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 (See Below)
- Tanzania
- Zimbabwe
Associate Countries
- 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, Major Countries: South Africa
Epidemiology
HIV/AIDS was, and to some extent still is, a silent disease to most South Africans. The first case of AIDS in South Africa was reported in 1982, and from 1982 to 1989 men who have sex with men (MWM) accounted for 66 percent of all AIDS cases. After 1988, infection among MWM declined as a proportion of the total reported cases, and cases of heterosexual transmission increased from 23 percent in 1988 to 72 percent in 1992.
AIDS case reports alone, however, provide an incomplete picture of the HIV/AIDS epidemic in South Africa. As diagnosis of AIDS is not a reportable disease, AIDS case reports reflect only those voluntarily reported to the South African Institute of Medical Research (SAIMR). In addition, the diagnosis of AIDS may not be understood by many physicians in South Africa and is often obscured by the presence of a variety of opportunistic infections.
Investigations to determine HIV infection rates in different population groups in South Africa -- selected urban and rural populations, mine workers, persons donating blood, and clients attending family planning, antenatal and sexually transmitted infection (STI) clinics -- have been undertaken by the Medical Research Council (MRC), the South Africa Institute of Virology, and government and academic institutions. During October and November 1996, the Department of Health conducted the seventh annual national survey in a series of unlinked, anonymous serosurveys of women attending public health service. Based on a sample of 15,044 women screened in all nine provinces, it was estimated that 14.07 percent of the women attending the clinics were infected with HIV by the end of 1996, an increase from 10.04 percent in 1995. Extrapolating from these figures, it is estimated that approximately 2.5 million people in South Africa are living with HIV.
Country Overview
As South Africa emerges from apartheid, the HIV/AIDS epidemic presents a new socioeconomic threat. Although the country experienced a relatively late introduction of HIV, South Africa now has a well established epidemic, with heterosexual transmission the main mode of transmission.
The primary objective of AIDSCAP's support in South Africa was to build the capacity of indigenous nongovernmental organizations (NGOs) and community-based organizations (CBOs) to provide technically sound and sustainable HIV/AIDS prevention interventions. To achieve that objective, AIDSCAP organized its support around the following seven areas:
- As HIV/AIDS program and CBO staff had been isolated from international and national experiences, AIDSCAP supported international and comparative educational travel. This component of the program sought to expose HIV/AIDS prevention activists to innovative and effective approaches and programs in other African countries.
- AIDSCAP supported pilot projects to demonstrate the effectiveness of innovative HIV/AIDS interventions.
- A small grants program provided funding for NGOs and CBOs to carry out comprehensive, integrated HIV/AIDS prevention activities and to establish coalitions of community-based organizations to strengthen HIV prevention programming.
- Training workshops were included as a means for HIV/AIDS prevention program staff from around South Africa, and particularly from the AIDSCAP focus regions, to exchange experiences, lessons, and strategies.
- Resource centers were established with a broad mandate to facilitate networking and coordination of community-based HIV prevention efforts.
- The HIV/AIDS prevention program of the South African government was significantly altered and intensified in the post-apartheid years. USAID and AIDSCAP provided technical assistance to the Government of South Africa to strengthen peer education and develop a national strategy for condom distribution.
- AIDSCAP's evaluation plan incorporated measurements of process, outcomes, and impact at both the program and activity level. Particular emphasis was placed on indicators for successful capacity building.
Within the scope of its capacity building activities, AIDSCAP sought to reach the following primary and intermediary target groups: adolescent youth, migrant workers, women living with HIV and their families, traditional healers, mass media professionals, and primary health care providers.
Accomplishments
AIDSCAP/South Africa provided funding and program support to 24 implementing agencies, most of whom were indigenous NGOs or CBOs. Several accomplishments were of particular importance. First, most implementing agencies (IAs) felt that their ability to develop, manage, and evaluate interventions had improved as a result of AIDSCAP's support. Second, the government recognized the important contributions of NGOs and CBOs, and this recognition gave them opportunities to inform and influence governmental policymaking. In addition, by the end of AIDSCAP, a national AIDS plan was completed and officially accepted by the Minister of Health. Third, work with traditional healers, the frontline health care providers for most South Africans, proved effective and established a precedent for similar activities elsewhere. Finally, a research intervention demonstrated that periodic presumptive treatment of commercial sex workers (CSWs) could reduce STI rates among them and their partners.
AIDSCAP/South Africa Process Data:
- Ten training-of-trainers (TOT) workshops were conducted for 73 females and 10 males.
- One hundred five peer educator (PE) workshops were conducted for over 981 females and 484 males.
- Twenty-two HIV/AIDS awareness workshops were held.
- Thirty-five AIDS-related drama workshops were held, at which 3,425 female and 3,460 male youth were trained.
- Outreach activities and special events reached over 28,792 females, 14,841 males, and an additional 84,308 persons (gender unspecified).
- Over 2,569,922 male condoms and 15,853 female condoms were sold through Population Services International (PSI) subprojects; 109,749 condom promotional materials were produced, of which 98,306 have been distributed.
- Nine capacity building workshops (PE refresher training, project management, computer skills) were conducted. Over 590 PEs were trained in the refresher courses.
Key Outcome Data
By increasing the capacity of local organizations, AIDSCAP contributed to the overall goal of reducing sexual risk taking among target populations in South Africa. An evaluation survey of NGOs and CBOs noted marked improvements in the articulation of contractual agreements, in maintaining updated records, and in the proper use, control, and management of project resources. In addition, IAs greatly improved their process data collection and gained experience in monitoring and reporting project activities. Half of them incorporated gender and development into their interventions, with three specifically targeting gender. Nearly all (98 percent) of the IAs are members of networking initiatives, and 75 percent were involved in policy initiatives at the end of AIDSCAP. At least six broadened their funding base to include other donors.
The increasing number of IAs involved in training, counseling, BCC materials development, advocacy, STI management, condom management (from 5 percent 3 years ago to nearly 88 percent at the end of the project) is testimony to the improvement in organizational capacity. The introduction of peer education and community-based development initiatives as effective strategies for STI management has proven to be a positive initiative with IAs and target audiences. The fact that the government is relying on IAs to help develop policy on HIV/AIDS is a clear acceptance of the role of service providers in this field.
The periodic presumptive treatment project for women at risk in mining communities produced dramatic results. After 9 months of the intervention, the prevalence of STI among the treated women had decreased significantly, and rates of STI among miners presumed to be their sexual partners had also decreased. The overall prevalence of genital ulcer disease dropped by 30 percent and nonulcerative STI rates decreased by 32 percent. The women reported a 20 percent reduction in the number of clients, and reported condom use by clients increased from 13 to 29 percent. These results helped convince the medical staff and management of the host company, Harmony Mine, to continue the presumptive treatment intervention and expand it to neighboring areas of the community.
AIDSCAP-supported training for traditional healers made a positive difference in the larger community. Several of the traditional healers trained under AIDSCAP have been hired by local clinics and hospitals as health care workers. Since participating in AIDSCAP-funded workshops, traditional healers who regularly train other healers have incorporated their knowledge of STI/HIV/AIDS into their standard course, creating a multiplier effect. In addition, hospital and clinic staff reported increased numbers of people seeking HIV testing following the traditional healer training sessions.
Various evaluation surveys conducted during the program provided valuable data regarding the knowledge, attitudes, practices, and beliefs of target populations. Awareness among miner populations and CSWs living in and around mining communities was high. Ninety-seven percent of mine workers and CSWs were aware of HIV/AIDS, and 73 percent of mine workers and 83 percent of CSWs cited condoms as a method of preventing HIV/AIDS. In addition, 42 percent of mine workers reported in 1997 that they had started using condoms as a result of becoming aware of HIV/AIDS. Reported condom use, however, remains low: only 12 percent of mine workers reported using condoms every time. Consistent condom among CSWs was much higher: 56 percent reported always using condoms with clients. Only 15 percent of CSWs reported using no form of protection.
Implementing Partners
- AIDS Training and Education
- Arts for All
- Bethesda House
- Border Institute for Primary Health
- Excelsior High School
- Harmony Hospital
- Hillbrow Primary Health Care Partnership
- Hope Worldwide
- Lawyers for Human Rights
- National AIDS Convention of South Africa (NACOSA)
- National Association for Child Care Workers (NACCW)
- National Association of People Living with HIV/AIDS (NAPWA)
- National Progressive Primary Health Care Network (NPPHCN)
- National Reference Center for STIs
- Nyangazezizwe Traditional Doctors Organization
- Operation Upliftment for the Homeless and Unemployed
- Out-in-Africa Film Festival Committee
- Phambili Women's Organization
- Population Services International/Society for Family Health
- South African Red Cross
- The House of Resurrection
- Training Institute for Primary Health Care (TIPHC)
- University of South Africa Institute for Behavioral Sciences
- Vista University
AFRICA, Major Countries: Tanzania
Epidemiology
By 1995, approximately 82,000 cases had been reported to the Ministry of Health, and the National AIDS Control Program (NACP) estimated that 1.2 million Tanzanians were infected with HIV. HIV prevalence in women seeking antenatal care is over 10 percent, and in one rural site in the Mbeya Region, it has reached 32.5 percent. According to the most recent available data, overall HIV prevalence in the Mara Region was 8.8 percent in urban areas, 6.5 percent in periurban areas, and 2.6 percent in rural areas. In high-risk transmission areas, such as truck stop towns along major transportation routes, substantially higher prevalence rates of HIV and other sexually transmitted infections (STIs) have been reported.
Country Overview
In response to the alarming spread of the virus, the government formed the NACP in 1987 and began activities in 1988. The government has actively engaged nongovernmental organizations (NGOs) in instituting its HIV/AIDS programs. USAID/Tanzania has supported the government's efforts since 1988, initially through AIDSTECH and AIDSCOM programs and, from 1991 to 1997, through AIDSCAP. Building on the previous USAID initiatives, the Tanzania AIDS Project (TAP), a $20-million, 5-year project managed by AIDSCAP, adapted its activities to respond to the expansion of the HIV/AIDS epidemic.
Accomplishments
TAP provided technical and financial assistance directly to more than 20 organizations and indirectly, through NGO clusters, to over 180. TAP sensitized local leaders and policymakers, implemented behavior change interventions, improved clinical STI management, distributed and promoted condoms, provided support to persons and families affected by HIV/AIDS, and conducted research to strengthen interventions. Collaborating with the NACP, TAP also implemented activities to create an enabling environment for community-based initiatives. These activities included training, distributing educational materials, and conducting advocacy and policy sensitization at the national level. The combination of community-based and national interventions produced a technically integrated, programmatically comprehensive, and geographically inclusive program.
Supporting Regional NGO Coalitions
The objective of TAP's support for regional NGO clusters was to enable community-based organizations to mobilize local resources for HIV/AIDS prevention and care and to gain the active participation of community leaders. By August 1995, TAP was supporting activities by 180 NGOs in nine regional clusters in Arusha, Dar es Salaam, Dodoma, Iringa, Kilimanjaro, Morogoro, Shinyanga, Tabora, and Tanga. All of the clusters accomplished their objectives. Even more important in the long term, the NGOs formed organizationally sound collaborations that are now positioned to further decentralize the NGO cluster model to the district level.
Workplace Prevention Initiatives
The objectives of the NGO cluster program were also pursued in TAP's other community- and workplace-based activities. These activities included integrating STI care, distributing and promoting condoms, behavior change communication, peer education, and targeted policy and advocacy initiatives. Approximately 100 private businesses developed HIV/AIDS prevention programs for their employees, and 18 companies assumed 50 percent of the operating costs for these programs. In 22 truck stop communities along major transportation routes, TAP implemented comprehensive projects targeting truck drivers, commercial sex workers, merchants, miners, youth, and women.
HIV/AIDS Care and Support
TAP responded to the escalating needs of people living with HIV/AIDS by integrating care and support into the activities of the NGO clusters. Complemented by prevention education, these interventions included upgrading clinical capacity and providing home-based care and pre- and post-test counseling, psychological and social support to AIDS patients and their families, and educational, vocational, and psychological and social assistance to hundreds of AIDS orphans. TAP emphasized collaboration and referrals between health care providers and program-trained traditional healers.
Capacity Building
TAP also increased the capability of implementing partners to manage projects and conduct HIV/AIDS prevention and support activities. To this end, the project organized and conducted training programs for staff from implementing organizations and government agencies. TAP also provided training and support to its implementing organizations through supervisory visits to project sites and intercluster study tours.
Communication and Advocacy
At the national level, TAP attempted to influence social and public policy by reinforcing community-based communication efforts and collaborating with the NACP to educate policymakers about HIV/AIDS. The project worked with partner organizations to produce and distribute educational materials, develop radio and TV broadcasts, and support promotional and educational events (such as World AIDS Day) and interventions with national decision makers. Due in part to these efforts, HIV/AIDS-related issues are prominently, regularly, and accurately featured in the Tanzanian media.
Strengthening STI Services
Over 750 health care providers from NGO clusters and from high-risk areas were trained in STI syndromic diagnosis and treatment, based on guidelines developed by AIDSCAP and adopted by the Tanzanian Ministry of Health. New, upgraded STI clinics are now accessible to target populations in most of TAP's project sites. Referral of STI patients to these upgraded facilities was an integral aspect of behavior change interventions. A study of target populations found that 72 percent of women who had sought STI care in the previous 12 months went to TAP-supported clinics; these women reported that peer educators had motivated them to seek care.
Condom Promotion and Distribution
In addition to extensive community- and workplace-based condom distribution, TAP supported a nationwide condom social marketing project. Population Services International repackaged and launched the Salama brand condom as a part of TAP's 1993 World AIDS Day activities, and by the end of the project had sold over 30 million condoms. Condom sales and behavior change were supported and encouraged by an intensive education and promotion campaign. More than 2 million people attended 457 mobile video presentations, and more than 3,111 community-based distribution agents were trained in HIV/AIDS prevention and condom promotion. More than 250,000 informational pamphlets were distributed, and over 2,000 condom prevention messages were communicated through radio, television, billboards, and newspapers.
Evaluation and Research
AIDSCAP evaluated behavior change with process data, cross-sectional survey research of target populations, and qualitative interviews with target audiences. The behavior change data in Tanzania were provided by both primary and secondary sources, including the USAID-funded Demographic and Health Survey (DHS) from 1991, 1994, and 1996 and knowledge, attitudes, beliefs, and practices surveys conducted by TAP in cluster regions.
Knowledge of HIV/AIDS has been consistently high: the 1991 DHS reported that 90 percent of males and females knew of AIDS and the 1994 and 1996 DHS survey showed that awareness of AIDS was almost universal. In the 1994 DHS, 36 percent of females and 49 percent of males cited condoms as a way to avoid HIV infection. The 1996 survey found improvement in knowledge of prevention methods, with 39 percent of females and 55 percent of males citing condoms. The DHS results suggest that the percentage of respondents with more than one sex partner is decreasing, especially among unmarried respondents.
There was no significant difference between the 1994 and 1996 DHS data regarding condom use with last nonregular partner. In the 1996 DHS, 17 percent of females and 35 percent of males reported using a condom the last time they had sex with a nonregular partner. However, the 4-region TAP KABP showed that 54 percent of youth (no gender distinctions), 38 percent of women, and 46 percent of men reported condom use with their last nonregular partner. The higher rates of reported condom use among samples from AIDSCAP intervention regions, when compared to DHS data, suggest that the behavior change interventions are having the intended effects.
Special Features
Two aspects of TAP set the project apart from its peers. First, by developing and supporting coalitions of community-based NGOs, TAP has demonstrated a commitment to achieving technically, institutionally, and financially sustainable projects. The NGO cluster exemplifies the idea that sustainable health interventions must be community based. TAP's experience shows that, given appropriate support, coalitions of community-based NGOs can be robust mechanisms for HIV/AIDS interventions. After 3 years of operation, TAP's NGO clusters have started weaving HIV/AIDS prevention and care into the very fabric of Tanzanian life.
The second outstanding feature of the project is TAP's goal of reducing the social and economic consequences of HIV/AIDS. By supporting activities to strengthen Tanzanians' ability to cope with these severe consequences, TAP has embraced the important notion that HIV/AIDS prevention and care are not distinct domains, but exist on a continuum of programmatic opportunities and urgent needs. Such a holistic outlook has produced an effective, comprehensive response to the HIV/AIDS epidemic in Tanzania.
Implementing Partners
- AIDS Intervention in Kilimanjaro and Arusha (AIKA), Arusha Cluster (26 NGO members)
- Walio Katika Mapambana na AIDS Tanzania (WAMATA), Dar es Salaam Cluster (12 NGO members)
- World Vision of Tanzania, Dodoma Cluster (11 NGO members)
- Family Planning Association of Tanzania (UMATI), Iringa Cluster (41 NGO members)
- AIDS Intervention in Kilimanjaro and Arusha (AIKA), Kilimanjaro Cluster (37 NGO members)
- Anglican Diocese of Morogoro, Morogoro Cluster (13 NGO members)
- World Vision International, Shinyanga Cluster (12 NGO members)
- Makoye Resources and Technologies Agency (MARTEA), Tabora Cluster (12 NGO members)
- Tanga AIDS Working Group (TAWG), Tanga Cluster (6 NGO members)
- African Medical Research and Education Foundation (AMREF)
- Tanzania Council for Social Development (TACOSODE)
- Organization of Tanzanian Trade Unions (OTTU)
- Pastoral Activities and Services for AIDS, Dar es Salaam Archdiocese (PASADA)
- Tanga AIDS Working Group (TAWG), home care project
- Centre for Educational Development in Health, Arusha (CEDHA)
- Primary Health Care Institute, Iringa (PHCI)
- Infectious Disease Center (IDC)
- Muhimbili University Medical Centre
- Population Services International
- Health for All Volunteers Trust
AFRICA, Major Countries: Zimbabwe
Epidemiology
HIV/AIDS is a serious problem in Zimbabwe, with an estimated 1 million people, or 22 percent of all adults in the country, infected with HIV. By September 1996, over 61,000 AIDS cases had been reported, but the true number of cases is estimated to be about 200,000. Young women (aged 15 to 19) are reported to have HIV/AIDS at five times the rate of young men in the same age group. Sentinel surveillance data from 1992 shows HIV prevalence rates ranging from 10 percent of rural antenatal clinic attendees to 60 percent of clients in an urban STI clinic. A 1995 study of 2,876 clinic attendees from six Harare antenatal clinics found that 892 (32 percent) of the women were infected with HIV. The mean age of that cohort was 21.3 years.
Country Overview
AIDSCAP/Family Health International was contracted by USAID in 1994 to support implementation of the first stage of the USAID/Zimbabwe Prevention and Control (ZAPAC) Project in conjunction with UNICEF and the Government of Zimbabwe National AIDS Coordination Programme (NACP). The AIDSCAP program focused on behavior change communication (BCC) interventions in the workplace. The specific target groups were commercial farm workers, transport workers, military personnel and their families, and commercial sex workers (CSWs). As in many other African countries, mobile populations found in or around major commercial centers and transport routes have higher HIV infection rates.
Accomplishments
The AIDSCAP strategy for reducing high-risk behavior among target groups was to train peer educators and support their efforts with BCC materials, including videos. As a result of behavior change activities implemented through peer educators in targeted regions
- 25,877 peer educators from rural and urban communities countrywide, including army and airforce camps, were trained.
- 2,307,712 people were educated by peer educators in worksites, along transport routes, on commercial farms, at military bases and in surrounding communities.
- 416,370 materials were produced and/or distributed.
- 19,450,770 condoms were distributed in rural and urban areas, at worksites, in bars and hotels along transportation routes, and in surrounding communities.
By focusing BCC workplace interventions on families as well as employees, the program helped workers realize the importance of educating and protecting their families. AIDSCAP also supported a range of media activities to establish and sustain an environment conducive to behavior change among targeted populations. These included a critical analysis of Zimbabwe media and HIV/AIDS reporting, a workshop for media gatekeepers and policymakers, radio and TV programs, a mass media program evaluation, and two columns about HIV/AIDS in national newspapers. With AIDSCAP support, the University of Zimbabwe developed an HIV/AIDS training module for postgraduate students enrolled in the diploma program for mass communications and media development.
Key Outcome Data
Both quantitative surveys and qualitative studies (focus group discussions, key informant interviews, and in-depth interviews) of HIV/AIDS knowledge, attitudes, beliefs, and practices were carried out by several evaluation research organizations. In 1995, baseline quantitative data was collected for commercial farm workers, youth, transport workers, CSWs, and military personnel. During the next year, research was conducted with railway workers, sugar plantation workers, and CSWs living on the Triangle sugar estate. And in 1997, a second data point was collected for commercial farm workers, youth, transports workers, and CSWs to provide comparative data on these populations. Population Services International (PSI) also conducted a general population survey in 1997.
This research showed high knowledge levels (knowledge of at least two preventive practices) at baseline, with slight increases at the second data point (with the exception of CSWs along truck routes, who showed a slight decrease from 84.2 to 82.3 percent). Knowledge levels increased for transport workers from 88 to 94 percent, for female commercial farm workers from 90 to 91.4 percent, and for male commercial farm workers from 88.8 to 92.8 percent. In comparison, the 1997 general population survey showed 44 percent of both males and females were able to cite at least two methods of HIV prevention and 57 percent were able to acquire a condom.
Despite the high levels of HIV/AIDS knowledge among AIDSCAP targeted groups, respondents in all study populations underestimated their chances of getting infected with HIV. Sixty-three percent of male commercial farm workers and 58 percent of female farm workers considered themselves at no risk in 1995. In 1997, the numbers for both show a decrease to 44 percent of men and 33 percent of women who believed they were not at risk.
Condom use levels increased in all groups, except CSWs along truck routes. Reported condom use among youth in 1995 was surprisingly high at 52.7 percent for males and 62.5 percent for females. The two most common methods cited by members of all target groups as examples of behavior change to avoid HIV/AIDS were condom use and partner reduction.
Implementing Partners
- AIDS Action Committee, Triangle Ltd.
- Bulawayo City Health Services Department
- Commercial Farmers Union
- CONNECT
- Delta Corporation
- Department of Community Medicine, University of Zimbabwe
- Department of English, University of Zimbabwe
- Dexter Enterprises
- Institute of Tropical Medicine
- National Employment Council for the Transportation Operating Industry
- National Railways of Zimbabwe Health Safety Branch
- Women and AIDS Support Network Zimbabwe
- Zimbabwe Broadcasting Corporation
