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Final Report for the
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A. Key Lesson Regionally based teams are an important mechanism through which decentralized activities can be implemented. The formation of focus site intervention teams (FSIT) in the four project sites of STAC led to efficient use of staff, materials, training, funds, etc. among the governmental and non-governmental implementing agencies at the sites. Such collaboration enhances interaction, avoids duplication of efforts and makes for effective coordination of activities. USAID and FHI/AIDSCAP/Ethiopia observed that several implementing agencies of its STI/HIV/AIDS prevention projects in the regions were working in a fragmented and uncoordinated manner. This resulted in several implementing agencies, for example, targeting the same groups with similar interventions, producing similar materials for the same target groups, and using the same peer educators and community workers, thus making unnecessary demands on their time. All of this led to restricted and repetitive coverage and wasted resources. The solution was to bring the implementing agencies together to review the needs and resources and come up with a plan on how to improve on the situation. The regional health bureaus were approached and the concept of Focus Site Intervention Teams (FSIT) developed. The Bureaus took the lead to create teams comprised of representatives from governmental and non-governmental organizations, including religious groups and representative from work sites, all of whom were working on AIDS prevention. At each regional site the RHB acted as chairperson of the team with an NGO or MOE representative as secretary. FSITs have regular monthly meetings to discuss achievements, problems, plans and activities and share resources, including IEC materials and information on STI/HIV/AIDS. Teams share expertise in training, use common resource persons, use available STI services for joint referral and organize and participate jointly in World AIDS Day activities. B. Additional Lessons Government and NGOs can complement each other's efforts in HIV/AIDS prevention. Under STAC, government health bureaus upgraded their clinics, and NGOs trained peer educators to refer STI cases to the government clinics. Those NGOs like FGAE Bahirdar, Awassa and Nazareth, branch offices of OSSA and PSI and others utilized the services at health centers through referrals of STI cases. The NGOs and government organizations involved in HIV/AIDS/STI prevention activities in the focus sites collaborated in producing IEC materials, sharing resources, and also promoting the use and distribution of condoms. Capacity can be built in local NGOs to implement HIV/AIDS prevention activities and research, often with the assistance of local consultants. Sixteen NGOs were involved in STAC, some of whom had no previous experience in HIV/AIDS. With training and technical assistance, the NGOs implemented subprojects reaching under-served populations such as out-of-school youth, the hearing impaired, commercial sex workers, demobilized soldiers and others. Syndromic management of STIs has been found to be acceptable by health care providers at most of the twenty STI clinical sites. Under STAC, twenty clinics were upgraded with equipment, essential drugs and protective supplies, and physicians were trained in syndromic management of STIs. The recent organizational assessment conducted by local consultants indicated that syndromic management is accepted and being used by the trained physicians. Implementing agencies can no longer rely on volunteerism to sustain community development and health activities in countries where financial resources are not available. In peer education subprojects, it was difficult to keep volunteer peer educators motivated. However, peer educators who were provided with vocational training or involved in income-generating activities were more motivated to participate in the subproject on a longer term. In addition, for youth peer educators, parents were much more likely to support the participation of their children in subprojects if they were gaining a vocational skill or earning money. Media and peer education are important channels for reaching a variety of target groups with behavior change messages. All of the target groups were reached with mass, print and electronic media. Follow-up KABPs with out-of-school youth and MPSCs as well as qualitative research, indicated that radio and peer education, both interactive approaches, were the most popular and accepted ways of providing behavior change messages. In addition, implementing agencies felt that dramas, puppet shows, and IEC at sporting events are key methods for reaching target populations. The general population and other groups such as women in stable relationships do not perceive themselves at risk when AIDS control and prevention strategies focus only on high-risk groups. Sentinel surveillance surveys of pregnant women are believed to be the most representative of the general population. HIV prevalence among antenatal clinic clients in Ethiopia has been increasing and, according to a Ministry of Health report, was around 10 to 13 percent in urban areas in 1993. These levels indicate that future prevention strategies need to extend beyond high-risk groups to the general population. Successful intersectoral collaboration can be achieved to realize the objectives of a project. Under the STAC project, international donor agencies, government ministries and international and local NGOs joined hands to successfully implement a comprehensive HIV/AIDS prevention program. It is not enough to involve managers in work site interventions; business board members and labor union leaders should be involved in future work site interventions in Ethiopia. During an AIDSCAP lessons learned meeting held in November 1996, the managers cited the urgent need to involve higher-level decision makers in the project. Without their sanction, the managers were not able to participate in the project as planned. Prevention efforts focused on MPSCs, need to target potential MPSC clients as well. MPSCs noted that in order to successfully negotiate condom use, potential MPSC clients within the community need to be targeted with BCC messages, too. MPSCs under the AIDSCAP/Ethiopia project were proactive in providing outreach education. They successfully engaged bar owners and patrons as well as street vendors such as shoeshine men in discussions on HIV/STI prevention. The street condom demonstration by MPSC females was an attraction point where many passersby join the street education. Targeting different segments of an entire community simultaneously is more effective than targeting only one segment of different communities. The above approach underscored another lesson learned by one IA: a holistic approach to project implementation. A work site peer education program can achieve greater longevity if a group of AIDS communicators is trained from each site. During an end of project workshop in November 1996, AIDS communicators from the factory-based peer education interventions expressed concern over the strategy employed of training one AIDS communicator per factory. While this strategy is cost-effective, the communicators would have been more motivated had they been working with a group of peers towards a common cause. In addition, employee turnover is such that communicators were not sure to stay with the factory after completing the training program. IEC materials need to be designed based on research. Materials produced based on findings of the STI Targeted Intervention Research (TIR) with STI clinic clients proved effective. The objective of this study was to understand the perception of the community about the transmission of STIs. The results clearly showed that people and providers have different perceptions about the transmission of STIs, as described in detail elsewhere in this report. Based on these findings, the focus sites' RHBs developed IEC materials that contributed to reducing misconceptions. IEC materials development in general should take into consideration the sociocultural life of the people for whom they are produced. Materials produced for urban populations might be irrelevant for rural populations. The IEC materials assessment conducted in November 1996 depicted this fact.
The HIV/AIDS epidemic has reached a point in Ethiopia where care and support services need to complement prevention efforts. The latest estimates put the number of AIDS cases in Ethiopia at about half a million by the year 2000. As the number of AIDS cases increases, Ethiopia will be confronted with the need to support persons living with AIDS (PLWAs) and their families with counseling, medicine and cost-effective care, most likely in the home. C. Recommendations
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