioral research; the Program for Appropriate Technology in Health, Ogilvy Adams & Reinhart, and Prospect Associates for communication support; and the Institute for Tropical Medicine, University of Washington in Seattle, and the University of North Carolina at Chapel Hill for STI technical assistance.
The project completion date was extended 1 year from September 21, 1996 to December 31, 1997. This was done to compensate for nearly 1 year of implementation time lost when AIDSCAP was changed from a cooperative agreement to a contract (2 1/2 years into the project) and to allow a smoother transition from AIDSCAP/FHI to the new USAID programming that would succeed the ATSP.
| . | Cumulative |
| Total People Educated: | 21,886,842 |
| Total People Trained: | 186,967 |
| Total Condoms Distributed: | 227,562,111 |
| Free: | 45,402,395 |
| Sold: | 182,159,716 |
| Total Materials Distributed: | 19,128,768 |
| 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. | |
Accomplishments and Results
"If AIDSCAP/FHI had to be compared to other initiatives undertaken globally in the field of STI/HIV/AIDS prevention, and if, in order to do so, one had to take into consideration the technical quality of the program's content, the variety of geographic, social, and cultural settings within which prevention interventions are adapted and implemented, the capacity of the program to reach particularly vulnerable communities and at-risk populations, and the ability of the program to share its experience with others, then AIDSCAP/FHI would rank among the very best and most powerful STI/HIV/AIDS prevention programs funded by any official development agency."
Management Review of the AIDSCAP Project, 1995
For 6 years, AIDSCAP/FHI successfully contributed on several levels to improving HIV/AIDS risk -- reduction strategies in selected populations and countries in the developing world. As the body of this final report articulates, the project
- facilitated the design, implementation, and evaluation of multidimensional programs.
- introduced innovative programming.
- increased the capacity of developing-country partners through technical cooperation, training, and the development of valuable field-targeted tools.
- conducted important intervention-focused research.
- disseminated its lessons learned and best practices widely.
- achieved impact on defined behavioral outcomes.
| Africa | Asia | Latin America/ Caribbean |
| Cameroon, Ethiopia, | India, | Brazil, |
| Kenya, Nigeria, | Indonesia, | Dominican Republic, |
| Rwanda, Senegal, | Nepal, | Haiti, |
| South Africa, | Thailand | Honduras, |
| Tanzania, Zimbabwe | Jamaica |
Designed, Implemented, and Evaluated Multidimensional Programs
Working in partnership with governments, nongovernmental organizations, and communities around the world, AIDSCAP/FHI designed and supported comprehensive, multiyear programs in 18 countries located in Africa, Asia, Latin America, and the Caribbean, as shown in Table 3. These programs generally included efforts in each of the six major strategies.
AIDSCAP/FHI also assisted more than 25 additional countries (see Table 4) in developing and implementing smaller targeted programs and activities, such as strengthening Zambia's national STI service, infusing state-of-the-art HIV prevention expertise into the design and implementation of a comprehensive reproductive health project in West Africa, and training epidemiologists and social scientists in the conduct of socioeconomic impact studies in Central America. In a few countries, including Benin, Burkina Faso, and Guinea, AIDSCAP/FHI provided short-term technical assistance.
In both the major countries and the smaller associate countries, AIDSCAP/FHI funded nearly 800 individual subprojects that were implemented by more than 500 program partners. These partners ranged from large U.S. PVOs implementing HIV/AIDS prevention efforts within larger community development efforts to microsized community groups.
| Africa | Asia /Near East | Latin America/ Caribbean |
| Benin | Bangladesh | Bolivia |
| Burkina Faso | Cambodia | Colombia |
| Côte d'Ivoire | Egypt | Costa Rica |
| Lesotho | Lao PDR | Ecuador |
| Mali | Mongolia | El Salvador |
| Mozambique | Morocco | Guatemala |
| Niger | Papua New Guinea | Mexico |
| Zambia | Philippines | Nicaragua |
| Sri Lanka | Peru |
Introduced Innovative Programs and Approaches
The AIDSCAP Project expanded both the range of at-risk groups reached by STI/HIV/AIDS prevention messages and innovative practices to guide the way to more effective interventions. Thus, for example, beyond reaching youth in and out of school and men and women where they work and socialize, AIDSCAP/FHI field partners developed programs to reach at-risk groups with special needs, including border-crossing migrant workers, refugees, orphans, and the deaf.
The project also tested several program innovations with the demonstrated capacity or potential for significantly improving prevention programming. Some innovations were adopted as best practices; others provided ground-breaking information on which to build further advances, as the following examples show:
- AIDSCAP/FHI contributed to the global effort to gain clinician acceptance of a syndromic management approach to STI diagnosis and treatment and developed a system for increasing partner referral for STI treatment. These approaches maximized the results obtained from frequently understaffed, poorly equipped government health clinics and from overused, rapid-turnaround private clinics.
- AIDSCAP/FHI refined strategies for dialogue on sexual behavior between partners and between mothers and daughters that have opened healthy communication.
- AIDSCAP/FHI also demonstrated that materials well crafted with participation from around the world can transcend national borders and cultural nuances to sound a broadly resonant chord. AIDSCAP/FHI's Emma Says comic books, originally designed for Senegal and Nigeria, have been widely accepted by audiences in countries as diverse as Benin, Burkina Faso, Tanzania, Zambia, Zimbabwe, Rwanda, Kenya, Cameroon, Côte d'Ivoire, Madagascar, South Africa, Thailand, Haiti, and Brazil.
- AIDSCAP/FHI developed a program for engaging nongovernmental organizations (NGOs) as condom social marketing partners. In Haiti, the strategy worked so well that NGOs accounted for one-third of condom sales.
- AIDSCAP/FHI defined the importance of, and created successful models for, addressing the unique challenges and opportunities for preventing HIV transmission in cross-border areas of affinity.
Increased the Capacity of Developing-Country Partners
Capacity building was a predominant focus of AIDSCAP. For the past 6 years, the project has conducted or sponsored training opportunities for 186,967 professional and volunteer frontline workers in STI/HIV/AIDS prevention. Capacity has been built to improve technical skills in providing services to thousands of peer educators, health care workers, pharmacists, clinicians, condom logistics managers, materials developers, and researchers. The capacity of hundreds of government agency and NGO managers has also been enhanced in strategic planning, resource development, advocacy, planning, budgeting, evaluation, and program and organizational management. These efforts were designed to help host country partners more effectively implement AIDSCAP/FHI-supported activities. They were also conducted with foresight to the long-term growth and viability of government and civil society.
In addition to technical support and training, AIDSCAP/FHI contributed to capacity building of institutions and individuals who had little or no contact with the project through the development and broad dissemination of learning tools. These tools include the following:
- The targeted intervention research manual that guides program planners in designing and carrying out ethnographic research on community attitudes and practices surrounding STI.
- Behavior change communication (BCC) how-to manuals that provide clear, insightful steps to developing, for example, a communication strategy, a peer education program, a media campaign, and a project-monitoring plan.
- The Private Sector AIDS Policy manual that walks worksite managers through the process for assessing, articulating, and implementing HIV/AIDS prevention programs and policies.
- A gender-training manual that guides the design of policies and programs that explicitly recognize and address gender as it relates to HIV/AIDS.
- Policy tools that make socioeconomic impact assessments more applicable and easier for field personnel use.
- A capacity assessment tool that helps organizations inventory their strengths and limitations and a strategic planning tool that guides long-term goal setting.
- An STI manager's handbook for clinicians and health care workers that provides practical directions and guidance for improving STI management and prevention at program or clinic level.
- Evaluation tools modules that address specific methodologies and practices for measuring project results and program impact.
- The behavioral surveillance surveys (BSS) methodology that monitors trends in sexual behavior among target populations.
In addition to providing training and tools, the AIDSCAP Project strengthened the capacity of developing-country partners through a special program to expand the participation of community-based groups in STI/HIV/AIDS prevention and care. AIDSCAP/FHI's rapid-response fund, managed at the country level, provided seed funding to more than 200 organizations, many of which had never received donor funding previously. A final accomplishment in capacity building was the transformation of a number of AIDSCAP/FHI country offices into independent NGOs, allowing them to continue serving their communities beyond the life of the project.
Although the project has been successful in developing the capacity of governmental and nongovernmental organizations around the world, clearly the need for collaboration, partnership, and financial assistance remains an ongoing, essential priority.
Conducted Intervention-Focused Research
AIDSCAP/FHI's research agenda focused primarily on intervention-linked issues with clear and potentially rapid application to improve programming. Examples of such research include the following:
- A presumptive treatment study conducted with commercial sex workers (CSWs) and the mining community in Welkom, South Africa demonstrated reduced STIs among partners of CSWs who were periodically treated presumptively for common STIs.
- An assessment of emerging patterns of HIV incidence in Uganda and other East African countries provided important information on the impact of population movements within and among countries.
- Targeted intervention research conducted in Senegal, Ethiopia, Malawi, Zambia, Benin, Swaziland, South Africa, and Morocco defined local customs and attitudes about STIs and treatment-seeking behavior. Research results were used in each country to refine STI programming.
- An indepth assessment of 21 peer education programs across Africa, Asia, Latin America, and the Caribbean identified strengths, limitations, and needs for further training to maximize the effectiveness of this popular intervention strategy.
- A study examining the impact of providing care and support to individuals newly diagnosed with HIV/AIDS on their adoption of safer sexual behaviors.
- The first pilot study conducted in Cameroon, of prepackaged antibiotic therapy for the treatment of urethritis, provided critical data on acceptability among consumers and on the barriers to effective introduction of this approach.
- A multicenter study on the effectiveness of voluntary HIV counseling and testing was jointly sponsored with WHO and the UNAIDS. Preliminary results of this study offered evidence of the effectiveness of such services as a prevention strategy in resource-poor countries. The final results of this study will help guide decisions about establishing and funding HIV counseling and testing services in countries throughout the developing world.
Disseminated Lessons and Best Practices
The AIDSCAP Project used several approaches for sharing information, lessons, and best practices. A primary vehicle was the written word presented in nine languages. Publications included books, peer-reviewed papers, reports, magazine issues, newsletters, book chapters, comic books, brochures, fact sheets, and press releases. Special accomplishments include the following:
- More than 150 peer-reviewed articles were published in medical, scientific, or other professional journals.
- AIDSCAP/FHI's magazine, AIDScaptions, was the first to focus on the prevention of STIs and HIV internationally. The magazine has a readership of 350,000 people worldwide.
- Information packages consisting of recent journal articles were sent quarterly in English and semiannually in French to approximately 1,000 individuals and institutions in developing countries.
- A CD-ROM containing more than 300 AIDSCAP/FHI publications, manuals, journal articles, and reports was produced and disseminated.
AIDSCAP/FHI also provided global leadership in advancing dialogue and discussion on the status and trends of the pandemic. Through its role as the Interim Secretariat of the Monitoring the AIDS Pandemic (MAP) Network, AIDSCAP/FHI worked with its partners (Harvard University's François-Xavier Bagnoud Center and UNAIDS) to bring together more than 100 global experts in five symposia to examine epidemiologic trends and monitor the effects of prevention and care programs. Finally, AIDSCAP/FHI sponsored 550 individuals to participate in international conferences.
During Last Sexual Intercourse by Target Population
| Country | Target Population | Reported Condom Use | |
| Baseline | Follow-up | ||
| Brazil | CSWs | 57% (1993) | 97% (Sept. 1996) |
| Cameroon | CSWs | 69% (1994) | 69% (1996) |
| University Students | 63% females (1993) 75% males (1993) | 77% females (1996) 70% males (1996) | |
| Dominican Republic | CSWs | 65% (1992) | 98% (April 1996) |
| Hotel Workers | 86% (1993) | 95% (April 1996) | |
| Ethiopia | CSWs | 75% (1993) | 80% (1996) |
| Out-of-School Youth | 21% females (1993) 49% males (1993) | 48% females (1996) 58% males (1996) | |
| Jamaica | General Population (national survey) (age 15-49 years) | 20% females (1994) 73% males (1994) | 17% females (1996) 74% males (1996) |
| Nepal | CSWs | 35% intervention area (1994) | 61% intervention area (1996) |
| 48% control area (1994) | 47% control area (1996) | ||
| Nigeria | CSWs | 23% (1989-90) | 84% (1997) |
| Long-Distance Drivers | 26% (1995) | 48% (1997) | |
| Tanzania | General Population (DHS)* (age 15-59 years) | 20% females (1994) 36% males (1994) | 17% females (1996) 35% males (1996) |
*Demographic Health Survey
Achieved Impact on Behavioral Outcomes
A major strength of the AIDSCAP Project was its recognition of the importance of program evaluation as a tool to guide program planning and management. In the area of behavior change interventions -- the core of AIDSCAP/FHI's prevention activities -- evaluation efforts focused on assessing accurate knowledge about HIV/AIDS risks, reduction of risk behaviors, and adoption of protective behavior as the most appropriate intermediate outcome indicators for interventions designed to reduce sexual transmission of HIV. Almost 400 quantitative and qualitative studies were carried out over 6 years to collect such behavioral outcome data.
The evaluation results, highlighted in the individual country overviews, suggest that the project did make a difference in most intervention settings. It should be noted that the detection of significant behavior changes is becoming increasingly difficult over time, especially after substantial changes have already occurred (a ceiling effect). In these cases, interventions have reinforcing rather than new effects. These effects may look small when they are, in fact, indicative of the prevention of relapses in unsafe behavior.
Overall, knowledge of HIV transmission modes and methods of HIV/AIDS prevention have reached high levels in the targeted populations, but misconceptions about acquiring or preventing HIV infection remain. Encouraging findings have been reported from different regions on the reduction of risk behaviors (such as avoiding commercial sex, having fewer casual partners, or delaying onset of sexual relations) and the adoption of protective behaviors (such as the use of condoms). Especially impressive is the high level of condom use in commercial sex among the groups targeted by programs that implemented peer education and condom social marketing as complementary prevention strategies. In other population groups, however, reported condom use with nonregular partners (WHO prevention indicator 5) was generally reported at lower levels. Selected examples from different countries are shown in Table 5.
Interpretation of these data requires an understanding of the social and cultural context within which the interventions were operating. Comparing outcome data from different countries is further complicated when the studies used different definitions of target audiences, outcome measures, or wording in survey instruments. Not only do these differences make it hard to compare studies, they also make results difficult to generalize. The BSS methodology, an innovative approach developed by AIDSCAP/FHI to monitor behavioral trends in target populations, is designed to eliminate the need for collecting data separately in a multitude of projects that reach the same target groups. When implemented at a national or a regional level, the BSS approach offers greater comparability and ensures a higher degree of standardization not necessarily present when data are collected by a variety of different implementing agencies.
Another interpretation issue involves the measurement of risk behaviors in either absolute or relative terms. Percentage figures of condom use measure the proportion of sexual exposures that are considered safe, which may or may not reflect the absolute number of sex acts that place individuals at risk for exposure to sexual transmission. For example, 25 percent condom use in 10 HIV-associated sexual episodes is still safer than 75 percent condom use in 100 HIV-associated sexual episodes. Therefore, it is also important to determine the frequency of condom use in absolute terms in a given risk situation. AIDSCAP/FHI's behavioral surveys began to address this dilemma by collecting additional data on -- always or consistent -- condom use during sexual episodes with nonregular partners.
For many reasons (e.g., cost and feasibility), nonexperimental observational methods with no control groups were routinely used in AIDSCAP/FHI's behavioral outcome evaluations. With such a design, however, it is often difficult to conclude that the observed differences are attributable to the intervention. Secular trends toward risk reduction will occur, especially when growing numbers of people are developing AIDS-related illnesses. For example, having a friend or relative with HIV/AIDS may influence adolescents to delay the onset of sexual relations or motivate those with nonregular sex partners to use condoms.
In the absence of more rigorous evaluation designs, triangulation procedures were applied to substantiate a link between interventions and observed behavior changes. In Cameroon, for example, process evaluation data on condom sales, the intensity of peer education, or the quality and coverage of media campaigns were combined with an analysis of behavioral outcome data to provide an understanding of the process through which interventions achieve effects. In addition, results from behavioral surveys were analyzed together with findings from qualitative evaluation research (e.g., focus group discussions, key informant interviews, and rapid ethnographic studies) carried out in subsamples of surveyed target populations. This analysis suggests that the observed outcome data are likely results of the aggregate effect of multiple interventions as well as environmental and personal factors.
Did the reported behavior changes lead to reductions in HIV transmission? This important question is usually not answered by individual intervention programs given the financial, logistical, and technical constraints and the methodological difficulties associated with field-based assessments of intervention impacts through large-scale incidence studies. However, AIDSCAP/FHI's newly developed AVERT model may provide answers. The AVERT model computer is used to estimate the impact of intervention outcomes, such as increased use of condoms, improved STI treatments, or changes in sexual behaviors, on the number of primary HIV transmissions averted over a given period. This spreadsheet-type model will also enable program managers to carry out analyses of the cost-effectiveness of different intervention combinations, providing the basis for designing cost-effective prevention measures for specific target populations in defined epidemiological settings.
Finally, it is important to realize that behavior change interventions have to be implemented for sufficient amounts of time and on a large enough scale to have an impact on personal behavior, social norms in communities, and on the epidemic. The example of Thailand shows that a focused intervention strategy implemented at a national scale can result in substantial declines in HIV incidence and prevalence in targeted populations. Two important program elements helped document this success story: STI/HIV/AIDS trends were systematically monitored by sentinel serosurveillance systems, and behavioral surveillance data provided the necessary supplementary information to interpret the observed seroepidemiological trends.
There is growing consensus that country programs need to monitor risk behavior trends together with trends in HIV infection. The AIDSCAP Project is proud to have made an essential contribution to that development
