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Programs |
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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 |
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| 1993/4 | 1996 | |
| Knowledge of two correct methods of HIV/AIDS prevention | Percent | |
| Male university students | 79 | 95 |
| Female university students | 84 | 95.6 |
| Clients of sex workers | 50 | 86 |
| CSWs | 40 | 87 |
| Male university students reporting > one sexual partner in the last 3 months | 53 | 36 |
| Male military personnel reporting > two sexual partners in the last 3 months | 47 | 37 |
| Proportion who report having ever used a condom | ||
| CSWs | 68 | 88 |
| CSW clients | 55.5 | 81 |
| Proportion of CSW clients reporting condom use during last sexual encounter with nonregular partner | 54 (1992) |
97 |
| Proportion reporting consistent condom use | ||
| Sex workers with nonregular clients | 52 | 75 |
| Military personnel with CSWs | 48 | 59 |
Condom Promotion and Distribution
Condom social marketing, implemented by AIDSCAP subcontractor Population Services International (PSI), complemented and reinforced BCC activities. Under AIDSCAP, the program expanded nationwide through officially recognized and supervised distributors in all major urban centers. Peer educators, especially CSWs, served as sales agents in nontraditional venues, while social marketing staff supplied more traditional commercial outlets. Over the life of AIDSCAP, the social marketing program sold over 24 million condoms.
Strengthening STI Services
At the initiation of the AIDSCAP/Cameroon program, no national STI control program existed, and many existing health care structures managed STI cases ineffectively. As a result of AIDSCAP activities, a national STI control plan and standard diagnosis and treatment guidelines were developed and adopted by the Ministry of Public Health (MOPH). Moreover, a core group of 10 physicians at the central level, as well as 40 military health care staff, received the necessary training and are currently disseminating the treatment guidelines to providers throughout the country. As part of the development of the guidelines, AIDSCAP also supported critical research to determine the sensitivity of Neisseria gonorrhoeae to 10 antibiotics commonly used in Cameroon. In addition, AIDSCAP, in collaboration with the MOPH and PSI, conducted an innovative pilot project to distribute prepackaged urethritis treatment kits using social marketing techniques. Although the MOPH discontinued this project after the pilot phase, it provided invaluable information for other countries considering such an approach.
Capacity Building
AIDSCAP assisted in building the capacity of governmental agencies as well as international and local NGOs. Capacity building focused on improving the skills of local experts to help them become more effective in HIV/AIDS prevention. Through AIDSCAP's efforts, approximately 20 master trainers now improve the skills of local staff in technical areas, including BCC materials development and STI case management. AIDSCAP-supported development of training manuals, adapted locally with the assistance of local health care, social science, and communication experts, were greeted enthusiastically by organizations conducting HIV/AIDS prevention activities.
Special Features
AIDSCAP/Cameroon's integration of CSW peer educators into condom social marketing efforts proved highly successful: CSW educators/salespersons sold over 3 million condoms in Yaoundé alone. The Cameroon program also capitalized on the effectiveness of drama as an HIV/AIDS prevention medium, particularly in noisy, crowded bars and clubs not conducive to educational activities. For example, with AIDSCAP support, three theatrical CSW troupes toured the country, giving highly popular performances in venues from small beer houses to small urban theaters. Troupes even performed for international audiences at HIV/AIDS and STI conferences. Video recordings of these troupes' performances were broadcast on national television and are currently used in a variety of educational programs.
Development of a close collaborative relationship with the Ministry of Defense and National Security provided an unusual opportunity to bring HIV/AIDS prevention activities to men and women in uniform, culminating in a military decree that made STI/HIV/AIDS prevention an obligatory component of military training and part of the examination for promotion in Cameroon's armed forces. Finally, as part of AIDSCAP's Care and Management Program, the Cameroon program provided technical assistance and financial support to the Association of United Brothers and Sisters, an indigenous NGO providing counseling and care to persons living with HIV/AIDS and their families.
Implementing Partners
- Ministry of Public Health
- Ministry of Defense and National Security
- Ministry of Higher Education
- Cameroon Health Program
- Institute of Tropical Medicine
- Population Services International
- Institut Pasteur
- Institut de Recherche et des Études de Comportement
- CARE Cameroon
- Save the Children
- The Association of United Brothers and Sisters
- Ministry of Defense and National Security
AFRICA, Major Countries: Ethiopia
Epidemiology
Ethiopia's first HIV-positive individuals were reported in 1986. In 1988, HIV prevalence rates among commercial sex workers (CSWs) were already 15 percent in Awassa and 20 percent in Bahirdar. Rates increased in Bahirdar to 70 percent by 1991. Rates among pregnant women aged 15 to 24 in Addis Ababa were 2 percent in 1989 and 13 percent in 1993. By 1996, estimates of HIV prevalence in four antenatal clinics in Addis Ababa were 26.5 percent, 21.4 percent, 15.7 percent, and 9.0 percent, and among CSWs, prevalence ranged from 40 to 60 percent. The HIV/AIDS epidemic is still in an expansion stage, and studies conducted in 1994 and 1996 indicate that HIV incidence rates remain high.
Factors contributing to the rapid spread of HIV/AIDS include the seasonal migration of workers in search of employment and better economic conditions, which leads to increased multiple partner sexual networking; dislocation of populations due to the 17-year civil war, which created social situations conducive to increased sexual networking; high rates of sexually transmitted infections (STIs) in high-risk and general populations; increased sexual activity among youth; and high unemployment rates, exacerbated by the return of 400,000 demobilized soldiers to rural areas, towns, and cities after 1991.
Country Overview
Northeast Africa's most populous country, Ethiopia has a 2,000-year history and over 70 ethnic groups speaking nearly 100 languages. The population, which is 90 percent rural, is predominantly Orthodox Christian, although there is a substantial Muslim population. For the past 3 decades, severe political, economic, and ecological crises -- a long civil war, unstable government, recurrent drought, massive environmental degradation, and an unfavorable international economic environment -- have created a context conducive to the rapid spread of HIV. The government of Ethiopia took an early aggressive stance toward coping with the epidemic and has continued its commitment in spite of these crises. From January 1993 to March 1997, AIDSCAP implemented a comprehensive set of HIV/AIDS prevention activities, under two USAID/Ethiopia bilateral projects, through the Ministry of Health (MOH), the Ministry of Education, and 15 nongovernmental organizations (NGOs).
Accomplishments
AIDSCAP/Ethiopia helped fill gaps left by the government's decentralization of HIV/AIDS control activities, which occurred at the beginning of the program. Twenty sites participated in interventions to improve STI services. Of the participating sites, four focus sites developed a model of integrated, comprehensive interventions that coordinated public and private resources at the regional level and featured improved STI care and outreach to high-risk individuals. National condom social marketing supported all activities.
The four focus sites targeted female sex workers (referred to locally as MPSCs, or multiple partner sexual contacts), factory and government workers, in- and out-of-school youth, and the general population with behavior change communication (BCC) messages. AIDSCAP/Ethiopia supported key players and organizations in the four targeted regions by implementating intervention activities that included creating innovative focus site intervention teams (FSITs); training health care providers, peer educators, and other stakeholders; supplying drugs and equipment for STI clinics; and supplying educational equipment to support BCC programming.
Behavior Change Communication
The foundation of AIDSCAP/Ethiopia's program was behavior change intervention which focused on promoting ways of reducing sexual risk taking. NGOs supported by the program developed innovative strategies to reach target groups and creative materials, including a pocket risk assessment calendar, traditional street theater with prevention messages, and an adaptation of the Fleet of Hope imagery originally developed in Tanzania. Messages promoted delayed sexual initiation for young adults, fidelity for couples, partner reduction, condom use, and prompt and effective treatment for STIs. Interventions used multiple, reinforcing communication channels and BCC activities, emphasizing drama, puppetry, sports events, and materials shared widely among implementing agencies.
During the life of the $3-million program, AIDSCAP/Ethiopia provided training to nearly 6,000 people, reached about 750,000 people with HIV/AIDS prevention messages, distributed nearly 900,000 educational materials, and distributed or sold close to 42 million condoms.
Results of evaluation research indicate that knowledge increased and risk behavior changed among the target audiences. For example, the proportion of MPSCs who could cite two or more prevention methods increased from 78 to 99 percent, and the proportion who had recently received appropriate STI treatment rose from 55 to 73 percent. Although a higher percentage of out-of-school youth reported that they were sexually active and had multiple partners at the end of the program, their use of condoms also increased. Qualitative research suggests that AIDSCAP/Ethiopia's intensive interventions made substantial progress in changing knowledge, attitudes, behaviors, and practices (KABP) related to HIV/AIDS.
Condom Promotion and Distribution
The Ethiopia Social Marketing Project (ESMP), implemented by DKT International and Population Services International (DKT/PSI), has emerged as one of the most successful social marketing efforts in Africa since its inception in 1990. During the 33 months of collaboration with AIDSCAP, the ESMP sold approximately 42 million condoms through more than 10,000 outlets in 533 different cities, towns, and villages. In the last full year of program activities, the ESMP sold over 15 million condoms, averaging 1.25 million per month -- 25 percent more than the target of one million per month. These impressive sales figures were achieved despite serious constraints to implementation, including the lack of a developed commercial marketing and distribution system, the expansion of civil war, and target populations' unfamiliarity with condoms. Sales through bars and hotels -- marketing and distribution outlets easily accessible to high-risk populations -- accounted for nearly 25 percent of all ESMP sales. AIDSCAP support enabled DKT/PSI to secure longer-term funding from USAID and the Dutch Government for the continued operation and expansion of social marketing in Ethiopia through 1999.
Strengthening STI Services
Improving STI services was a significant component of the program. AIDSCAP refurbished the 20 clinical sites by providing STI drugs and laboratory equipment, improving infrastructure, training providers in syndromic management, developing case management guidelines and counseling protocols, and increasing the availability of condoms.
The program also sponsored a rapid ethnographic study (targeted intervention research, or TIR) of KABP related to STI/HIV/AIDS among targeted populations, which yielded results that were used to develop educational materials, and conducted a gonococcal chemosensitivity study in two locations.
A comprehensive assessment of the 20 clinical sites at the end of the program found that 97 percent of health care providers had the skills and knowledge required for appropriate STI case management and had accepted syndromic management as essential for managing STI cases. In all focus sites and in 80 percent of the STI clinical sites, STI services are integrated into maternal child health and family planning (MCH/FP) services as a result of onsite training conducted for MCH/FP workers that emphasized STI screening of FP attendants and syphilis screening of pregnant women.
Capacity Building
Through its collaboration with local public and private partners, AIDSCAP/Ethiopia made a substantial contribution to developing local capacity to design, implement, and evaluate HIV/AIDS prevention programs, despite the massive decentralization of government activities that occurred during the first year of the program. Capacity building took a variety of forms in Ethiopia, including training workshops, a study tour, attendance at regional and international conferences, collaboration with local researchers to collect and analyze data, and providing resources for implementing agencies that were not contractual partners with AIDSCAP. A rapid organizational assessment performed at the end of the project revealed that implementing partners believed there had been significant improvement in technical, organizational, and management skills building; organizational systems development; and enhancement of networks and global learning.
Special Features
In collaboration with the Ethiopian government's regional health bureaus, AIDSCAP/Ethiopia developed the concept of FSITs so that HIV/AIDS prevention interventions could be effectively implemented at the regional level. FSIT members were drawn from regional health care and education sectors, NGOs, municipal government offices, regional agricultural offices, factories, religious organizations, and regional DKT/PSI staff. Their activities involved convening monthly meetings to discuss achievements and challenges and to plan complementary activities among members. They also shared a wide range of educational materials and training resources. The FSITs enabled implementing agencies in each region to maximize the types of interventions implemented and the types of populations reached. They continued to operate after the end of the AIDSCAP program.
Implementing Partners
- Ministry of Health
- Ministry of Education
- DKT/Population Services International
- Christian Children's Fund
- Family Guidance Association of Ethiopia
- GOAL
- Nazareth Children's Center for Integrated Development
- Marie Stopes International Ethiopia
- Tigray Development Association
- Integrated Holistic Approach Urban Development Project
- Society for Women and AIDS/Ethiopia
- Development Aid for Youth
- Ethiopian Aid
- Organization for Social Services for AIDS
- Save Your Generation Association
- Beza Lewegen
- Love to Human Beings Ethiopia AIDS Prevention Society
- Ministry of Education
AFRICA, Major Countries: Kenya
Epidemiology
Kenya has one of the best established HIV/AIDS surveillance systems in sub-Saharan Africa. Since 1990, the National AIDS/STD Control Programme (NASCOP) has been monitoring HIV prevalence among antenatal clinic attendees in 13 urban sites around the country. Eleven additional periurban and rural sites were added in 1994 and 1995. Results are widely disseminated through a regular report published by NASCOP.
Trends between 1990 and 1995 indicate that the epidemic is still growing and is spreading from urban to periurban areas. HIV prevalence in the adult population in Kenya, estimated to be 3.1 percent in 1990, rose an average of 1 percent per year to 7.5 percent in 1995. While prevalence may have reached a plateau in some areas such as Mombasa (12.5 percent in 1995), the epidemic is still growing in areas of central and western Kenya, particularly periurban sites. In the western areas, prevalence increased between 1990 and 1995 from 17 to 22 percent in Busia and from 19 to 27 percent in Kisumu. There have also been dramatic increases in Nakuru, from 9.9 to 27.2 percent, and in Nairobi, from 5.8 to 24.6 percent. Prevalence has remained lower in areas to the north and east of Nairobi, with two rural sites in central and eastern Kenya having 2 percent prevalence rates in 1994.
Changes in the patterns of infection and the impact of past infections are evident. The peak ages for AIDS cases are 25 to 29 for females and 30 to 34 for males, with young women aged 15 to 24 twice as likely to be infected as males of that age. The number of reported AIDS cases was 65,647 as of June 1996, and it is estimated that by the year 2000, about half of all hospital beds will be used for AIDS patients. The effect on families is increasingly severe. For example, the number of AIDS orphans is projected to be to 580,000 by the year 2000.
Country Overview
Kenya, a country with an estimated population of 27.6 million, is rapidly urbanizing. However, approximately 80 percent of the population still live in the rural areas. Eighty percent of the population is Christian, with a significant minority of Muslims, particularly along the coast. The national languages are Kiswahili and English, and numerous local languages are also spoken. Diverse local languages and cultures play an important role in shaping the social norms that govern sexual behavior, particularly in the rural areas.
The Government of Kenya, working through NASCOP, developed two medium-term plans to address the epidemic. Numerous donors, including United Nations agencies, governments, and international private voluntary organizations, also support HIV/AIDS prevention and care activities. In addition, a growing number of Kenyan nongovernmental organizations (NGOs) are involved in HIV/AIDS interventions.
In September 1992, Kenya became an AIDSCAP priority country. Activities began in 1993 with four projects to bridge the transition from the earlier AIDSTECH program in Kenya to AIDSCAP. These activities were followed in early 1994 with the start of major subproject activities. The target populations were men and women in the formal workplace; men and women seeking sexually transmitted infection (STI) services at clinics, including maternal and child health/family planning clinics; and students in institutions of higher education. The populations were targeted in periurban and urban areas in Nairobi, Mombasa, and Eldoret, which are high-prevalence areas along the Trans-Africa Highway. The program sought to reduce high-risk sexual behavior in the target populations in order to reduce the incidence of sexually transmitted HIV/AIDS.
Accomplishments
AIDSCAP/Kenya implemented 32 subprojects and three additional initiatives addressing policy, sustainability, and gender issues. The Kenya program worked with 21 organizations on major subprojects, as well as providing technical assistance to NASCOP.
Behavior Change Communication
The behavior change communication (BCC) component of the Kenya program combined reaching specific target audiences, primarily through a peer education approach, with broader mass media interventions and capacity building in BCC skills.
Peer education projects were set up at 17 worksites in Mombasa, Eldoret, and Nairobi and at nine institutions of higher education. The higher education intervention trained 240 peer educators, reached 19,000 students, and distributed 10,600 materials and over 300,000 condoms. The worksite projects trained 375 peer educators and reached over 24,000 workers. Other workers were reached through incorporating HIV/AIDS education into training for five security guard companies.
Media projects included a theater group, Miujiza Players, which combined plays on HIV/AIDS with interactive communication with audiences; a weekly radio soap opera, Maajabu, produced in five local languages; and a weekly newspaper column, AIDS Watch, in the national press. Mechanisms for learning about and responding to the audiences were built into all the media interventions. For Maajabu, this resulted in an astonishing average of 2,000 letters per month from listeners.
The Kenya program also contributed to building long-term BCC capacity among NGOs. First, the program supported the Kenya AIDS NGOs Consortium (KANCO) to set up a resource center for HIV/AIDS and reproductive health materials. Within 3 years, the center's collection grew to over 800 materials, serving as a resource for an average of 230 visitors a month. In addition, AIDSCAP funded the Program for Appropriate Technology in Health to train participants from 19 NGOs in materials development, resulting in seven new materials and a core group of trained staff who continue to apply their new skills.
Finally, the Kenya program worked with Medical Assistance Programs (MAP) International to train church pastors in HIV/AIDS prevention and counseling and to develop church-based education, training, and counseling materials. The training resulted in at least 576 activities carried out by trained pastors for their communities. In addition, a manual was developed for pastoral training institutes, which will facilitate the institutionalization of HIV/AIDS counseling, prevention, and support skills. MAP also developed Growing Together: A Guide for Parents and Youth, which helps parents discuss sexuality with their children. In response to demand, 11,000 copies of this guide were distributed.
Strengthening STI Services
AIDSCAP supported training and supervision of health workers in STI case management through two subprojects. Family Planning Private Sector (FPPS) trained 402 health workers, mainly from FPPS-supported clinics. Moi University Department of Reproductive Health provided training and an innovative approach to supervision for 95 nurses, clinical officers, and doctors in private practice. Results showed that syndromic management of STIs is acceptable in the private sector, but post-training supervision is necessary. Notifying and treating sexual partners was perceived to be problematic. AIDSCAP also participated on NASCOP's committee that reviewed and revised the national STI guidelines.
Policy Dialogue
Work in the policy area was one of the most important aspects of the Kenya program. An initial AIDSCAP policy assessment found a sense of frustration that HIV/AIDS policy issues were not being addressed. As a result, three organizations were funded to facilitate debate and policy development. The first was KANCO, which conducted eight workshops with nearly 300 district, provincial, and national leaders. The workshops identified and prioritized HIV/AIDS policy issues, which were later presented as recommendations to policymakers, including those drafting the national sessional paper on HIV/AIDS. All of these issues were addressed in the paper, which is the government's first comprehensive policy statement on HIV/AIDS. The second organization, MAP International, was supported to facilitate policy development with churches in Kenya. MAP's baseline research on sexual activity among churchgoing youth helped motivate senior church leaders to publish a statement of commitment to developing HIV/AIDS policies and strategies for their denominations. AIDSCAP also worked with NASCOP to train senior government officials in making policy-related presentations using the AIDS Impact Model. These presentations to government and community leaders are credited with raising awareness about the extent of the epidemic in Kenya and its impact on all sectors.
Working with over 20 Kenyan and North American authors, AIDSCAP developed new data on the impact of HIV/AIDS on the national economy, businesses, and households. The book, published in 1996 and titled AIDS in Kenya: Socioeconomic Impact and Policy Implications, was launched by the vice president of Kenya and received wide media coverage.
Research and Surveillance
Four AIDSCAP-supported research projects studied different aspects of interpersonal relationships and how they affect decision making about sexual behavior. The Kenya Association of Professional Counselors (KAPC) took part in the AIDSCAP/UNAIDS multicenter randomized study of the efficacy of counseling and testing. Over 1,500 people were recruited for the study. Another multisite study on the female condom looked at ways in which use of the device affected women's ability to negotiate safer sex and at the role of women's groups in sustaining its use. The acceptability of the device was good, with over 70 percent of participants wishing to continue using it. KAPC also studied strategies for renegotiating sexual relationships among stable couples. Results showed the need for an education program focusing on dialogue, equality, condoms, and knowledge. A small study of 20 mother and daughter pairs implemented by the Centre for the Study of Adolescence found poor communication patterns and a lack of effective information and skills for HIV/AIDS prevention.
AIDSCAP financial and technical support made it possible for NASCOP to expand sentinel surveillance to 11 new rural and periurban sites. The program also helped NASCOP upgrade its hardware and training for site surveillance officers.
Capacity Building
Capacity building was provided through technical assistance, support for attendance at conferences, training workshops, and through the focus of many projects on skills building in both technical and management skills. The main approach, which was to assign an individual or group of consultants to work with a partner organization over time, facilitated a sense of mutual trust and led to supportive and enabling interactions. In addition, AIDSCAP developed a methodology to review, in collaboration with selected partner NGOs, their organizational status and the cost of their interventions. These data were condensed into brief reports recommending ways to improve the sustainability of each project and the institution.
Special Features
AIDSCAP/ Kenya had a strong emphasis on policy interventions, with the objective of creating a more supportive and positive environment for HIV/AIDS programming. Interventions to facilitate debate and policy development were directed at government officials, religious leaders, and provincial and national leaders. AIDSCAP/Kenya also emphasized working with the private sector through workplace peer education programs and by upgrading the skills of health care personnel in private clinics. Finally, there was a strong interest in integrating HIV/AIDS prevention into family planning activities, building on USAID/Kenya's leading role in supporting family planning in Kenya since the 1970s. These priorities were reflected in the choice of target populations and in the design of subprojects.
Implementing Partners
- Ace Communications Limited
- Appropriate Health Resources and Technologies Advisory Group (AHRTAG)
- Association of Medical Students of the University of Nairobi AIDS Awareness Campaign (AMSUNAAC)
- Artistic Network Productions (APNET)
- Artnet Waves Communications
- Braeburn Limited
- Centre for the Study of Adolescence
- Collaborative Centre on Gender and Development
- Family Planning Private Sector (FPPS)
- Health Economics and Development Research Associates (HEDRA)
- John Snow Incorporated: Family Planning Private Sector (FPPS)
- Kenya AIDS NGOs Consortium (KANCO)
- Kenya Association of Professional Counsellors
- Kenya One World Linking Forum (K-OWL)
- Medical Assistance Program (MAP) International
- Miujiza Players Limited
- Moi University Department of Reproductive Health
- Nairobi AIDS Task Force
- National AIDS/STD Control Programme (NASCOP)
- Owen House
- Program for Appropriate Technology in Health (PATH)
- Rotoract Club, University of Nairobi
- University Students AIDS Control Association (USACA)
- Appropriate Health Resources and Technologies Advisory Group (AHRTAG)
