This report covers the FHI AIDS Control and Prevention (AIDSCAP) Project (1991-1997). Volume 2 contains brief summaries of each FHI/AIDSCAP country program or activity.
Table of Contents
Volume 2
Introduction
Africa
Major Countries
- Cameroon
- Ethiopia
- Kenya
- Nigeria
- Rwanda
- Senegal
- South Africa
- Tanzania
- Zimbabwe
Associate Countries (See Below)
- Côte d'Ivoire
- Lesotho
- Mali
- Mozambique
- Niger
- West Africa
- Zambia
Asia
Major Countries
- India
- Indonesia
- Nepal
- Thailand
Associate Countries
- Bangladesh
- Egypt
- Mongolia
- Morocco
- Philippine
- Sri Lanka
Areas of Affinity
- Indian Subcontinent
- Indonesia/Philippines
- South Pacific Island Nations
- Thai/Cambodia/ Vietnam
- Thai/Lao PDR/Burma
Latin America/ Caribbean
Major Countries
- Brazil
- Dominican Republic
- Haiti
- Honduras
- Jamaica
Associate Countries
- Bolivia
- Colombia
- Costa Rica
- Ecuador
- El Salvador
- Guatemala
- Nicaragua
- Peru
- Regional Activities
Volume 1
AFRICA, Associate Countries: Côte d'Ivoire
Epidemiology
AIDS was first diagnosed in Côte d'Ivoire in 1985. During the epidemic's early stages, the HIV prevalence rate was about 1 percent among the general urban population, with no detectable presence in rural populations. However, by 1995, HIV prevalence among the sexually active population in both urban and rural areas had reached 10 percent, the total number of persons living with HIV exceeded 640,000, and the number of persons with AIDS had climbed to 14,655. By 1998, the World Health Organization (WHO) projects that there will be over 25,000 people living with AIDS and over 1 million persons with HIV in the country. Côte d'Ivoire has the sixth highest rate of HIV prevalence in Africa and the highest prevalence of any West African country. Both HIV-1 and HIV-2 have been identified in the country, but HIV-1 is five times more common.
Sexually transmitted infections (STIs) have long been a problem in parts of rural Côte d'Ivoire, and the number of STI cases among youth is growing at an alarming rate. In addition, the HIV/AIDS epidemic has been exacerbated by certain social factors. First, because of the Liberian civil war, more than 300,000 Liberians immigrated to Côte d'Ivoire, placing additional strains on an already overburdened health care system. Moreover, destitute refugees often turned to commercial sex to survive, increasing the possibility for the transmission of STI/HIV/AIDS. Second, Côte d'Ivoire's western regions, which produce coffee and cocoa, receive large numbers of buyers and transporters during harvest time. These people often engage in sexual risk taking with commercial sex workers, who are attracted to the area by the influx of potential clients.
Country Overview
The population of Côte d'Ivoire is estimated at 14.7 million, and the country has the highest rate of natural population increase in West Africa. Almost 75 percent of the country's inhabitants are 29 years of age or younger. This young, rapidly growing population is comprised of over 60 independent ethnic groups, each with numerous tribal affiliations in neighboring countries. These affiliations, coupled with an economy performing better than those of other nations in the region, have fueled an immigration of impoverished or unemployed persons to Côte d'Ivoire, especially to Abidjan. Despite the influx of persons to the city, however, 56 percent of Ivoirians still live in rural areas. Approximately 60 percent of the nation's workforce are agriculturists.
Recognizing the threat of HIV/AIDS, the Ministry of Health and Social Welfare launched a multisectoral prevention program involving numerous nongovernmental organizations (NGOs) and six Ivoirian ministries. Most prevention activities focused on Abidjan and a few other cities. However, as HIV/AIDS prevalence has risen in rural areas, prevention activities targeting rural populations have become necessary. In 1993, to assist Côte d'Ivoire in curtailing the epidemic in rural areas, AIDSCAP supported Africare, an NGO with extensive experience in rural development, in the implementation of a 3-year, $500,000 STI/HIV/AIDS prevention program targeting the approximately 50,000 sexually active persons (aged 15 to 25) living in 60 villages in the rural Guiglo district. In addition to being one of the few programs focusing on rural populations, especially youth, the project was noteworthy because Guiglo included a large community of Liberian refugees among its target population and because the program integrated STI/HIV/AIDS prevention into primary health care services in villages.
Accomplishments
In collaboration with AIDSCAP, the National AIDS Advisory Commission, the local health department, and a large condom social marketing project implemented by Population Services International, Africare established a community-based STI/HIV/AIDS prevention program that promoted the reduction of sexual risk taking and distributed condoms in over 200 villages in Guglio district. Creation of a local AIDS advisory committee increases the likelihood of the continuation of project activities and has fostered cooperative, coordinated action among local community-based organizations and agencies involved in STI/HIV/AIDS prevention. Project staff attained these achievements despite the civil unrest and constant movement of the refugee population in western Côte d'Ivoire caused by incursions of armed Liberian groups.
Behavior Change Communication
Behavior change communication (BCC) activities empowered individuals with knowledge and skills needed to protect themselves from STI/HIV/AIDS by creating a network of 90 volunteer health educators (VHEs) who provided prevention education to over 150,000 persons. Educational activities included small group sessions, presentations, drama skits conducted at village organizations and schools, and other community-wide events. Twenty-five VHEs were Liberian refugees, whose awareness and educational activities reached 23,835 fellow Liberian refugees. To reduce sexual risk taking among students, Africare helped the STI/HIV/AIDS committees of Guiglo's secondary schools implement a range of educational activities, ranging from one-on-one discussions to campus-wide activities, which were attended by more than 8,900 students. More than 40,000 educational materials, such as stickers and newsletters, were produced and distributed to members of target populations.
Moreover, to integrate STI/HIV/AIDS prevention into primary health care services offered to villagers, VHEs also received training in first aid, midwifery, and the management of health huts and small pharmacies. As a result of this activity, beneficiary villages now have a comprehensive, community-based health care system where affordable and professional care can be obtained.
Results of a postintervention knowledge, attitudes, beliefs, and practices (KABP) survey of 1,000 persons aged 15 to 25 from 30 target villages highlighted the program's impact on the target population:
Key Findings of 1996 KABP Survey
- 84 percent had received STI/HIV/AIDS information from a VHE
- 96 percent had obtained greater knowledge of HIV/AIDS transmission modes
- 47 percent had reduced their number of sexual partners
- 28 percent reported greater acceptance or use of condoms.
Condom Promotion and Distribution
VHEs received training in condom storage, sales, and promotion and functioned as vendors for the national condom social marketing project. The social marketing project also established sales points at small pharmaceutical depots and stores located in villages throughout the district. By the end of the project, 190,996 condoms had been sold or distributed free-of-charge at promotional events to target populations.
Capacity Building
Creation of a local AIDS Advisory Committee (AAC) was a milestone for STI/HIV/AIDS prevention in Guiglo. The AAC, consisting of local NGO representatives, health care providers, and community representatives, oversaw the project's educational activities, established linkages with local and regional private organizations and government agencies, and coordinated outreach efforts in the district. By assuming managerial responsibility for all project activities, including recruitment, training, and supervision of VHEs, the AAC ensured the continuation of STI/HIV/AIDS prevention activities for target populations. Moreover, integration of prevention activities into the primary health care services offered to villagers increased the likelihood that authorities would consider STI/HIV/AIDS management a basic part of primary health care and be more willing to support related efforts in the future.
Implementing Partner
- Africare
AFRICA, Associate Countries: Lesotho
Epidemiology
AIDS was first reported in Lesotho in 1986, and by 1993 the cumulative number of AIDS cases had reached 348. Sentinel surveys conducted in 1993 among lowland populations showed HIV prevalence rates of 12 to 21 percent among samples of sexually transmitted infection (STI) patients and from 3 to 6 percent among antenatal clinic attendees. Data regarding HIV seroprevalence among highland populations are limited but suggest increasing prevalence.
Syphilis prevalence rates among lowland populations range from 7 to 9 percent, and STIs account for a significant morbidity among Basotho adults. Data collected by the Ministry of Health from 1983 to 1993 reveals that STIs are the second most common reason for outpatient visits to health care facilities in Lesotho. Sentinel surveillance data shows an alarming increase in the number of teenage STI patients, who accounted for 9.4 percent of all patients tested. Migration of many Basotho workers, who leave their families in Lesotho to work in South Africa, is a contributing factor to HIV/STI transmission because these workers frequently establish sexual relationships with South African women, and because their spouses in Lesotho may resort to commercial sex to increase their incomes.
Country Overview
The Kingdom of Lesotho, which is completely surrounded by South Africa, has a population of 1.8 million persons and is growing at an annual rate of 2.6 percent. Eighteen percent of the population live in urban areas. Lesotho has close economic and ethnic ties with South Africa and is economically dependent on its industrialized neighbor. Only 34 percent of Basotho households derive their main source of income from farming and livestock. Many Basotho find work in South Africa, and about 116,000 Basotho work in South African mines. A severe drought over the past 3 to 5 years has greatly reduced domestic food production, making the country even more dependent on South Africa. As the economic situation worsens (Lesotho's unemployment rate is approaching 30 percent), highly skilled professionals are emigrating to South Africa, resulting in a labor shortage in Lesotho.
With support from USAID/Lesotho, AIDSCAP initiated a two-year program to assist Lesotho's Ministry of Health (MOH) and nongovernmental organizations (NGOs) in reducing the sexual transmission of HIV among highly vulnerable groups, principally through STI prevention and control interventions, peer education to promote behavior change, and condom promotion and distribution.
Accomplishments
Although the AIDSCAP program ended prematurely with the closing of the USAID Mission, AIDSCAP was instrumental in strengthening the MOH's STI control services. In addition, AIDSCAP financial support and technical assistance to one indigenous NGO and two U.S. NGOs operating in Lesotho strengthened the capacity of these organizations to provide HIV/AIDS prevention information and condoms to high-risk groups, particularly in nonclinical, rural settings.
Strengthening STI Services
AIDSCAP's technical assistance to the MOH, coupled with its successful efforts to engage other international donors and coordinate their activities for STI control and prevention, resulted in the creation of a comprehensive STI control program for the entire country. Four elements comprised the STI component of the AIDSCAP/Lesotho program. First, with assistance from the World Bank, AIDSCAP-supported researchers completed etiological studies of nearly 7,000 STI cases and used these data to develop appropriate syndromic management protocols for STIs in Lesotho. Second, AIDSCAP, in collaboration with the MOH's STI and AIDS units, provided training in syndromic STI case management to all physicians and to providers in a majority of the country's government clinics. Third, AIDSCAP provided technical assistance in the development of reporting forms, partner referral forms and procedures, and drug use forms to support clinic-based STI control activities. Fourth, AIDSCAP dialogue with international donors, such as the World Bank and the European Union, generated interest in STI control, and these organizations provided financial support that enabled the MOH to obtain necessary laboratory supplies and drugs.
Behavior Change Communication
Behavior change communication (BCC) activities provided groups vulnerable to STI and HIV infection with the necessary knowledge and skills to reduce sexual risk taking. AIDSCAP and its collaborating NGOs developed a network of 146 peer educators who provided information and support to four targeted communities. One project promoted safer sexual practices by members of the professional football (soccer) teams that are so popular in Lesotho, particularly among the youth. More than 380 players and coaches not only received HIV/AIDS prevention information and condoms, but also participated in a "Footballers Against AIDS" educational campaign that targeted the wider community and was publicized in the mass and sports media.
With technical assistance from AIDSCAP's BCC unit, approximately twenty MOH and NGO staff members acquired skills in BCC materials development and designed and produced materials for peer educators and STI clinic attendees. Over the life of the program, AIDSCAP-supported peer educators distributed over 600,000 condoms and 10,000 educational materials to target groups.
Condom Promotion and Distribution
With funding from USAID/Lesotho, AIDSCAP subcontractor Population Services International developed an aggressive social marketing campaign to promote and sell Lovers Plus condoms to target populations in urban and periurban Lesotho. In 14 months, 250,000 condoms were sold through approximately 270 nonpharmacy outlets that had been established in locations convenient for groups at high risk of STI/HIV infection. Although initially controversial, the promotional campaign, which included radio, billboards, face-to-face communication, and the innovative use of puppet troupes, proved highly popular.
Capacity Building
Despite the relatively short duration of the program, AIDSCAP/Lesotho significantly improved the capacity of the MOH and its partner organizations to implement STI/HIV/AIDS prevention programs. As a provider of technical assistance and coordinator of STI-related donor activities, AIDSCAP helped to develop and institutionalize a national STI control program. Moreover, AIDSCAP's work with NGOs helped these organizations reach target populations with effective educational activities.
Implementing Partners
- CARE International
- Lesotho Red Cross Society
- Lesotho Ministry of Health
- Population Services International
- South African Institute for Medical Research
AFRICA, Associate Countries: Mali
Epidemiology
Although less severe than the HIV/AIDS epidemic in central and East Africa, the epidemic in Mali is a serious public health problem with an impending threat of rapid expansion. The first AIDS case was diagnosed in Mali in 1985, and within 10 years, 2,600 cases had been reported to the Ministry of Health. 1992 regional survey data compiled by the International Program Center of the U.S. Bureau of the Census showed HIV prevalence rates of 1 to 5 percent of the general population. In all regions except Sikasso, rates were higher among women than among men. HIV prevalence rates among commercial sex workers (CSWs) ranged from 16 percent in Gao to 74 percent in the capital city of Bamako and the regions bordering Côte d'Ivoire.
Country Overview
Mali, one of the landlocked Sahelian countries of West Africa, has a predominantly Muslim population of close to 10 million. Recognizing the need for early intervention in the epidemic, USAID committed support to the National AIDS Control Program (NACP) in 1990. These funds enabled AIDSCAP and the NACP to continue and expand a pilot intervention for brothel-based CSWs in Bamako that had been implemented by Family Health International (FHI) in 1988 with USA for Africa support. The broader two-year education and condom distribution project aimed specifically at educating CSWs and their potential clients about HIV/AIDS, the means of HIV transmission, and ways to reduce sexual risk taking. Encouraged by evaluation research indicating a significant increase in knowledge of HIV and condom use, USAID, through AIDSCAP, continued to support an expanded intervention from September 1992 through March 1995.
AIDSCAP/Mali targeted mainly women with multiple partners (WMPs) in the city of Bamako and the Segou and Sikasso districts with HIV/AIDS education and condom promotion and distribution. A complementary outreach project targeted the clients of WMPs through behavior change communication (BCC) sessions, drama presentations, and informal visits to bars and brothels. The ultimate goal of the intervention was to promote behavior change that reduces transmission of HIV and other sexually transmitted infections (STIs) among WMPs, bar patrons, and other groups at high risk, including transport workers and military personnel. The project also funded and trained local nongovernmental organizations (NGOs) to run HIV/AIDS prevention projects in Bamako.
Accomplishments
The AIDSCAP project, in collaboration with both national and international NGOs and governmental organizations, contributed to enhanced awareness of the existence and the dangers of HIV/AIDS among a large proportion of primarily urban Malians. Through its distribution of more than 2 million condoms free-of-charge, the program tackled existing prejudices and taboos and created a climate in which safer sex is increasingly negotiable. The quality of the project's relationship with WMPs made the use of condoms a group-enforced, standard code of behavior.
Sixty-eight bars and 15 brothels participated in the project, which trained a total of 328 peer and community educators. Those trained included 102 WMPs, 46 bar managers, 34 drivers, 60 military personnel, 22 health care providers, and 64 other persons. More than 150 brothel-based WMPs received systematic STI diagnosis and treatment during the life of the project, and over 16,700 target group members were educated on STI/HIV/AIDS prevention. In addition, AIDSCAP trained more than 200 NGO staff and local youth as HIV/AIDS peer and community educators. NGO initiatives reached an additional 1,849 individuals through interpersonal educational sessions, 24,976 through discussion groups, 25,256 at popular and cultural events, 37,691 at sports events, and more than 27,000 through local radio broadcasts.
Key findings of a knowledge, attitudes, beliefs, and practices (KABP) survey conducted at the end of the project include the following:
- Knowledge about HIV/AIDS and its transmission and prevention was high (94 to 95 percent) among all target groups.
- Close to 100 percent of brothel-based WMPs in Bamako reported using condoms with their clients, although use with regular partners remained between 30 to 40 percent.
- Sixty-five percent of bar patrons and transport workers reported condom use with their last nonregular partner.
- There was a remarkable decrease in STI prevalence among the brothel-based CSWs.
- Results from several STI surveys conducted by AIDSCAP and the World Bank showed that from 1991 to 1994
- prevalence of gonorrhea decreased from 72 to 11 percent.
- prevalence of Trichomonas vaginalis decreased from 15.6 to 4.1 percent.
- prevalence of syphilis decreased from 24 to 3.2 percent.
Many of the small, indigenous NGOs that started HIV/AIDS interventions under AIDSCAP's small grants program have since received long-term funding for activities in HIV/AIDS prevention and/or family planning through the Groupes Pivot et Survie de l'Enfant, a USAID-funded NGO umbrella organization, and Plan International, which is also funded by USAID. The training and experience received by these NGOs facilitated their access to such support.
Implementing Partners
- Ministry of Health, Solidarity, and the Elderly
- University of Washington
AFRICA, Associate Countries: Mozambique
Epidemiology
The national AIDS control program (NACP) estimates current adult HIV prevalence in Mozambique at about 8 percent, an increase from an average urban prevalence of 3 percent in 1987. Epidemiological surveillance data collected from 10 sentinel sites in provincial capitals and major commercial centers throughout the country indicate that the situation is deteriorating in key areas. Manica province, for example, registered an increase in HIV-positive women attending antenatal consultations from 11 percent in 1994 to approximately 20 percent in 1996, while HIV prevalence among antenatal attendants in the province of Tete increased from 18 to 22 percent. Of the reported 3,318 AIDS cases, slightly more than two-thirds occurred in the 20 to 39 age group. Sexually transmitted infection (STI) prevalence has also been increasing, with districts reporting an average of 801 cases per 100,000 population in 1996 compared to 640 per 100,000 in 1995.
Country Overview
The HIV/AIDS epidemic in Mozambique is at a critical junction. While HIV appears to have reached Mozambique later than neighboring countries, the movement of HIV across its borders has increased, resulting in rapid increases in HIV transmission. Factors fueling the epidemic include nearly 30 years of war, labor migration, major transportation routes to neighboring high-prevalence countries, rapid urbanization, high levels of poverty, insufficient health infrastructure, and significant rates of STIs. In addition, from 1993 to 1996 almost half of the population of Mozambique was highly mobile, including more than 1.7 million refugees returning from neighboring countries, 5.7 million internally displaced persons, and 270,000 demobilized soldiers and their families.
In fiscal year 1993, USAID/Mozambique funded AIDSCAP to conduct an assessment of the status of STI/HIV/AIDS, identify gaps in prevention programming, and recommend program areas for USAID. A limited number of activities would be implemented in fiscal year 1997, based on opportunities identified by the assessment.
The five-month AIDSCAP/Mozambique project was launched in April 1997. In line with the USAID Mission strategy, AIDSCAP/Mozambique sought to strengthen the capacity of private voluntary organizations and nongovernmental organizations (NGOs) working in HIV/AIDS prevention and to provide technical support to the Ministry of Health (MOH).
Accomplishments
AIDSCAP strengthened the MOH and NGOs by providing technical and material support to develop BCC materials (print materials, radio broadcasts, video and local theater productions) and to train community-based providers and peer educators in STI/HIV/AIDS prevention and condom promotion.
A video was produced to train local condom promotion groups in theater techniques that could be used to educate audiences about HIV/AIDS prevention. AIDSCAP trained a local actor, who in turn trained theater group participants in eight provinces to use drama to convey prevention messages and stimulate discussion about HIV/AIDS. In addition, videos of six different plays were produced for distribution. Population Services International's one-minute radio spots, already airing in Portuguese, were translated into 10 local languages.
The HIV/AIDS information, education and communication task force of the NACP, supported by AIDSCAP, produced a manual for community-based peer educators, a packet for STI clinic clients, and a translation of The Silent Epidemic, the Kenyan video on STIs. The manual for community-based educators was developed and pretested, and 5,000 copies were produced and distributed. Clinic packs, which contained two partner referral cards, two pamphlets with STI information, condoms, and condom use instructions, were also pretested, and 50,000 were produced and distributed. In addition, six AIDSCAP BCC booklets and two new episodes of the popular comic book, Emma Says, were translated into Portuguese and produced for distribution.
Ten community-based educators received training to teach community-based volunteer health workers about STI/HIV/AIDS prevention, reproductive and sexual health, family planning, and gender issues. As a result, a total of 406 volunteer health educators were trained in 22 villages in two districts in Gaza Province.
AIDSCAP also supported a new group for out-of-school male youth in Maputo. The group's social activities and sporting events developed and nurtured an interest in healthy activities and included educational sessions on topics related to STIs/HIV/AIDS control and prevention.
Implementing Partners
- Mozambique Red Cross
- Muleide
- Population Services International
- Save the Children
AFRICA, Associate Countries: Niger
Epidemiology
The first AIDS case in Niger was reported in 1987, and by December 1994, 1,729 cumulative AIDS cases had been reported. Data from HIV sentinel surveillance in Niger show a prevalence of less then 1 percent in the general population. The national AIDS control unit's 1992 sentinel data found HIV prevalence of 1.1 percent among women attending antenatal clinics in the capital city of Niamey, 1.4 percent for the Tahoua region, 0.89 percent in Maradi, and zero prevalence in Zinder. Prevalence was higher among high-risk groups, with HIV prevalence rates for commercial sex workers (CSWs) at 14 percent in Arlit and 15.4 percent in Niamey in 1993. A 1994 study found that 3 percent of truckers in Niamey and Dosso were infected with HIV.
The eleventh most frequently diagnosed disease at health care facilities is sexually transmitted infection (STI). In Niamey, syphilis prevalence was 4 percent among pregnant women and 26.8 percent among CSWs in 1993. Of 2,133 clients treated at a Niamey public STI clinic from 1993 to 1994, 19.6 percent were diagnosed with chancroid, 40.5 percent with gonorrhea, and 2.5 percent with syphilis.
Country Overview
Niger is a largely agrarian Sahelian country with an estimated 1993 population of 8.6 million. The vast majority of the people live in the southern quarter of the country, where the land is most suited to agricultural activities. Farming and herding are the major economic activities of 80 percent of the population.
In 1991, due to the rise in HIV prevalence among its clients, the Directorate of Hygiene and Mobile Medicine (DHMM) initiated a 20-month pilot HIV/AIDS prevention project with Family Health International to reinforce its STI diagnosis and prevention activities with CSWs and STI patients. The success of this intervention led to an expanded HIV/AIDS prevention project in 1992, which was supported by USAID through AIDSCAP and implemented by the Directorate of Surveillance, Epidemiology and Prevention (DSEP, formerly DHMM). The goal of AIDSCAP/Niger was to reduce the rate of STI/HIV infections among high-risk groups in Niamey.
Accomplishments
The AIDSCAP-supported project targeted CSWs, truck drivers, and STI clients, offering peer education, condom promotion and distribution, and improved STI diagnosis and treatment. It was implemented by DSEP, which also serves as an urban referral center for the diagnosis and treatment of STIs. By the end of the project, a total of 6,737 target population contacts had been made and more than 1.14 million condoms had been distributed.
Behavior Change Communication
Peer education was the primary behavior change communication (BCC) strategy employed in Niger. The CSW component covered eight urban communities in Niamey, training 29 CSWs as peer educators and educating 3,431 CSWs about HIV/AIDS prevention. End-of-project knowledge, attitudes, beliefs, and practices (KABP) surveys indicated an increase in condom use and more accurate risk perception among CSWs as a result of peer education activities. Transport workers in three unions and one trucking company also participated in peer education activities, which reached 1,173 truckers with BCC messages through the efforts of 57 trained volunteers. Educational materials such as buttons, T-shirts, bumper stickers, and key chains were produced and distributed to reinforce BCC messages.
Strengthening STI Services
AIDSCAP trained 10 DSEP clinical staff in diagnosis and treatment of STIs, and four laboratory staff in STI diagnostic techniques. It also provided diagnostic reagents to the DSEP laboratory. STI clinic staff counseled 2,133 STI patients in risk assessment and HIV/AIDS prevention. In addition, more than 10,000 screening tests for syphilis were performed on blood from antenatal clients and STI clinic attendees. With AIDSCAP technical assistance, health care professionals from all regions of Niger worked to develop national STI treatment guidelines, which included diagnostic and treatment protocols. These protocols were subsequently submitted to the Programme National de Lutte Contre le SIDA for pilot testing.
Key Outcome Data
KABP surveys were conducted among 200 female CSWs and 200 male truckers in 1994 and compared to similar surveys conducted among CSWs in 1991. The results of the survey comparison are as follows:
In 1994, 96.4 percent of women surveyed reported using condoms with 5 or more of their last 10 sexual partners, compared to 22 percent in 1991.
In 1994, 57 percent of men surveyed reported having sexual relationships with CSWs, and only 13 percent of these men reported using condoms. No baseline comparison is possible because men were not surveyed in 1991.
Over 80 percent of women perceived their risk of HIV/AIDS infection as high in 1994, compared with 2 percent in 1991.
In 1994, 75 percent of men surveyed reported their risk of HIV/AIDS infection as high.
Implementing Partners
- Direction de la Surveillance Epidémiologique et de la Prevention (DSEP), Ministère de la Santé Publique
AFRICA, Associate Countries: West Africa
Epidemiology
The West African countries of Benin, Burkina Faso, Cameroon, Côte d'Ivoire, and Togo, with a combined population of approximately 48 million, have more than 22,000 AIDS cases. Moreover, HIV seroprevalence among sexually active populations in these countries ranges from 3.1 percent in Benin to 10 percent in Côte d'Ivoire and parts of Burkina Faso. Côte d'Ivoire has the highest HIV prevalence in West Africa. Migration, sex with multiple partners, women's lack of decision-making power, and untreated STIs have exacerbated the STI/HIV/AIDS situation in the region. Migration across international borders to trade or find employment occurs on a massive scale and plays a major role in the spread of the epidemic. For example, an estimated 300,000 persons travel yearly on the Ouagadougou, Burkina Faso to Abidjan, Côte d'Ivoire route. Migrant workers stay in host countries for 5 to 9 months a year, and often engage in sex with multiple partners or commercial sex workers (CSWs) while away from their families. Other migrant workers resort to commercial sex to survive and support their families. Moreover, social and cultural norms throughout West Africa generally give women minimal sexual decision-making power. As a result, women and girls are particularly vulnerable to the threat of HIV/AIDS. Access to reproductive health services, including treatment for sexually transmitted infections (STIs), is limited for most West Africans.
Overview
West Africa, 3.1 million square miles of the African continent stretching from Senegal to Cameroon, consists of 19 countries and is inhabited by more than 206 million people. Although the region shows considerable geographical, social, and cultural diversity, the countries constituting West Africa share similar transnational concerns and constraints in providing reproductive health and STI/HIV/AIDS prevention services. In 1996, in recognition of the potential effectiveness and cost-efficiency of developing regional approaches to address these concerns, USAID's Regional Economic Development Services Office (REDSO) for West and Central Africa, in collaboration with numerous American and African nongovernmental organizations (NGOs), initiated the five-year Family Health and AIDS (FHA) Project in West and Central Africa. AIDSCAP assisted in the development and start-up of this project's STI /HIV/AIDS component, which targeted five West African nations -- Benin, Burkina Faso, Cameroon, Côte d'Ivoire, and Togo -- and consisted of five primary program areas: HIV/AIDS counseling and testing, HIV/AIDS prevention among migrants, STI case management, gender-sensitive prevention programming, and NGO capacity building.
Accomplishments
Counseling and Testing
AIDSCAP assisted an Ivoirian NGO, Espoir/Centre d'Information et de Prévention du SIDA en Côte d'Ivoire (ESPOIR-CIPS), in assessing the type and quality of, and demand for, HIV counseling and testing (C&T) services in Benin, Burkina Faso, Cameroon, and Togo. Based on the assessment, a plan was developed to strengthen each country's C&T services. In addition, initial management training was conducted with ESPOIR-CIPS to develop its capacity to function as a resource and training center for the region.
HIV/AIDS Prevention Among Migrants
Three NGOs began an HIV/AIDS prevention intervention among migrants with technical assistance from AIDSCAP. The Association des Femmes Africaines Face au SIDA au Burkina Faso, Economie Formation et Développment en Côte d'Ivoire, and the Union des Routiers Burkinabè de Lutte Contre le SIDA, created a cross-border network of 103 truck drivers, CSWs, and migrant plantation workers who served as peer educators along the main road between Burkina Faso and Côte d'Ivoire. AIDSCAP assisted in identifying and training the peer educators, who subsequently provided over 2,550 peers with skills to reduce sexual risk taking and distributed over 33,000 condoms. AIDSCAP also assisted in the development of a variety of behavior change communication materials, such as leaflets, posters, billboards, TV and radio spots, and condom demonstration models, to support the peer educators. To ensure an adequate condom supply, the NGOs, with the assistance of condom social marketing projects operating in Côte d'Ivoire and Burkina Faso, established condoms sales outlets readily accessible to truckers, CSWs, and migrant workers.
Strengthening STI Services
To support the efforts of the Johns Hopkins Program for International Education and Training in Reproductive Health and the Morehouse School of Medicine to integrate STI management into family planning services, AIDSCAP sponsored a training-of-trainers workshop in syndromic STI case management for 16 clinicians from family planning clinics operated by the International Planned Parenthood Federation's affiliate in Côte d'Ivoire. As a result of this initiative, one Ivoirian clinic will now serve as a regional center for future training in syndromic STI case management.
Gender-Sensitive Programming
AIDSCAP, Johns Hopkins University, and REDSO's Women in Development Unit conducted a workshop in which participants from regional ministries of health, partner NGOs, and chapters of the Society for Women in AIDS in Africa designed pilot initiatives sensitive to the problems and HIV/AIDS prevention needs of West African women and girls. Participants also developed guidelines for the use of a funding mechanism to implement the proposed pilot programs.
Capacity Building
AIDSCAP collaborated with the Cameroon Health Project in strengthening the management skills of the three African NGOs implementing the FHA Project. Technical assistance focused on transfer of program design, budgeting, training of peer educators, evaluation, and reporting skills.
Implementing Partners
- Academy for Educational Development
- Association des Femmes Africaines Face au SIDA au Burkina Faso
- Cameroon Health Program
- Economie Formation et Développement
- Espoir/Centre d'Information et de Prévention du SIDA en Côte d'Ivoire
- John Snow, Inc./Research and Training Institute
- Johns Hopkins Center for Communications Programs
- Morehouse University
- Population Services International
- Tulane University School of Public Health and Tropical Medicine
- Union des Routiers Burkinabè de Lutte Contre le SIDA
AFRICA, Associate Countries: Zambia
Epidemiology
As early as 1990, HIV prevalence in Zambia was among the highest in the world. Although HIV/AIDS epidemiological data were not comprehensive and were at times ambiguous, 1990 sentinel survey results showed an HIV prevalence of over 25 percent among urban and periurban antenatal attendees. Data from university students donating blood in Lusaka in 1990 found that 22 percent were HIV-positive. The impact of these high prevalence rates among groups considered representative of the general public will be dramatic increases in morbidity and mortality, decreased productivity of the workforce, and the deterioration of social structures.
Clients at sexually transmitted infection (STI) clinics are at particularly high risk of contracting HIV infection. Of the approximately 170,000 cases seen each year at the 47 STI clinics under Zambia's national STI program in the early 1990s, an estimated 55 to 75 percent were HIV-positive.
Gonorrhea is the most commonly diagnosed STI in Zambia. In 1993, gonorrhea represented 21.8 percent of all reported cases of STIs in the 38 clinics reporting to the national STI unit. At that time, laboratory facilities were used for diagnosis in 75 percent of cases of urethral discharge in men. Penicillin-resistant gonorrhea was first identified in Zambia in 1980.
Country Overview
According the Ministry of Health (MOH), STIs are one of the five primary reasons for outpatient clinic attendance among adults in Zambia. In 1993, when the STI control program was joined with other programs to form the Zambian National AIDS/STI/Tuberculosis/Leprosy Program, the need to increase the capacity to diagnose and treat STIs at first encounter with the health care system was identified as a fundamental goal.
AIDSCAP sought to reduce the incidence and transmission of STIs through improved case management and greater availability and access to prevention information. The primary target groups were health care providers who could be trained in syndromic management and community members who could be trained as peer educators. The secondary target groups were community members who either had an STI or were at risk of contracting an STI.
Accomplishments
AIDSCAP supported three projects in Zambia: a gonococcal susceptibility study conducted in conjunction with UNICEF and two training and behavior change communication materials development interventions.
In 1995, a study was carried out to determine the antibiotic susceptibility of Neisseria gonorrhoeae and to identify the possible factors influencing the infection pattern in selected populations in Lusaka and Ndola. This information could then be used to make recommendations for appropriate treatment guidelines for gonococcal urethritis. A total of 218 isolates were tested, the majority from the Lusaka area. Based on the study findings, which were shared with the MOH, AIDSCAP recommended that penicillin and tetracycline be abandoned as treatment for gonococcal infection and identified alternative drugs (streptomycin, ciprofloxacin, cefriaxone, and Kanomycin).
AIDSCAP also supported Project Concern International to upgrade the training facilities at University Teaching Hospital and assist with the development of a 3-week residential course, including clinical practice, to train trainers of clinical officers, midwives, and nurses in syndromic STI management. Forty-six health care providers were trained at the district level. As a result, for the first time Zambia has nurses and clinical officers at the district level trained in these STI management skills. In addition, teaching aids, which included color slides, manuals, and wall charts, were developed and distributed.
With AIDSCAP support, Morehouse University trained 69 health care providers from 41 public, parastatal, and private clinics in the Ndola urban area in the syndromic approach to STI management. In addition, 12 peer educators were trained, who in turn reached 18,751 community members with STI/HIV/AIDS prevention messages. Four STI clinics were upgraded, and a total of 1,383 STI clients were treated over a 5-month period. More than 1.8 million brochures and posters were produced in several indigenous languages, 2,000 syndromic management cards were distributed to health care providers, and 1,230 video cassettes of 10 video dramas and 40 audio cassettes of 10 radio dramas were produced and distributed in both English and indigenous languages.
Surveys to assess the quality of STI case management were carried out in Ndola health facilities before and after the training of health care providers in the syndromic approach. The results for World Health Organization (WHO) prevention indicator 6 (PI 6), which measures the proportion of individuals presenting with specific STIs in health facilities who are assessed and treated according to national standards, showed that there was a statistically significant improvement in physical examination and treatment of STI patients from one survey to the other. However, at 33 percent, the score for treatment was still low.
WHO PI 7 measures the proportion of patients presenting to health facilities with STI symptoms who receive appropriate condom and partner notification advice. The results of the PI 7 survey indicate that although there was a numerical increase in the positive scores for condom advice and partner notification, as well as for the overall final score for both variables from one survey to another, the differences were not statistically significant. The scores for the second survey, however, were high, with 73 percent of the surveyed clients receiving appropriate condom advice and 98 percent receiving partner notification advice.
Implementing Partners
- Institute of Tropical Medicine
- Project Concern International
- Morehouse School of Medicine
