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 (See Below)
- 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
ASIA, Major Countries: India
Epidemiology
HIV was first detected in India in 1986. As of mid-1997, more than 50,000 people are living with HIV, and the Joint United Nations Programme on HIV/AIDS estimates the prevalence of infection is 1 to 3 million. If prevalence estimates are correct, India has more cases of HIV infection than any other country. Detection of HIV trends is difficult, however, as there is no uniform, nationwide surveillance method among India's 35 state governments. However, patterns of frequent male contact with commercial sex workers (CSWs), high rates of sexually transmitted infections (STIs), low condom use rates, and injecting drug users in parts of the country suggest that the epidemic will increase unless major prevention efforts are initiated. The primary mode of HIV transmission is heterosexual, although bisexual and homosexual transmission occurs.
Country Overview
The world's largest democratic country, India is home to more than 900 million people and at least 35 major and 200 minor languages. In its 50 years of independence, India's economy has grown significantly. The country boasts a burgeoning middle class and the world's largest movie industry. Despite these indicators of growth, however, more than 60 percent of the population live below the poverty line and illiteracy rates are more than 50 percent, with estimates as high as 80 percent for women. The population also suffers high morbidity and mortality from malaria, tuberculosis, leprosy, cholera, and other diseases. Recently, India has experienced political instability, with the resignation of three prime ministers in the past 2 years and four changes of multiparty ruling coalitions in the past 4 years.
In this climate of uncertainty and change, AIDSCAP, in 1992, assisted USAID/India in the design of a 7-year, $10 million AIDS Prevention and Control (APAC) Project in the state of Tamil Nadu (population of 55 million). The state of Tamil Nadu was chosen as a demonstration state for a comprehensive HIV/AIDS control program because of the interest of state officials and the significant rate of HIV infection. The AIDSCAP/India program was designed to build the capacity of nongovernmental organizations (NGOs), especially those involved in the APAC Project, which is implemented by Voluntary Health Services. Long negotiations between USAID and state and federal government officials in India delayed the initiation of APAC by more than 2 1/2 years. During this period, however, AIDSCAP was able to provide modest funding to NGOs to initiate formative research activities and pilot projects through rapid response grants.
In addition to fulfilling its capacity building role in Tamil Nadu, AIDSCAP was able to support demonstration projects and major policy initiatives in other regions with complementary funds from the Asia/Near East Bureau. An AIDSCAP private voluntary organization (PVO) grant enabled PLAN International and a local NGO, MYRADA, to implement a community intervention in Karnataka, one of Tamil Nadu's neighboring states. The project initially targeted devadasis (women who tend the temples of a Hindu goddess and support themselves through commercial sex), but soon widened its range to include the general population, becoming one of the first comprehensive HIV/AIDS prevention projects in the country. Through outreach workers, street plays, folk music programs, wall painting competitions, training programs, and STI clinic staff, the project communicated STI/HIV/AIDS prevention messages to more than 1.3 million people and distributed more than 68,000 condoms and 380,000 materials. In 199697, AIDSCAP, at the request of USAID/India, supported a number of pilot projects, including outreach to low-income populations and injecting drug users, in Delhi.
Accomplishments
AIDSCAP/India provided initial funding for a number of innovative intervention and research activities in Tamil Nadu to stimulate activities and build experience in the region while waiting for the approval of the APAC Project. It has also served as a resource center in the region for both NGO and government agency staff. AIDSCAP successfully assisted APAC in the early initiation and implementation of a project now seen as a model, comprehensive, statewide HIV prevention and control program. Nationally, the AIDSCAP/India program played a leading role in stimulating discussion on the growing epidemic among policymakers and in raising issues about gender and people living with HIV/AIDS (PLWAs).
Behavior Change Communication
With six rapid-response fund grants, the PVO grant to PLAN and MYRADA, workshops, and support to APAC, AIDSCAP was able to initiate a number of pilot interventions among target populations. These interventions included peer education activities with college students; a low-cost newsletter for semiliterate readers; street plays in low-income areas; an educational film for transvestites and men who have sex with men; and outreach to truckers and devadasis in Karnataka. Through directly supported AIDSCAP activities, more than 26,720 people were trained, 1,408,227 people were educated, 468,955 materials were distributed, and at least 46 mass media events were held.
During its last month of implementation in June 1997, AIDSCAP/India sponsored a training-of-trainer's workshop for NGO staff persons in behavior change communication (BCC) for HIV/AIDS prevention projects. More than 30 NGOs from across the country were represented. AIDSCAP also worked with APAC staff to design their BCC strategy.
Condom Promotion and Distribution
In 1993, AIDSCAP commissioned Population Services International to conduct a condom availability and accessibility study in Tamil Nadu in preparation for APAC. The report noted that the wide availability of free condoms from the government, as well as condoms in the market place, limited the need for extensive condom social marketing. Further research on condom quality was conducted in 1996, and at APAC's request, samples were tested in Family Health International's laboratories. The results suggested the need for improved packaging and storage of condoms in order to maintain quality. Through the PLAN/MYRADA project in Karnataka and the demonstration projects in New Delhi, approximately 78,934 condoms were distributed free-of-charge and 64,190 were sold.
Strengthening STI Services
AIDSCAP provided technical assistance in STI case management throughout the life of AIDSCAP in India. In 1993, the STI advisor from the Asia regional office reviewed the National AIDS Control Organization (NACO) manual on syndromic treatment and developed a manual for training nonspecialist health care practitioners. In addition, AIDSCAP staff conducted a number of STI case management training workshops for physicians in Tamil Nadu and Karnataka. AIDSCAP also assisted APAC in designing its STI control strategy and identifying research issues.
Policy Development
AIDSCAP and USAID/India were able to stimulate a number of policy initiatives. Through consultations with internationally recognized epidemiologists, NACO staff, and key government officials, both state and federal officials began identifying more systematic methods for conducting HIV surveillance. A national law conference on HIV/AIDS and Human Rights, partially supported by AIDSCAP, was the first HIV/AIDS event in the country to draw the attention of the president and prime minister. AIDSCAP also influenced the media at statewide and national workshops on reporting on HIV/AIDS.
Capacity Building
AIDSCAP's primary role in India was building the capacity of institutions rather than direct project implementation. It did so through technical assistance and sponsorship of key individuals to local, national, regional, and international training events to strengthen skills in BCC, STI case management, epidemiologic projections and modeling, HIV/AIDS reporting, and program management. By disseminating HIV prevention and control data and sponsoring advocacy activities, AIDSCAP stimulated the creation of a significant number of HIV prevention projects across the country and developed the expertise of local institutions to design, manage, and evaluate such projects.
Special Features
Three unique features of the AIDSCAP/India program are its (1) work to support the first PLWA organizations in India (one in Tamil Nadu and one nationwide); (2) initiatives in raising awareness of the women's risk of HIV infection through state and national workshops as well as formative research; and (3) support of cross-border interventions with mobile populations along the India-Nepal border. In each of these areas, AIDSCAP has led the way in calling attention to the needs of these vulnerable populations.
Implementing Partners
- All India Women's Conference
- Bhoruka Research Centre for Hematology and Blood Transfusion
- Community Aid and Sponsorship Program
- CEDAC Communications Pvt., Ltd.
- India Institute of Health Management Research
- Indian Law Institute
- JAGORI/Positive Life
- MCRC
- Mindspace
- MYRADA
- Nalamdana Charitable Trust
- PLAN International
- Seva Trust/Society for Demographic Research and Training
- Society for AIDS Awareness and Prevention
- Society for the Promotion of Youth and Masses
- Sulabh International Institute of Health and Hygiene
- Tamilnadu Network of Positive People
- Tamil Nadu State AIDS Control Society
- World Vision of India
- YRG Care for AIDS Research and Education
ASIA, Major Countries: Indonesia
Epidemiology
HIV infection has not reached an epidemic stage in Indonesia. AIDS case reports and HIV seroprevalence data indicate that the spread of HIV in Indonesia is following a pattern more like the one observed in the Philippines and Sri Lanka than the pattern seen in Thailand, India, or other Asian countries with well-documented epidemics. A cumulative total of 550 HIV-positive individuals (136 living with AIDS) had been reported to the Ministry of Health as of June 30, 1997. The actual number of individuals living with HIV, however, could easily be 10 times higher.
Several factors contribute to the spread of HIV in Indonesia. An extensive commercial sex industry reaches rural and urban areas, and there is high mobility of commercial sex workers (CSWs) throughout the archipelago. In addition, CSWs cater to a large number of mobile men, including land and sea transport workers and migrant laborers in construction and mining.
Country Overview
Indonesia is the fourth most populous nation in the world, with an estimated population of 190 million. It is an archipelago of more than 13,000 islands stretching over 3,200 miles and 3 time zones. Sixty percent of the population reside on the island of Java, one of the most densely populated islands on earth.
The HIV/AIDS Prevention Project (HAPP), is a five-year, $20-million USAID project that supports the implementation of the national HIV/AIDS strategy of the Government of Indonesia (GOI). In November 1995, the HAPP implementation plan was designed for a five-year period. The plan was approved by Indonesia's communicable disease control and environmental health director in May 1996, HAPP activities were initiated in July 1996.
HAPP was directed by the Ministry of Health (MOH), with technical assistance and subproject administration assigned to AIDSCAP. The HAPP team also included seconded staff from the Futures Group in the area of condom social marketing and from the Centers for Disease Control and Prevention in the area of sexually transmitted infection (STI) control. HAPP is an integrated HIV/AIDS prevention project comprised of four major technical components: (1) improved management of STIs, (2) behavior change communication (BCC), (3) improved access to and promotion of condoms, and (4) policy support and dissemination. The geographic focus of the program is North Jakarta and Surabaya, which are both located on the island of Java, and Manado. The target audience included youth, female CSWs, other women at risk, clients of CSWs, commercial sex and brothel managers, and waria (transvestites).
Accomplishments
During its first 10 months of implementation, HAPP was active at the community level, funding 38 subgrants, eight small grant activities, and eight activities directly funded by the HAPP office for a total of 54 interventions and activities.
Behavior Change Communication
HAPP supported the national BCC strategy developed by the GOI. At the beginning of the project, neither the appropriate BCC curricula nor the skills to develop needed curricula existed. Therefore, a curriculum development activity was designed and initiated as an action-learning process, by which outreach workers and trainers were involved in developing a behavior change, theory-based set of training modules.
The project collaboratively developed and disseminated materials ranging from stickers to TV and radio drama. Outreach to target audiences was achieved through a network of implementing agencies (IAs) that recruited and supported outreach workers and peer educators who, in turn, promoted and supported the adoption of safer sexual practices by target audiences. Stronger links were also initiated between IAs, local governments, provincial AIDS commissions, and private businesses. HAPP carried out coordinated mass media activities by buying-in to an ongoing mass media collaboration with the Center for Health Education. The buy-in provided funding for broadcast of a previously developed set of TV spots and development and broadcast of media targeting youth.
Condom Promotion and Distribution
HAPP supported a wide range of condom social marketing activities, including condom quality assurance, operations research, training for CSWs in condom negotiation, mass media promotions, and other marketing efforts. The project funded special task force teams in designated intervention areas to increase availability of condom supplies. Condoms are now readily available to clients and CSWs in the red light districts of North Jakarta. Evaluation and monitoring of the condom component was completed in July 1997.
Increasing the acceptance and use of condoms was a project priority. In 1996, studies reported that only 14 to 30 percent of CSWs used condoms with their clients. By June 1997, the percentage of CSWs targeted by the project who were using condoms was 89 percent in Surabaya and 90 percent in North Jakarta.
Strengthening STI Services
Guidelines for the management of patients with STIs are a cornerstone of any national STI prevention program. The recent development and promulgation of STI management guidelines by the MOH was therefore a major achievement. HAPP was a partner in developing the guidelines and used them in its STI clinical training. High STI rates among CSWs, along with guidance from HAPP staff on the effectiveness of Thailand's national condom policy, persuaded the GOI to issue a formal declaration requiring 100 percent condom use in commercial sex -- a major step forward in the effort to combat HIV/AIDS in Indonesia. HAPP supported improvements in clinic-based STI activities for men and women by providing STI management and lab skills training to health care providers at HAPP sites and by supplying laboratories with essential equipment.
Capacity Building
Advocacy, capacity, and policy support were built through study tours for government and religious leaders. These tours allowed Indonesian leaders to observe and discuss HIV prevention activities in the Asian region as well as in key areas of Indonesia. HAPP provided follow-up meetings that encouraged dissemination of learning from the study tours. Other capacity building and networking activities for IAs and local governments included training in STI management, participatory evaluation, training skills development, curriculum development, condom negotiation, outreach, and other interpersonal communication skills. IAs also received training in proposal writing, budgeting, financial management, and programmatic reporting.
Behavior Surveillance
HAPP worked with the MOH to adapt its behavior surveillance surveys (BSS) methodology to follow trends in sexual behavior in Indonesia. Several findings from the first round of surveys suggest a relatively modest risk of STI /HIV among the general population. The age of first intercourse is relatively high (20-24 years), there is a low prevalence of concurrent partnerships among women (with only 1.5 percent of female factory workers admitting to having more than one sex partner in the past year), and commercial sex is limited (with, for example, sailors and seaport laborers reporting an average of only 2.5 CSW contacts per year). Other findings, however, suggest a higher level of CSW contacts (mainly at brothel complexes), and a low level of condom use in commercial sex (17 percent).
Special Feature
Islam plays a strong role in the Indonesian culture, and the Islamic leaders have taken on the responsibility of providing guidance on HIV/AIDS issues to the people of Indonesia. Their approach, in comparison to that of religious leaders in other Muslim and non-Muslim countries in the region, is a decidedly compassionate and liberal one. Islamic religious leaders commented on how their study tour assisted them in validating their current open-armed policy of care and support to people with HIV/AIDS. These experiences led to the Second National Workshop of Islamic Religious Leaders on HIV/AIDS in June 1997, where issues of care and support for people with HIV/AIDS were addressed. Sponsored by HAPP, the workshop was held under the auspices of the National AIDS Commission and all provinces were represented. It resulted in
- the development of Islamic religious guidelines for giving support to and caring for people with HIV/AIDS.
- the development of a plan of action for implementing the guidelines.
- a statement rejecting euthanasia for people suffering from AIDS.
- a statement reinforcing the principle of respect and dignity toward all humans, including people living with HIV/AIDS.
- a statement calling for no discrimination or isolation practices toward people living with HIV/AIDS.
- a statement recommending the creation of an environment conducive to HIV/AIDS prevention and control.
Implementing Partners
- Center of Health Education, MOH
- The Futures Group
- Communicable Disease Control/Environmental Health, MOH
- Program for Appropriate Technology in Health
- Center for Health Research, University of Indonesia
- Project Concern International
- Private Agencies Collaborating Together (PACT)
- Yayasan Bahagia Harapan Kita
- Yayasan Prospectiv
- Yayasan Mitra Indonesia
- Atmajaya Research Center
- Yayasan Mitra Masyarakat
- Yayasan Pelit Kasih Abadi
- Yayasan Abdi Asih
- Yayasan Pelita Ilmu
- Ikatan Ahli Kelehatan Masyarakat
- Yayasan Investasi Kemanusiaan
- Ikatan Dokter Indonesia
- Center for Health Education, MOH
- PKBI Daerah Jawa Timur
- Yayasan Kusuma Buana
- Yaysan Jaringan Epidemiology
- Pusat Media dan Pelatihan AIDS
- Population Services International
- Working Group on AIDS Control, National AIDS Control Commission
- The Indonesian Council of Islamic Religious Leaders (Majelis Ulama Indonesia)
- APB-Target
ASIA, Major Countries: Nepal
Epidemiology
The National Centre for AIDS and STD Control (NCASC) reported 647 HIV infections and 136 AIDS cases by mid-1997. Given Nepal's public health structure and its limited HIV/AIDS surveillance system, the actual number of AIDS cases may be 5 to 10 times the reported number and the number of HIV infections may be 20 to 30 times the detected number. A large proportion (up to 50 percent) of these infections were most likely acquired in India.
Country Overview
After the first case of AIDS was discovered in 1988, the World Health Organization (WHO) provided His Majesty's Government (HMG) with technical assistance to set up a National AIDS Control Program and develop Medium-Term Plan I (MTP I). Following the implementation of the MTP II in 1993, HMG, in collaboration with WHO, the European Community (EC), and other donors, developed a blood screening program, a sentinel surveillance system, and sexually transmitted infection (STI) management guidelines. In 1996, the development of a policy paper on HIV/AIDS and STI control established HMG's commitment to manage STI/HIV/AIDS prevention as a priority multisectoral program.
Beginning in 1993, AIDSCAP/Nepal sought to reduce the rate of STIs in the Terai region of Nepal by reducing the high-risk behavior of commercial sex workers (CSWs) and their clients. The Terai was chosen because it stretches along Nepal's long border with India, a country in which numerous pockets of HIV infection had already been identified. The high volume of traffic between the two countries resulted in a high probability of sexual contact due to the labor migration of both Indian and Nepalese men across the borders, and domestic migration of Nepalese men and women from rural areas to Nepal's border cities. In addition, there were reports of the trafficking of Nepalese women to be sold into sexual slavery in India. These patterns of interaction put persons living, working, and traveling in this heavily populated region at risk of contracting HIV infection.
USAID supported AIDSCAP/Nepal's strategic plan with special HIV/AIDS program funding from the Asia/Near East Bureau, and later with direct support from its Mission in Nepal.
Accomplishments
Prior to the design of interventions, AIDSCAP supported a rapid assessment of sexual networking in five urban areas and adjacent satellite towns in the Terai. The assessment confirmed an underground commercial sex industry and highlighted CSW mobility and client demand along major transport highways leading to India. As a result of its findings, geographical coverage of the project was refocused from an east-west urban strategy to one focused on 435 kilometers of highways in the Central region.
Behavior Change Communication
Through AIDSCAP, USAID supported indigenous organizations to develop and implement community-based outreach education. Working in highway halting points, urban centers, small communities, and at the Birgunj-Raxaul border, field workers reached CSWs, other marginalized women with multiple partners; and transient workers, including truck drivers, military personnel, police, students, and migrant workers. As the project progressed and field workers gained confidence, 545 peer educators were trained. By the end of the project, 2,600 CSWs and 36,500 CSW clients had been reached.
Strengthening STI Services
In an effort to ensure access to effective STI services at the first point of contact with service providers, AIDSCAP worked to strengthen private sector service delivery in the program area with three partners: Nepal Medical Association (NMA), Nepal Chemists and Druggists Association (NCDA), and Family Planning Association of Nepal (FPAN). The NMA developed a training curriculum on the syndromic management of STIs that was later modified for chemists and formed the core of a training curriculum developed by the EC to train nurses and paramedics. The NMA trained 50 physicians in syndromic management of STIs, and the NCDA trained 32 trainers of trainers and 631 community chemists (approximately 72 percent of chemists serving target populations in the project area).
AIDSCAP supported FPAN in the integration of STI services into three of its existing clinic and community outreach family planning and maternal-child health care sites. Health care providers were educated on the syndromic approach and clinics were renovated and equipped. In 14 months, 1,275 clients were treated for STIs at the three clinic sites. Support to establish a revolving drug fund for STI drug supply made it possible to supply clients with lower-cost medications (15 percent below market price).
Condoms
To increase overall accessibility and demand for condoms for disease prevention, AIDSCAP collaborated with the Futures Group International Social Marketing for Change Project, Nepal Contraceptive Retail Sales Company (CRS), and Stimulus, a Kathmandu-based advertising firm. CRS expanded its retail sales base beyond the traditional chemist's shops to include outlets in tea shops, restaurants, lodges, and general goods shops adjacent to the highway and in key urban areas. CRS condom sales in the 22-district Terai region expanded by 189 percent from 1993 to 1996, with approximately 4 million condoms sold in the Terai in both 1995 and 1996. The increased demand for condoms was influenced by a strong multimedia campaign that included a campaign logo and slogan, an animated condom character, TV advertising spots, radio shows, a nationally televised videodrama, and various print media. Between 79 and 93 percent of CSWs and clients surveyed report hearing the condom campaign slogan.
Policy Development
AIDSCAP provided technical assistance in epidemiologic modeling to the NCASC and initiated policy dialogue among key stakeholders to create an environment in which the government and the private sector could better mobilize resources to control STI/HIV/AIDS. Seventy-five representatives from government, nongovernmental organizations (NGOs), donors, and the media attended the AIDSCAP/NCASC- sponsored presentation on the epidemiological situation and HIV/AIDS projections for Nepal. In addition, AIDSCAP supported an Asia study tour, orientation workshops on the management of HIV/AIDS for members of Parliament, and workshops for local journalists. AIDSCAP policy initiatives ceased in 1995, when the Minister of Health discontinued the practice of working with international NGOs on HIV/AIDS policy issues.
Key Outcome Data
- More than 44 percent of patients seeking services for urethral discharge from trained chemists receive treatment in accordance with national guidelines, compared with 0.85 percent before project intervention.
- Between 21 percent (trained chemists) and 100 percent (FPAN clinics) of persons seeking STI treatment receive appropriate prevention education.
- Over 74 percent of CSWs surveyed in the Central region can name at least one correct way to prevent HIV transmission.
- Between 77 and 92 percent of persons surveyed in the Central region report realistic perceptions of risk.
- Of CSWs surveyed, 61 percent reported using a condom with their last client, compared to 35 percent at project start-up.
Implementing Partners
- Contraceptive Retail Sales (CRS)
- The Futures Group International, Inc.
- General Welfare Pratisthan
- Lifesaving & Lifegiving Society
- Nepal's Chemist and Druggist Association
- Nepal Medical Association
- New ERA
- Population Services International (PSI)
- Program for Appropriate Technology in Health (PATH)
- Save the Children/United States
- Stimulus Advertisers
- Valley Research Group
ASIA, Major Countries: Thailand
Epidemiology
Data from HIV sentinel surveillance of the female population in Bangkok were beginning to show significant levels of infection by 1992. For all three sentinel populations of women (direct and indirect commercial sex workers [CSWs] and antenatal clinic clients) the level of HIV infection in Bangkok was higher than for the rest of Thailand. One-third of direct (brothel-based) CSWs in Bangkok were infected, compared to one-fourth nationally. The prevalence of HIV infection among Bangkok's indirect CSWs (who usually work out of bars, restaurants, and night clubs) was twice that for all of Thailand. Finally, in 1992, infection in young married women in Bangkok surpassed the national average.
Country Overview
When AIDSCAP/Thailand was launched in 1992, the Royal Thai Government had already established a national program that was focused on provinces outside of Bangkok. International donor assistance, guided by the first Medium-Term Plan of the Ministry of Public Health, was steered mostly toward the northern region of Thailand, where the epidemic was spreading rapidly.
The urban province of Bangkok, which was not directly targeted for prevention activities, experienced a significant migration of unattached lower-income men and women in the peak age range for sexual activity (estimated at 10,000 persons per month in 1992). It became clear that the HIV/AIDS epidemic was present among the general population and was no longer confined to the core population of CSWs and their clients. At the request of Thailand's National AIDS Control Program, USAID supported AIDSCAP to design a comprehensive HIV prevention program for the lower-income population of Bangkok. The goal was to slow the transmission of HIV in the Bangkok population aged 15 to 29 with a comprehensive program of mutually reinforcing interventions.
When AIDSCAP began implementation, services for sexually transmitted infection (STI) treatment, condom distribution, and behavior change communication (BCC) existed in Bangkok, but they were small-scale and not readily accessible. By forging an alliance of prevention agencies and creating a program identity (Bangkok Fights AIDS), AIDSCAP sought to promote community action and targeting of services to the most vulnerable populations.
Accomplishments
A total of 28 subprojects were implemented by 20 agencies from the public, private, and university sectors under AIDSCAP. These subprojects provided approximately 9,000 persons with curriculum-based training, reached more than 200,000 lower-income women and men with BCC messages, and distributed more than 800,000 BCC materials and 1.6 million condoms free-of-charge.
Community Mobilization
AIDSCAP supported the Faculty of Public Health at Mahidol University to work through district AIDS committees (DACs) to identify and strengthen networks of members of high-risk communities. Technically skilled agencies directed targeted communications to these vulnerable networks through a variety of channels. In addition, clinical service structures were strengthened to increase access to STI services, counseling, and condoms. Throughout this process, community networks were identified, created, and reinforced to increase the opportunities for communication and diffusion of STI/HIV/AIDS information to other networks.
Behavior Change Communication
AIDSCAP used mass media, outreach, public relations, and interpersonal and peer education communications to reach female and male CSWs, adolescents and married women in low-income communities, and female and male wage earners in large formal and small informal worksites. As a result of BCC activities, these target groups, with the exception of non-CSW single women, reported adopting safer sexual behaviors. As shown by behavioral surveillance surveys (BSS) of members of target groups showed increases in condom use in high-risk situations, and a decline in the proportion of men visiting CSWs.
Strengthening STI Services
AIDSCAP developed projects to extend and strengthen the ability of Bangkok service providers to rapidly diagnose and treat STIs in the target population of lower-income young men and women and to conduct outreach BCC. Eleven Bangkok Metropolitan Administration (BMA) STI clinics and their laboratories received the necessary equipment to diagnose and treat STIs, and the hours of operation were extended in two clinics.
Competency-based training curricula in STI management were developed, and physicians in the public and private sectors and nurses and laboratory technicians in the public sector were trained in the syndromic approach. Laboratory technicians were also trained to improve quality control and other standardized laboratory procedures, to perform more diagnostic tests, and to implement the new systems. Nurses who provide STI services under the direction of a physician received training in the national guidelines for the syndromic approach, HIV prevention, compliance with medical prescriptions, and partner notification. In addition, approximately 900 outreach staff members from 60 BMA clinics were trained in outreach education.
As persons with STIs in Thailand frequently seek treatment from pharmacies without prior medical diagnosis of their illness, AIDSCAP supported the development of a model intervention for improving pharmacy-based STI diagnosis, referral, and prevention services. AIDSCAP trained pharmacists and nonpharmacist staff from 210 drugstores in Chiang Mai, where a successful pharmacy training program in contraceptive services had been conducted in 1990. The training project was later replicated in Bangkok with funding from the European Community.
Condoms
With condom availability already high in Bangkok, AIDSCAP focused on addressing cultural barriers to condom use through BCC materials, community outreach, and mass media. For example, AIDSCAP attempted to modify social norms in a way that would allow single women to be more assertive in condom use. Booklets, pamphlets, and videos encouraged women to acquire condoms themselves and insist on their use if they were unsure about their partner.
Key Outcome Data
BSS were conducted at intervals among cross sections of Bangkok population groups that were similar to those targeted by AIDSCAP interventions. Surveys were administered to school youth; employees of offices, factories, and brothels; male STI clinic patients; and antenatal clinic patients. The five survey rounds revealed a decline in the proportion of men visiting CSWs and a significant increase in condom use in high-risk situations. In addition, condoms were reportedly used more consistently. Single females reported no increase in sexual activity.
Key findings include the following:
93 to 94 percent of men surveyed in 1996 among various populations in Bangkok reported using a condom during their last sexual contact with a CSW, compared with 88 to 92 percent in 1993.
89 percent of indirect CSWs surveyed in 1996, 89 percent reported using a condom with every client, compared with 56 percent in 1993.
29 percent of indirect CSWs surveyed in 1996 reported using a condom with every nonpaying sexual partner, compared with 23 percent in 1993.
18 percent of single women (non-CSWs) reported using a condom during their last sexual contact in both 1993 and 1996.
Special Feature
A special feature of the AIDSCAP/Thailand program was the linkage of its subprojects through community mobilization and DACs and the creation of a project identity (Bangkok Fights AIDS) to establish a sense of indigenous partnership.
The community mobilization process employed in Bangkok can be described as follows: an implementing agency, such as a university, works through a local coordinating mechanism (the core members of the DAC) to identify and strengthen networks of individuals in high-risk groups. Technically skilled agencies arrange targeted BCC to these networks through a variety of channels to promote the social norms that support STI/HIV/AIDS prevention. Meanwhile, clinical service structures are created or strengthened to increase access to STI treatment, counseling, and condom supplies. Throughout this process, the community networks are identified or created, and reinforced to increase the opportunities for communication between them and for diffusion to other networks.
Initially, the network strengthening component of the community mobilization effort focused on community diagnosis that mapped out and highlighted the complexity of Bangkok's social networks. Approximately 117 DAC members were trained and 7,273 men and women were reached in six districts. In the remaining 32 districts, greater emphasis was placed on strengthening DAC performance, rather than creating social networks.
Implementing Partners
- Asean Institute for Health Development
- Association for the Promotion of the Status of Women
- Association for Voluntary Sterilization
- Bangkok Metropolitan Administration
- Chulalongkorn University
- Department of Health, Bangkok Metropolitan Administration
- Foundation for Thailand Rural Medical Practitioners Association
- Johns Hopkins University
- Mahidol University, Faculty of Public Health
- Medical Society for the Study of Sexually Transmitted Diseases
- Ministry of Public Health of Thailand
- Office for Population and Technical Assistance (OPTA)
- Planned Parenthood Association of Thailand
- Program for Appropriate Technology in Health (PATH)
- School of Public Health, Mahidol University
- Thai Association for Voluntary Sterilization
- Thai Medical Society for the Study of Sexually Transmitted Diseases
- Thai Red Cross Society
- Thailand Rural Reconstruction Movement
- World Vision Relief and Development
