Condom Promotion and Distribution

AIDSCAP collaborated with a large, ongoing national condom social marketing project to create sales outlets convenient to target populations and to incorporate condom distribution into NGO activities. AIDSCAP-supported NGOs sold over 820,000 condoms and distributed another 261,000 free-of-charge to target groups. Moreover, the social marketing project sells over 50 million condoms per year. Focus group discussions with members of all AIDSCAP target populations indicate that people who want to use condoms have no difficulty finding them.

Strengthening STI Services

Reliable data about STI prevalence in Nigeria exist only for syphilis; 1993-94 surveys showed a national prevalence rate of 3.8 percent. As a result of AIDSCAP-sponsored training in STI syndromic management, over 200 private doctors, nurses, pharmacists, and nonpharmacy medicine vendors practicing in 15 states now provide more effective STI case management. Based on pre- and post-training evaluation, providers are now more likely to diagnose STIs correctly, offer an effective treatment regimen, provide counseling on prevention, and promote condom use. In addition, trained, nonpharmacy medicine vendors are more likely to refer clients to providers who can legally prescribe antibiotics. Perhaps the most powerful indicator of the importance of AIDSCAP's activities to improve STI treatment capacity is the demonstrated willingness of Nigerian health care professionals to pay for the syndromic management training.

Policy Development

Mindful of the prohibition on collaboration with the Nigerian government, AIDSCAP, through one of its partner NGOs, affected public education policy by assisting in the development and incorporation of HIV/AIDS prevention components into the curricula of university and secondary school students. AIDSCAP/Nigeria's involvement with the private sector was more extensive. The program assisted 12 corporations -- located in Lagos, Cross River, and Jigawa states and ranging in size from private hospitals to large oil and manufacturing companies -- to formulate corporate HIV/AIDS policies and implement HIV/AIDS-prevention interventions in the workplace.

Capacity Building

AIDSCAP/Nigeria focused on building three regional networks of NGOs capable of implementing STI/HIV/AIDS prevention activities. Technical assistance to strengthen the capabilities of partner NGOs focused on four key components: technical skills, management and organizational skills, organizational systems development, and networking and global learning enhancement. NGOs were encouraged to participate in project design and implementation. Results of a capacity building survey conducted with each NGO's staff indicated that capabilities in technical areas (BCC materials development, training of trainers, condom programming) increased dramatically as a result of AIDSCAP assistance. Moreover, all members of AIDSCAP's NGO network reported strengthening of certain key management systems, including finance, budgeting, and project monitoring.

Special Features

Because of political constraints, AIDSCAP/Nigeria worked almost exclusively with the private sector to stop the spread of HIV. As part of this effort, the program's Rapid-Response Fund, one of the largest in AIDSCAP's entire program, provided opportunities for more than 100 local NGOs and community-based organizations to contribute to HIV/AIDS prevention efforts in Nigeria and to gain valuable experience in collaborating with donor organizations and managing interventions. Several of these NGOs were created specifically in response to the HIV/AIDS epidemic and were, therefore, young, small, and inexperienced in implementing activities. However, by capitalizing on their enthusiasm and commitment to stop the epidemic, AIDSCAP/Nigeria helped make these NGOs more effective vehicles for preventing STI/HIV/AIDS in their communities.

In keeping with the current USAID Mission strategy, AIDSCAP/Nigeria integrated its HIV/AIDS prevention activities with the activities of other U.S.-based implementing agencies and Nigerian NGOs addressing health related concerns, such as family planning, maternal and child health, and child survival. This integration, which necessitated planning sessions with all involved organizations, was accomplished by including an STI/HIV/AIDS prevention component into the training curricula for the community outreach workers of these organizations and by developing mechanisms for these organizations to receive and distribute condoms to their target communities.

Implementing Partners

Africare

B.E. Medical Services, Ltd.

Cross River AIDS Committee

Federation of Muslim Women Associations of Nigeria

Health Matters, Inc.

International Center for Research on Women

Jigawa League of NGOs

Jigawa State Youth AIDS Program

Lagos NGO Consortium

Media Health Alliance

National Council for Women's Societies

NGO Consultative Group

Nigerian Society for Environmental Management and Planning

Nigeria Youth AIDS Program

Nka Iban Uko in Calabar

Program for Appropriate Technology in Health

Society Against the Spread of AIDS

STOPAIDS

University of Calabar

Women in Nigeria

AFRICA, Major Countries: Rwanda

Epidemiology

In 1986, the first national HIV serological survey indicated that HIV seroprevalence was slightly over 1 percent in rural areas, and approximately 18 percent among the urban population. Data from antenatal clinics in Kigali showed that HIV seroprevalence was increasing among pregnant women by approximately 3 percent a year between 1988 and 1990. In 1991, the rate among antenatal women in Kigali was 27 percent, and among semiurban and rural antenatal women the rates were 10 percent and 2.2 percent, respectively. Among sexually transmitted infection (STI) clinic patients in Kigali, HIV rates were 70 percent for women and 49 percent for men in 1991, and rates in commercial sex workers (CSWs) were 90 to 100 percent.

Before the genocide of April 1994, the HIV/AIDS epidemic showed some signs that it had reached a plateau, as 1991 sentinel sites showed decreases in HIV/AIDS rates for both pregnant women and STI patients. It is assumed that HIV spread dramatically during and after the April 1994 war. A variety of factors associated with the war are believed to have affected the epidemiological profile of HIV/AIDS in Rwanda, including massive migrations, breakdown of traditional families and values, sexual violence, and the relocation of hundreds of thousands of rural Rwandans in refugee camps.

A study of 500 pregnant women screened in May 1995 at the Centre Hospitalier de Kigali found that HIV prevelance was 24.5 percent and syphilis prevalence was 10 percent. Rates of HIV infection did not vary based on place of residence before the war, although 41.8 percent of the overall study population were recent migrants to Kigali. In 1996, the Programme National de Lutte Contre le Sida (PNLS) reactivated its serosurveillance system, establishing 10 sentinel posts in rural and urban areas. The 1996 data show seroprevalence rates of 3.6 percent in rural Kigali and 32.6 percent in Kigali city. In three of the ten sites, rates exceeded 22 percent. Among STI patients, the rates were 54.5 percent at Biryogo (Kigali), 29 percent at the Centre Hospitalier de Kigali, 42.3 percent at Kabgayi (Gitarama), and 13.2 percent in rural Kigali.

Country Overview

Rwanda, a landlocked and mountainous country of approximately 10,000 square miles located in the Great Lakes region of eastern Central Africa, is among the most densely populated and least urbanized countries on the continent. Ninety percent of Rwandans live in rural areas and engage in subsistence farming. Prior to the 1994 civil war and its subsequent population exodus, Rwanda had a population of 7.2 million, primarily Catholic, with a literacy rate of just under 50 percent. Civil war plagued the country intermittently from 1990 through mid-1993, when warring factions signed a peace accord. In April 1994, however, the assassination of the Rwandan president precipitated 3 months of intense warfare and ethnic genocide. It is estimated that close to 1 million people lost their lives. Following the Rwanda Patriotic Army's victory in July 1994, people displaced by the war began returning to their homes. More recently, with the closing of refugee camps in Tanzania in December 1996 and the civil war in Zaire in 1997, most civilian refugees have returned to Rwanda, although some are still internally displaced and waiting resettlement. The country continues to suffer from rebel insurgencies, mostly by Hutu ex-soldiers loyal to the previous regime.

In 1987 the Rwandan Government decided to establish the PNLS. By the early 1990s, seroprevalence among antenatal women had reached a rate of close to 30 percent in the capital city of Kigali.

The USAID-supported AIDSCAP program was designed to contribute to the national efforts to reduce the rate of sexual transmission of HIV by building the capacity of governmental and nongovernmental organizations (NGOs) to implement HIV/AIDS prevention interventions. The project focused on three mutually reinforcing strategies -- STI control, accessibility to and acceptability of condoms, and implementation of communication strategies aimed at reducing sexual risk taking -- implemented at the national and regional levels. Nationwide activities included condom social marketing, institutional strengthening of the PNLS, and mass media programming. Regional activities included interventions with STI patients, youth, single and married women, and military personnel. Refugees were reached under a separate community-based intervention at the Benako camp in the Ngara district of Tanzania.

Accomplishments

The AIDSCAP/Rwanda program was implemented by the PNLS of the Ministry of Health in collaboration with the Medical Services of the Ministry of Defense, the Gitarama Health Region, the Centre d'Information, Documentation, et Counselling (CIDC), and international and local NGOs. National interventions included the condom social marketing program implemented by Population Services International (PSI); support to the PNLS to coordinate nationwide prevention efforts, with an emphasis on STI control using the syndromic approach; and support to the CIDC to improve the quality of communication resources in Rwanda. The comprehensive and integrated population center activities included education and prevention counseling by peer educators and health care providers for military personnel, antenatal women, single and widowed women, youth, STI patients, and commercial sex workers.

The AIDSCAP Rwanda program distributed over 4 million condoms and sold over 3 million through the condom social marketing program. National STI treatment guidelines were adopted in April 1995, using results from the prewar operations research conducted by AIDSCAP and the Rwanda Integrated Maternal Health Project (RIM), and implemented in seven of the 11 medical regions. In a country with low literacy rates, a tradition of oral communication, and a wide reach of radio, mass and alternative media played a key role in diffusing messages on safer sex, condom use, abstinence, and fidelity for both the general population and specific target groups. Rapid-response funds were used to support small interventions to reach CSWs, disadvantaged women and youth, and HIV-positive people with prevention messages, and, in the case of CSWs, with STI treatment at highly reduced cost.

Behavior Change Communication

AIDSCAP/Rwanda's behavior change communication (BCC) strategy included formative and audience research to guide the interventions, the choice of communication channels, and the development of appropriate messages and materials. The strategy also included training of staff and volunteers in the use of prevention messages, demonstrating condom use, and encouraging health-seeking behavior.

The program combined a variety of approaches to influence behavioral change among its target populations. It used the peer educator approach with military personnel, young and single women, youth, and CSWs. Antenatal women and STI patients were reached at primary health care clinics with prevention counseling provided by trained social workers and other health care staff. Community-based outreach programs worked through head-of-household women, elected, head-of-sector women, and community health volunteers to reach women, youth, and CSWs. The combined programs reached over 300,000 people with BCC and prevention messages.

Mass and alternative media were used extensively to support and reinforce the prevention messages being communicated through educational sessions and informal chats. These media activities included fashion shows, song festivals, drama, skits, video presentations, and radio soap operas, music programs, and radio talk shows. A play and discussion guide specifically developed for young adults was part of an HIV/AIDS prevention program introduced in 23 schools in the Kigali prefecture. Over 4,000 media messages were aired, and over half a million educational materials were distributed in support of BCC, condom, and STI activities.

Strengthening STI Services

The AIDSCAP program was instrumental in the adoption of national treatment guidelines, a prerequisite for upgrading STI services in the country. Following a March 1995 consensus meeting on STI case management guidelines, the Ministry of Health, with financial support from the World Health Organization and technical assistance from AIDSCAP, trained a core of 38 trainers in syndromic management, prevention counseling, and partner referral. A total of 521 service providers were trained in syndromic diagnosis treatment of STIs according to Rwandan guidelines. Training also focused on partner referral and other elements of counseling, such as condom use and compliance with prescribed drug regimens. Thirty-one trained social workers reached more than 90,000 antenatal women and STI patients through group prevention counseling at primary health care centers.

An evaluation of the STI component of the AIDSCAP program by the Institute of Tropical Medicine (Antwerp) in February 1997 revealed that the appropriate drug chosen in 94 percent of STI drug prescriptions in the Gitarama Project site, 74 percent of STI prescriptions in the military site, and in 46 percent of STI prescriptions in the PNLS project areas. According to the study, correct case management was found in 93 percent of the STI cases in the Gitarama Health Region, 77 percent in the Kigali Health Region, and 67 percent in the military health center surveyed. Condoms were available in 11 of the 14 centers surveyed, and the three centers where condoms were not available were affiliated with the Catholic church. The program developed a training manual for syndromic management, a wall chart with syndromic algorithms, and a pocket guide for prescribers, were distributed to all participating clinics.

Condom Promotion and Distribution

Behavioral research data at the time of the program design showed that despite high knowledge of HIV/AIDS and its modes of transmission, condom use was very low. Therefore, the condom programming strategy aimed to increase and improve condom accessibility, educate Rwandans about HIV/AIDS, and promote condom use as an effective prevention strategy.

As a result of PSI's marketing efforts, average national monthly sales reached 230,000 by August 1996. Fifteen hundred condom sales outlets were opened during the 19 months of postwar AIDSCAP support. Additional outlets were established by NGOs and independent wholesalers. Access to condoms has been increased, with 71 percent of condoms being purchased from four widely accessible outlet categories: boutiques/kiosks, clinic/health centers, pharmacies, and community-based outlets.

Social marketing of condoms was effective, despite the mass movement of people and the destruction of the infrastructure during the war, because the private sector was one of the first components of the Rwandan society to reorganize and because people were willing to buy condoms despite severe economic constraints. In addition to the 3.15 million Prudence condoms sold, the project distributed over 1 million condoms through its peer education, outreach, and community-based programs.

Capacity Building

Under the AIDSCAP program, Rwandan NGOs and governmental institutions developed a core staff capable of conducting formative and audience research and developing materials based on effective communication theories and practices. CIDC and other implementing partners now use a systematic process of audience segmentation and research to guide message development and involve their target audiences in the design and pretesting of materials and messages.

Special Features

In response to the displacement of hundreds of thousands of Rwandans, AIDSCAP implemented the first large-scale HIV/AIDS prevention program for refugees. By August 1994, AIDSCAP had reoriented its activities to the Rwandan population living in refugee camps in northwestern Tanzania along Rwanda's eastern border. CARE International, assisted by John Snow, Inc. (JSI), and PSI, launched a community-based STI/HIV/AIDS prevention program in the CARE-managed Benaco camp in Tanzania. The activities gradually expanded to three other refugee camps in the Ngara District. Trained community volunteers and NGO personnel provided information and counseling to 90 percent of the adult population. STI treatment was provided at most NGO outpatient clinics by providers trained by the African Medical Research and Education Foundation (AMREF).

Through continued formative research, the project responded to changing community needs. A home-based component was added to provide help to, among others, people living with AIDS. A group of women volunteers set up a soup kitchen to provide food for the home bound. A crisis intervention team was created to provide social, legal, and medical support to women and young girls who had experienced sexual violence. Young adults were reached in other ways, including adolescent health days, which were held to acquaint teenagers with the health care services available to them, and sporting events, such as soccer matches. Not only did these events keep young people occupied, but they also offered opportunities to convey HIV/AIDS messages to large audiences through traditional dance and songs at halftime.

Working with refugees stretches the boundaries of traditional prevention programming. The project's experiences in the Ngara District offered numerous insights for future work with refugees, including the following lessons:

• Planning HIV/AIDS prevention programming for refugees requires flexibility, creativity, and cultural sensitivity. Behavior change comes slowly in any environment, but in a refugee camp where people struggle with survival issues far more real to them than HIV/AIDS, changing sexual behavior is a monumental task. Yet the project has shown that it is possible to successfully engage refugees at many levels to reduce sexual risk taking, largely through empowerment and enabling strategies.
• HIV/AIDS prevention programming for refugees cannot be successful if it does not address the vulnerability of women and young people struggling through social crisis. Women need assistance in developing both self-esteem and opportunities to generate income so they can resist coercive sexual advances that offer short-term financial benefits but are detrimental to their health in the long term. Young refugees also need assistance, especially when their family members have disappeared.
• Coordinating the work of relief agencies and prevention programs is particularly important in a refugee setting. In the Ngara District, several organizations that shared the same objectives were able to divide the tasks involved in both HIV/AIDS prevention and home care to avoid duplication. Daily collaboration and weekly meetings made such coordination possible.

Implementing Partners

Ministry of Health: Programme National de Lutte Contre le Sida

Ministry of Defense: Division of Medical Services

Ministry of Health: Region Medicale de Gitarama

Centre d'Information, Documentation et de Counselling (CIDC)

Population Services International, Kigali (PSI)

CARE International, Kigali

Bilyogo Health Centre, Kigali

Cor Unum, Kigali

Caritas, Kigali

Rafiki Club, Kigali

Refugee Program

Care International, Tanzania

Population Services International (PSI)

John Snow, Inc. (JSI)

AFRICA, Major Countries: Senegal

Epidemiology

Statistics from the Programme National de Lutte Contre le SIDA (PNLS) of Senegal show that in 1993 there were 911 cumulative documented AIDS cases in Senegal, and the prevalence of HIV among hospital patients in 1993 was 15.9 percent. By May 1995, the number of AIDS cases had risen to 1,573 -- a 73 percent increase in 2 years. As of June 1997, 80,000 HIV/AIDS infections had been reported. The most recent data from the PNLS show that rates of HIV infection among pregnant women seen at maternity clinics range from 0.5 to 1.5 percent in major cities. The highest levels of HIV prevalence -- 10 to 16 percent in 1995 -- are among registered commercial sex workers (CSWs). The overall prevalence rate is currently 1 percent, with the ratio of men to women approximately 3:1. Senegal is characterized by a high prevalence of HIV-2. Persons infected with HIV-2 develop AIDS more slowly than those infected with HIV-1 and may infect others for a longer period while remaining in apparently good health.

Country Overview

Senegal has a population of 8.3 million persons, primarily Muslim and primarily of the Wolof ethnic group. Forty-five percent of the population live in urban areas, with the majority of urban residents living in the cities of Dakar, Thies, and Kaolack.

Following the first identified AIDS case in 1986, the Government of Senegal (GOS), in collaboration with the World Health Organization and other donors, developed a blood screening program, a surveillance system, a public information program, and two Medium-Term plans to fight the epidemic.

Beginning in 1992, AIDSCAP/Senegal sought to strengthen the capacity of Senegalese institutions to implement HIV/AIDS prevention and control programs, with the goal of reducing the rate of sexually transmitted HIV infection in Senegal. The program focused primarily on four geographic regions -- Dakar, Thies, Kaolack, and Ziguinchor -- and on urban populations. The targeted populations were men and women with sexually transmitted infections (STIs); men and women with multiple partners, including CSWs and their clients and regular partners; women in the marketplace; truck drivers and male employees of other industries; and youth.

Accomplishments

The AIDSCAP/Senegal program supported 24 organizations and institutions and 34 local associations, and provided technical assistance and training to PNLS, public and private health care structures, religious and opinion leaders, and educational facilities. The program consisted of targeted interventions to encourage positive behavior change; improve STI service delivery; improve research and surveillance (both behavioral and biological); stimulate policy dialogue to increase the awareness of religious leaders and policymakers of the impact of the epidemic; and improve the quality of HIV/AIDS prevention activities, including condom promotion and distribution, materials development, and mass media campaigns.

Behavior Change Communication

Of the 58 organizations that received AIDSCAP support, 49 conducted targeted behavior change communication (BCC) interventions. This number includes 34 small local associations (such as women's and youth associations) that received Rapid-Response Fund (RRF) grants to conduct short-term activities within their communities and among the members of their associations. These RRFs provided first-time funding for many of these associations.

1997 BSS Results

• More than 90 percent of persons surveyed have knowledge of two or more methods of prevention.
• 85 to 99 percent of persons surveyed know where to procure a condom.
• 77 to 93 percent of persons surveyed can state their risk of infection with appropriate justification.
• 67 to 81 percent of males reported using a condom during last sex act with an occasional partner.

Behavioral Surveillance Survey

A behavioral surveillance survey (BSS) was implemented during the fifth year of program implementation to collect relevant baseline data on sexual behavior in the following target groups: male and female secondary school students, male and female university students, male workers, and registered CSWs. Data from various knowledge, attitudes, beliefs, and practices (KABP) surveys and data from the first round of the BSS in Senegal suggest that awareness about HIV/AIDS, knowledge of prevention, and the use and availability of condoms all increased during the AIDSCAP program.

Strengthening STI Services

The STI component of AIDSCAP/Senegal sought to strengthen the capacity of public and private sector health care providers, located in the target regions, to diagnose and treat STIs, and to integrate education, prevention counseling, and the provision of condoms into STI services. AIDSCAP collaborated with the PNLS and other partners to develop, validate, and disseminate national guidelines for the diagnosis and treatment of STIs. Subsequently, 1,167 health care workers were trained in the use of these guidelines, including STI prevention education, and counseling methods. In addition, equipment was supplied to public and private health care facilities.

Policy Dialogue

Recognizing the important role of community leaders in behavior change communication, AIDSCAP targeted key religious leaders and policymakers for HIV/AIDS education and policy dialogue. The goal of these interventions was to increase the knowledge of religious and opinion leaders about the HIV/AIDS epidemic and encourage their support for and participation in HIV/AIDS prevention activities. Six regional seminars for opinion leaders and a seventh seminar for parliamentarians were held, as well as two national seminars on HIV/AIDS and religion involving both Muslim and Christian leaders. By the end of the project, both religious and political leaders were making public statements about the HIV/AIDS epidemic in their sermons and political speeches.

Capacity Building

Capacity building was an overriding theme of the AIDSCAP program. Activities in Senegal were evaluated using a comprehensive key informant interview questionnaire (CKIIQ), focus group discussions with representatives of implementing agencies, and a case study on policy dialogue. Thirty-five organizations participated in the CKIIQ, which provided quantitative data on the agencies' perceptions of changes in their organizations' capacity at the completion of AIDSCAP. Implementing agencies reported increased capacity in all areas where technical support and training had been provided, with particularly high increases for BCC education and training, project planning, financial management, and condom promotion and distribution. Agencies also reported increased recognition of their organization, not only by their communities, but also by other organizations working in HIV/AIDS prevention.

Special Features

The Senegal program was characterized by its intense focus on community-level interventions through peer education. BCC activities resulted in the training of 1,022 peer educators, who in turn conducted BCC sessions involving group discussions, video and theater presentations, drama skits, games, songs, and dances. Such participatory activities brought the target audiences together to learn about HIV/AIDS and to discuss the problem with their peers and family and community members. A total of 963,147 condoms were distributed free-of-charge during these and other activities.

Implementing Partners

African Consultants International (ACI)

Association des Postes de Santé Privés Catholiques du Sénégal (APSPCS)

Association des Professeurs des Sciences Naturelles (ASPN)

Association Nationale pour le Bien Être de la Population (ANBEP)

Association pour la Promotion Sociale en Milieux Rural et Urbain (APROSOR)

Association Sénégalaise pour le Bien Être Familial (ASBEF)

Christian Reformed World Relief Committee (CRWRC)

Education Pour la Santé (EPS)

Environnement et Développement du Tiers-Monde (ENDA-Santé)

Fédération des Associations Féminines (FAFS)

Femme Développement Entreprise en Afrique (FDEA)

Institut Supérieur Africain pour le Développement de l'Entreprise (ISADE)

JAMRA

Mouvement International pour le Développement en Afrique (MIDA)

Programme National de Lutte Contre le SIDA (PNLS)

Radio Kaolack

Radio Ziguinchor

Red Cross

Santé de la Famille (SANFAM)

Social Marketing for Change (SOMARC)

Society for Women Against AIDS in Africa (SWAA)

SUD Communications

Union Groupement Agro-Pastoral pour la Promotion Sociale (UGAPS)

University Cheikh Anta Diop