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
- Côte d'Ivoire
- Lesotho
- Mali
- Mozambique
- Niger
- West Africa
- Zambia
Asia
Major Countries
- India
- Indonesia
- Nepal
- Thailand
Associate Countries (See Below)
- 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
ASIA, Associate Countries: Bangladesh
Epidemiology
For reasons that are unclear, reported HIV prevalence rates are remarkably low in Bangladesh. In 1995, the national HIV prevalence rate was estimated to be 0.05 percent among sexually active adults. Other sexually transmitted infections (STIs), however, exist at high levels, particularly among groups with high-risk behaviors. Samples of commercial sex workers (CSWs) in Dhaka revealed 30 percent syphilis prevalence rates and 23 percent gonorrhea prevalence rates. A national prevalence study revealed that 6 percent of sexually active adults are serologically positive for syphilis. Bangladesh has many of the epidemiological and social factors that could produce a devastating epidemic: high-density population, low health standards, high rates of STIs, minimal sex education in schools or by families, an active commercial sex network, and a high degree of international migration and trade with countries where HIV is spreading rapidly. By the year 2000, the World Bank projects 300,000 cumulative HIV infections and over 30,000 cases of AIDS in Bangladesh.
Country Overview
Bangladesh, with a population of 117 million persons, is already the most densely populated country in the world, and its population is expected to double in 30 years. Bangladesh is also one of the poorest nations in the world. An estimated 70 million Bangladeshi live in absolute poverty. More than 80 percent of the population live in rural areas and have very little access to health care. All health problems are exacerbated by malnutrition; 67 percent of rural children suffer chronic malnutrition.
Because of this country's high population growth, the Bangladeshi government has made family planning a public health priority. As part of this effort, the Social Marketing Company (SMC) operates one of the largest condom social marketing programs in the world, with yearly sales of 120 million condoms.
In 1993, USAID/Bangladesh, concerned about the country's vulnerability to HIV and the lack of a formalized national HIV/AIDS prevention plan, requested that AIDSCAP assist the government and other agencies in raising awareness about the epidemic and developing appropriate prevention programs. AIDSCAP's initial contact with in-country officials revealed a growing recognition of HIV/AIDS and desire on the part of nongovernmental organizations (NGOs) to become involved in prevention, even though these organizations lacked support and, in some cases, technical expertise in STI/HIV/AIDS prevention. Consequently, with USAID/Bangladesh support, AIDSCAP initiated a $200,000 program to strengthen NGOs' capacity to implement effective STI/HIV/AIDS prevention activities. AIDSCAP/Bangladesh activities initially focused on developing educational programs for NGO employees, but later expanded to include providing technical assistance in developing behavior change communication (BCC) materials for condom promotion and community-based peer education, and training family planning clinic staff in the syndromic approach and integration of STI services in family planning clinics.
Accomplishments
AIDSCAP worked to improve the capacity of indigenous NGOs to implement AIDS prevention activities and to speak with one voice to affect national policy. Accomplishments included the establishment of workplace STI/HIV/AIDS prevention education for NGOs operating in Bangladesh; improved STI case management through the use of the syndromic approach in family planning clinics; and facilitation of a conference on the development of a national consensus on the role of NGOs in HIV/AIDS prevention.
Behavior Change Communication
With AIDSCAP's assistance, 28 participants from 17 national and international NGOs received the knowledge and skills needed to develop effective HIV/AIDS staff education programs involving peer educator and counseling approaches. The training sessions, based on a curriculum successfully employed in similar sessions in Thailand, were adapted for Bangladesh and may be used by any local organization planning to implement HIV/AIDS prevention programs for its employees. AIDSCAP BCC activities also targeted groups at high risk of infection. Condom salespeople who participated in a training program developed by AIDSCAP/Bangladesh and the SMC now provide educational outreach to CSWs.
Condom Promotion and Distribution
With technical assistance from AIDSCAP, the SMC launched a new initiative called Shurokha to promote condoms for the prevention of HIV/AIDS among male and female CSWs and their clients. AIDSCAP's primary role was to provide technical assistance in the design of the intervention (target groups, sites, methods) and in pretesting BCC materials for condom promotion. Moreover, condom packaging now includes STI/HIV/AIDS protection messages in addition to standard messages about contraception.
Strengthening STI Services
Service providers from 20 NGO maternal-child health/family planning clinics now provide more effective STI case management for clients as a result of AIDSCAP-supported training in STI diagnosis and the syndromic management approach. Moreover, use of a training-of-trainers approach has enabled these NGOs to conduct their own STI diagnosis and management training sessions as needed.
Policy Dialogue
AIDSCAP/Bangladesh, at the request of USAID/Bangladesh, provided the necessary funding and technical assistance to conduct the 1995 NGO Conference for a National Consensus on HIV/AIDS, which drew representatives from 72 organizations providing primary health care and family planning services in Bangladesh. At this conference, participants identified activities that must be implemented to limit the HIV/AIDS epidemic in Bangladesh and clarified the collaborative role NGOs might play with the government in STI/HIV/AIDS prevention. Recommendations formulated by conference participants were presented to the Government of Bangladesh for inclusion in the country's Second Medium-Term Plan.
Implementing Partners
- Access to Voluntary and Safe Contraception (AVSC) International
- International Center for Diarrhea Disease Research
- Program for Appropriate Technology in Health
- Voluntary Health Services Society
ASIA, Associate Countries: Egypt
Epidemiology
In 1996, of the 129 cumulative AIDS cases were reported to the National AIDS Control Program (NACP), heterosexual transmission accounted for 61 cases (47 percent); blood or blood products for 34 cases (26 percent); injecting drug use for 16 cases (12 percent); and homosexual transmission for 15 cases (12 percent). Three cases (2 percent) were of unknown origin. No AIDS cases were reported from prenatal transmission. Ten percent of the reported AIDS cases occurred in females, and no pediatric cases were reported. Egypt has no surveillance system, which makes reliable sexually transmitted infection (STI) estimates impossible. Male sexual dysfunction, infertility, and STI cases are reported together; the number recorded by the Ministry of Health and Population (MOHP) from 1992 to 1995 ranged from 41,740 to 42,849 cases.
Country Overview
Egypt has a population of more than 50 million, with more than 50 percent of the population living in rural areas in the Nile valley. Approximately 94 percent of Egyptians are Muslims, and Coptic Christians are the largest minority religious group. The political climate is dominated by debates of the role on Islam in Egyptian political and social institutions.
The MOHP established the NACP in 1986 under the auspices of the preventive care sector. The main objectives of the program are to educate the public about HIV/AIDS and to implement an HIV/AIDS prevention policy. STIs are part of the curative care sector. This makes coordination and integration of NACP activities with STI prevention and control very difficult.
AIDSCAP began communication and design work with USAID/Egypt in August 1995, following the merger of USAID's Asia and Near East Bureaus. Activities in Egypt then fell under the scope of work of the new Asia/Near East Bureau. The AIDSCAP scope of work in Egypt included conducting an STI/HIV/AIDS assessment to determine the areas of greatest need for donor assistance and a policy study tour to Thailand for Egyptian and Moroccan participants. In addition, USAID/Egypt requested that AIDSCAP to conduct a behavioral research among university youth in Cairo.
Accomplishments
During 18 months of implementation, AIDSCAP completed an STI/HIV needs assessment with recommendations for action and a 13-month behavioral research study of university students in Cairo. In addition, AIDSCAP organized the participation of three leading physicians in a policy study tour to observe the response to the epidemic by the Thai government, nongovernmental organizations, and the public health sector.
The needs assessment took place in April 1996 with a team of STI, behavior change communication (BCC), and program management specialists. Key recommendations from the assessment included (1) a review of HIV surveillance and testing in Egypt, (2) a study of STI prevalence, (3) the design of BCC training for Egyptian health care workers, (4) an assessment of the potential for promoting and marketing of condoms for disease prevention, (5) an assessment of the HIV/AIDS-related policy environment, and (6) the design of a plan for three new behavioral studies of groups at high risk of HIV infection.
Behavioral Research
Knowledge, attitudes, beliefs, and practices (KABP) research among university students in Cairo revealed relatively low levels of sexual intercourse (26 percent among males and 3.2 percent among females). Rates of condom use, however, were low. This study suggested that traditional Islamic culture may inhibit some young people from sexual risk taking, but high-risk behavior still occurs among university students. In addition, while knowledge of HIV/AIDS was high, students require additional, frequent, and more accessible information on prevention. The research team found that the students were much more willing to discuss sexual issues than had previously been assumed.
Capacity Building
AIDSCAP's primary capacity building role was raising awareness among policymakers and NGOs of the complexities of designing and managing STI/HIV/AIDS care and prevention programs. The initial assessment prompted the government and USAID/Egypt to reexamine the necessity for and process of collecting STI/HIV/AIDS data and to plan an STI prevalence study. The KABP survey went through a lengthy approval process, in part because university officials were concerned about the propriety of conducting a sexual behavior study among unmarried university students. Part of the institutional and cultural learning process in developing effective STI/HIV/AIDS prevention programs is recognizing and adapting to conventional mores and inhibitions about discussing and investigating sexual behavior.
Implementing Partner
- International Medical Technology Ltd.
ASIA, Associate Countries: Mongolia
Epidemiology
The HIV/AIDS epidemic in Mongolia is at an early stage compared with those in other countries in Asia. By the end of 1993, only one Mongolian living with HIV had been reported. In 1993, prevalence rates for other sexually transmitted infections (STIs) were generally less than 1 percent among various population groups -- including soldiers, pregnant women, and truck drivers -- but were significantly higher among samples of male and female commercial sex workers (CSWs) in Ulan Bator (1.7 to 3.7 percent for syphilis and 10.2 to 12.1 percent for gonorrhea). Based on this epidemiological picture of generally low STI/HIV prevalence, Mongolian and international public health specialists believe the country is in an excellent position to prevent HIV, especially with effective STI case management.
Country Overview
Mongolia is the seventh largest Asian country in area but, with 2 million inhabitants, is one of the smallest Asian countries in population. Approximately half of the country's residents live in urban areas. Nearly 500,000 people, or one-fourth of Mongolia's entire population, live in the capital city of Ulan Bator. Ethnically, the population is relatively homogenous, as almost 80 percent of the population belong to the Kalkha-speaking Mongol group. Most of the population is Buddhist, though a small percentage of the population, belonging mainly to the Turkic-speaking Kazak group, is Muslim.
Mongolia's Ministry of Health (MOH) has developed a relatively comprehensive health structure for treating STIs. In 1993, however, concern about antibiotic-resistant strains of gonorrhea and the effectiveness of certain diagnostic methods prompted the MOH and USAID to request AIDSCAP assistance in assessing the STI/HIV/AIDS situation in Mongolia and to strengthen the country's STI control measures. AIDSCAP developed a 1-year program, based on the result of its assessment to improve STI case management in Mongolia.
Accomplishments
Strengthening STI Services
In collaboration with the National Dermatology and Venereology Center and the Dermatology and Venereology Hospital, AIDSCAP completed the first comprehensive assessment of STI data and services in Mongolia. With the Mongolia STI services assessment, AIDSCAP dispelled concern that STI prevalence rates among general population were rising rapidly; confirmed increasing resistance of certain STIs to commonly used antibiotics; revealed increasing public access to medication through drug vendors who were selling newly imported antibiotics, with little concern for indication or quality; and revealed the absence of STI treatment drugs on the national essential drug list.
Through a series of training workshops, AIDSCAP and Mongolia's National AIDS Program (NAP) augmented the abilities of 58 physicians working in STI reference centers and provincial clinics to diagnose STIs correctly and to use the syndromic approach to STI case management. AIDSCAP and the NAP also developed a list of recommended STI treatment drugs that was included in Mongolia's drug registration and essential drug list. Finally, AIDSCAP supported the translation into Kalkha of The Handbook of STDs, a guide for clinicians published by the Australian Department of Community Services and Health.
Behavior Change Communication
AIDSCAP provided technical assistance and financial support in the design and production of three different educational materials for STI patients. These materials were distributed to health care centers that provide STI services.
Capacity Building
With AIDSCAP assistance, Mongolia updated its STI services to correspond more closely with international standards, and improved its access to modern drugs for treatment of STIs. As a result, Mongolian health care providers are now better able to control STIs and, consequently, the spread of HIV.
Implementing Partner
- Mongolian National AIDS Program
ASIA, Associate Countries: Morocco
Epidemiology
The first case of AIDS in Morocco was diagnosed in December of 1986. As of June 30, 1996, the cumulative number of declared AIDS cases had risen to 335. The distribution of these cases throughout the population has changed over time. In the early stage of the epidemic, heterosexual transmission was responsible for 20 percent of all infections. Currently, however, more than 50 percent of new infections are a result of heterosexual transmission.
In contrast to the relatively low number of AIDS cases, the Ministry of Health (MOH) reports high rates of other sexually transmitted infections (STIs) -- mainly gonorrhea, chlamydial infection, trichomonas, syphilis, and chancroid. In 1995, the NACP reported 150,541 new cases of STIs. However, anecdotal information indicates significant underreporting of STIs, which may be attributable to the asymptomatic nature of many STIs, cultural taboos, self-medication, and health care professionals' failure to recognize STIs. The MOH estimates that the real number of new cases of STIs is closer to 400,000 per year.
Country Overview
STIs are an important cause of morbidity, disability, sterility, and loss of productivity, especially among women. One study in Tanzania found that a person infected with an STI is between two to five times more likely to contract HIV if exposed (Grosskurth, H., Mosha F., Todd, J., et al. in The Lancet, Vol. 346, August 26, 1995). The same study also found a 40 percent reduction in HIV incidence with the introduction of the syndromic approach to management. These findings and the rising number of cases in Morocco led the country's Ministry of Health (MOH) to adopt STI control as a primary strategy of its National AIDS Control Program (NACP).
AIDSCAP's objective was to strengthen the capacity of the Moroccan MOH to address reproductive and child health issues related to STIs and HIV/AIDS in Morocco. It did so by providing technical assistance to develop a pilot activity at three sites -- Agadir, Marrakech, and Tangier -- designed to address several key areas in STI service delivery at the primary health care level. This activity complemented concurrent activities of the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO) that specifically addressed clients of family planning clinics. The project compared JHPIEGO's approach with other models of STI identification and management and provided equipment, training, and materials support to certain pilot JHPIEGO sites.
Accomplishments
AIDSCAP conducted an algorithm validation study to provide the information needed to test and adopt the recommended World Health Organization (WHO) algorithms for STI case management in Morocco. Morocco was the first Arab-Muslim country where the syndromic approach to STI case management was introduced. Prevalence data on STI etiology were made available to the Moroccan MOH, and risk factors for STI specific to Morocco were determined, also for the first time. In addition, pilot training workshops on the syndromic approach were conducted for private physicians, pharmacists, and vendors.
Laboratory capabilities to diagnose STIs were also reinforced, providing a model for sentinel surveillance of STIs. Techniques that proved successful in the pilot project are being used to establish a STI sentinel surveillance system. In addition, information from an ethnographic targeted intervention research (TIR) study conducted by AIDSCAP is being used to guide the development of future behavior change communication and training efforts.
AIDSCAP conducted an assessment of the quality of STI care in Morocco to provide a baseline for evaluation. It found that
- 24 percent of patients with specific STIs in public sector health facilities and 18 percent of STI patients in private sector health facilities were assessed and treated according to national standards (WHO prevention indicator 6).
- 6 percent of individuals seeking STI care in health facilities received appropriate advice on condom use and 15 percent received appropriate advice on partner notification (WHO prevention indicator 7).
Implementing Partners
- Moroccan Ministry of Health
- University of Washington
ASIA, Associate Countries: Philippines
Epidemiology
The Epidemiology Unit of the Philippine Department of Health conducted HIV surveillance in six sites in 1996-97. It found unexpectedly low HIV prevalence, even among injecting drug users and commercial sex workers (CSWs) charging low fees. Epidemiologists have concluded that pockets of undetected HIV infection are unlikely and an epidemic has not yet materialized. AIDSCAP believes that if an epidemic did occur it would start with interactions between seafarers in the Celebes Sea and CSWs along sea traffic routes.
Country Overview
In the early 1990s, the political climate in the Philippines and the social practices of CSWs were similar to those found in Thailand, leading to predictions that an HIV/AIDS epidemic was imminent. The tolerant position of the government toward commercial sex had allowed the expansion of the industry into massage parlors, cocktail lounges, beer houses, and the streets.
The Philippines has a national network of sexually transmitted infection (STI) clinics (social hygiene clinics) that provide routine screening and treatment to registered CSWs. The number of STIs diagnosed by these social hygiene clinics showed an increase from 1988 (54,347) to 1991 (72,329), with a rapid decline in 1992 (32,968). This decline probably resulted from lapses in case reporting caused by the decentralization of the network rather than lower incidence of STIs. In addition, because these clinics serve mostly registered CSWs, the incidence of STIs among unregistered CSWs was expected to be higher.
In FY93, the Asia/Near East Bureau, through AIDSCAP, supported the implementation of an STI assessment to establish baseline data and guide future implementation decisions. AIDSCAP identified the health-seeking behavior of persons at increased risk of STIs, assessed the STI management practices of a cross section of STI care providers, and conducted baseline epidemiologic surveys of STIs for the development of standardized case management guidelines. Based on research findings, the USAID/Mission supported AIDSCAP activities that included developing behavior change communication (BCC) materials for social hygiene clinics, establishing a training course for STI practitioners, developing and disseminating national STI management guidelines, and hiring a full-time AIDSCAP program coordinator.
Accomplishments
Initially, the AIDSCAP/Philippines program supported research to establish areas for intervention. Based on these research findings, AIDSCAP recommended: concentrating STI control resources in urban areas with groups practicing high-risk behaviors; emphasizing the treatment of STIs during a patient's first encounter with the health system, and; standardizing STI case management to increase confidence in the national control program and to limit the emergence of resistant strains of pathogens.
STI and microbial resistance studies were conducted in Manila and Cebu City, the two largest urban areas in the Philippines. The three groups of women who voluntarily enrolled were registered CSWs, unregistered CSWs, and women attending antenatal clinics (ANC). These studies confirmed the higher STI vulnerability of unregistered CSWs, who experienced two to four times greater prevalence than registered CSWs. Also noteworthy was the higher than expected percentage of ANC attendees with chlamydial infection, suggesting that male partners form a bridge for infection from CSWs to their homes. Forty-six percent of the gonorrhea isolates showed resistance to ciprofloxacin treatment, which had been the national choice for gonorrhea treatment. These findings led to immediate action by the Department of Health to revise treatment protocols and give higher priority to reaching unregistered CSWs.
The targeted intervention research (TIR) methodology, developed by AIDSCAP in collaboration with Johns Hopkins University and the University of Washington, was used to identify health-seeking behaviors among CSWs and the determinants of such behaviors, including motivation; the quality, accessibility, and convenience of health services; and health care providers' attitudes toward STI clients. The findings were used by AIDSCAP to design behavior change communication (BCC) materials for STI clinics and a training program for STI clinic managers.
The findings of the prevalence study and the TIR emphasized the need for new national STI case management guidelines. AIDSCAP consequently supported STI consensus and advocacy workshops to promote understanding and acceptance of the research findings and to ratify revised national guidelines. A National STI Management Guide and a Manual for Training in the Care and Prevention of STIs were produced.
Implementing Partners
- Art for Education and Communication Foundation, Inc.
- Cebu City Health Department
- Philippines General Hospital
- Research Institute of Tropical Medicine
- Training Institute for Managerial Excellence
- University of the Philippines, College of Public Health Foundation
ASIA, Associate Countries: Sri Lanka
Epidemiology
The first case of HIV in Sri Lanka was identified in 1987. By 1993, the number of persons known to be infected with HIV had risen to 118, and 33 of them had developed AIDS. Estimates of the number of persons living with HIV rose from 3,500 in 1993 to 6,800 in 1996. Heterosexual contact is believed to be the major mode of transmission. In 1991, the World Health Organization estimated that more than 200,000 cases of sexually transmitted infection (STI) occurred yearly, but only a small proportion of these cases were treated in government clinics. Most persons sought treatment from private STI practitioners, general practitioners (GPs), or pharmacists. GPs, in particular, play a major role in STI control in Sri Lanka, because their accessibility and generally good rapport with clients frequently make them the preferred point of first contact with persons seeking treatment for an STI.
Country Overview
Sri Lanka is an island nation of approximately 18.3 million inhabitants. Three ethnic groups, the Sinhalese, Tamil, and Sri Lankan Moor, make up more than 99 percent of the population. The Sinhalese alone account for almost 83 percent of Sri Lanka's inhabitants. Buddhism is the predominant religion, followed by Hinduism, Islam, and Christianity. More than 78 percent of the population live in rural areas, and most Sri Lankans are agriculturists. While Sri Lanka's health and demographic indicators are considered good for a low-income country, it has a dearth of physicians. Moreover, armed conflict in the northern and eastern regions has led to a deterioration of health care services and increased levels of malnutrition and communicable disease.
Since the creation of Sri Lanka's National AIDS Control Program (NACP) and implementation of the Medium-Term Plan (1990-1993), USAID/Sri Lanka has supported several HIV/AIDS prevention programs to assist the NACP. In 1993, with support from USAID/Sri Lanka and the Asia/Near East Bureau, AIDSCAP and its partner, the Independent Medical Practitioners Association of Sri Lanka (IMPA), implemented a 1-year project to improve the capacity of Sri Lankan health care providers to manage STIs more effectively.
Accomplishments
With AIDSCAP technical assistance, the IMPA taught GPs how to manage STIs more effectively through two major activities. First, 126 GPs developed additional skills in STI diagnosis, management, and counseling techniques in a series of 12 regional workshops conducted in five provinces. Second, with input from these GPs, AIDSCAP and IMPA developed a continuing education program for 600 general practitioners throughout the country to acquire skills in STI management. The program consisted of a series of 10 STI training modules covering topics such as STI epidemiology, syndromic management approaches, laboratory confirmation procedures, counseling, partner management, and health education. The use of a long distance training approach proved effective and appropriate because most GPs have solo practices and are unable to take leave to attend training sessions.
Capacity Building
As a result of the AIDSCAP activities, standardized STI diagnosis and management procedures were developed and introduced to GPs for the first time in Sri Lanka. Coupled with the Ministry of Health's efforts to increase access to appropriate STI treatment drugs and to eliminate illegal distribution or sale of antibiotics, AIDSCAP's assistance made a major contribution to Sri Lanka's capability to control STIs.
Implementing Partner
- Independent Medical Practitioners Association of Sri Lanka
