FHI - I. Accomplishments and Outcomes

C. Accomplishments and Outcomes

1. Introduction

The AIDSCAP/Kenya Country Program was designed to carry out comprehensive interventions to impact the progress of the epidemic through addressing behavior change, improved STD case management, increased use of condoms, policy, and capacity building.

These strategies were implemented through subagreements or Letters of Agreement for 27 subprojects. Three further initiatives were developed in collaboration with AIDSCAP headquarters, who provided technical assistance: a policy book on Kenya (AIDS in Kenya: Policy Responses and Opportunities) sustainability activities, and gender-focused activities. The Rapid Response Fund was used to fund five additional sub-projects, as well as to provide initial support to some activities, technical assistance, and support for international conference attendance.

This section contains information on accomplishments and constraints characterized by the major strategic areas. More detailed information is available in the section describing individual subprojects.

2. Accomplishments and Constraints

2a. Behavior Change Communication

Interventions to promote HIV/AIDS prevention through behavior change communication (BCC) were a major component of the Country Program. The AIDSCAP BCC technical strategy (May 1992) stated as guiding principles that BCC interventions should: work at the community level to create a social context to facilitate behavior change; work at the individual level to increase and improve skills, provide role models and change perception of norms; and emphasize building local capacity. BCC programs should incorporate the effective use of: research, including formative research; audience segmentation; target audience involvement; and use of multiple reinforcing messages and channels.

The Kenya program's design therefore combined reaching individuals through interpersonal, locally-based interventions for selected target audiences with a mass media component to complement and reinforce these approaches and capacity building in BCC skills, particularly in the areas of training, materials development, and information dissemination.

The selection of target populations was based on potential epidemiological and economic impact, gaps in programming, priorities in the Kenya Second Medium Term Plan, accessibility, and the opportunity to build on established USAID programs. A major factor in determining target groups was AIDSCAP's perception that, given the medium to high prevalence HIV rate in Kenya, interventions should go beyond targeting very high risk populations to include members of the general, sexually active population. This group does not perceive itself at risk, despite the fact they or their partners may be practicing high risk activities. The primary target groups selected were therefore: men and women in the workplace, STD patients, and family planning clinic attendees. Secondary target groups were: out-of-school youth, university and college students, and sex workers. The interventions would focus on three urban centers: Nairobi, Mombasa, and Eldoret.

Workers were selected as a primary target based on: their likelihood of risk, since many are separated from their spouses, have disposable income, and ready access to regular and casual partners; their role as a probable transmission link between urban and rural areas; the ease of accessing this group; and their role as influential members of their home communities. In the Delivery Order contract between USAID and FHI, however, only the three primary target groups were specified. In practice, two of the secondary target groups, sex workers and out-of-school youth, were not addressed, while one was added, church pastors (and through them, their congregations). This change in target groups resulted from a decision to target interventions through institutional structures (such as churches, worksites, institutions of higher education) where the multiplier effect was likely to be greatest.

The output level indicators in the Strategic and Implementation Plan were:

80% of target population in worksites reached by communications programs
80% of staff of participating NGOs trained in HIV/STD/AIDS awareness and IEC strategies for HIV/STD prevention by the end of year 4
All institutions of higher learning in the three intervention areas establish AIDS education programs by year 3.

The outputs were simplified in the Delivery Order to: "Implement targeted communication interventions to reduce high risk behavior in three geographical areas in Kenya."

Targeted Interventions: Peer Education for Worksites and Institutions of Higher Education

The main approach used to work with target groups was peer education. Programs were set up at 17 worksites in Eldoret, Nairobi and Mombasa and 9 institutions of higher education. The peer education programs addressed facts about HIV/AIDS and STDs, methods of transmission and prevention, personal risk assessment, how to negotiate for safe sex, including condom use, and interpersonal communication skills, including facilitating discussions, making presentations, identifying resources and providing referral services. In the worksite program, initial discussions with management were followed by a five-day training for peer educators and the appointment of worksite coordinators for the peer educator team. A refresher training was given after the first six months. Peer educator training combined didactic and participatory methodologies, with emphasis on the latter.

Worksites were also given materials (though most worksites wanted more), and condom dispensers. A poster was developed targeting worksite populations. After the Implementing Agency (IA) was trained on gender sensitivity, the training became more gender-sensitive, for example, including case studies that illustrated gender concerns. By the end of the project, 375 peer educators had been trained, of whom 300 are currently active; over 24,000 workers had been reached with peer education activities; and 100 condom dispensers had been installed in companies participating in the project.

In the final year of the Country Program, the worksite project was expanded to target five security guard companies, employing approximately 10,000 guards. The project was implemented by the Program for Appropriate Technology in Health (PATH)/Kenya. A baseline KABP showed that the guards are generally aged 20-39, the majority having migrated to Nairobi from rural areas. Many are separated from their regular partners, making them a vulnerable group to HIV/STD infections. A peer education strategy proved to be unworkable, owing to the isolated nature of their work, so AIDS/STD education was incorporated into the ongoing training courses given by companies to their employees. A major accomplishment of this sub-project was the development of a series of materials on STDs and AIDS aimed at guards and their partners. At the request of the guards, a pamphlet dealing with women and STDs was designed for them to discuss with their partners, rather than targeted directly at women.

At the institutions of higher education, the project worked with members of the administration to form anti-AIDS clubs, led by a trained club leader, who then participated in workshops that trained club members to be peer educators. The clubs used a mixture of highly creative approaches to reach other students, including public events, discussions, lectures, and fund-raisers. This project also motivated students through developing a newsletter, Crossroads, to share ideas and experiences, and designing two posters aimed at students. Results for this target audience were over 250 peer educators trained, approximately 19,000 students reached through the reproductive health clubs, and 11,800 materials (including over 3,000 posters, 4,000 "lifestyle" information packages, and 3,600 copies of Crossroads), and over 300,000 condoms distributed in the institutions.

Issues raised in the peer education projects included: how to disseminate materials effectively; how to motivate peer educators on a continuing basis, including issues of incentives, whether financial or otherwise; broadening the focus of the program to maintain interest; and achieving long-term sustainability. Obstacles to peer education, including maintaining motivation. were topics discussed by worksite peer educators in all the mid-project on-site reviews. Obstacles included the personal impact of HIV/AIDS prevention work on volunteer staff, increased job demands, and lack of recognition. Periodic innovations in programming, and tokens demonstrating appreciation and recognition of efforts, were cited as contributing positively to morale and motivation.

There were, in addition, two smaller pilot projects for these target audiences, both of which suggest interesting methodologies to consider in the design of future programs. Kenya One World Linking Forum (K-OWL) carried out an innovative intervention with matatu drivers and touts in the last four months of the project. This project addressed a group, matatu operators (or drivers and touts of the small passenger buses in Kenya), who are notorious in Kenya for their high energy, flashy life-style, loud music and crude slogans in buses, and for "corrupting" schoolgirls. By taking the education program to a location near the passenger collection points, and designing the content to answer the needs of the operators through including civic and survival issues of their choice, this project managed to hold the interest and increase the knowledge of 35 operators, who graduated out of a class of 50. They were also forming their own association, and urging K-OWL to extend the project to other matatu routes.

A study into the knowledge, attitudes, and practices of medical students, carried out by the Association of Medical Students of the University of Nairobi AIDS Awareness Campaign, combined practical training in quantitative and qualitative research skills with an AIDS prevention intervention for medical students at the university. AIDSCAP worked with a group of students to guide them, through technical assistance, in developing KABP questionnaire and focus group topic guides, focus group methodology, data analysis, and report writing. The students followed the initial focus group discussions with two more discussion groups (carried out with six groups for 119 participants in total) in which student couples modeled couple interactions and discussed safe sex behavior, including abstinence, mutual monogamy, and condom use. Besides providing information on constraints to change of behavior among medical students, the project gave the student leaders valuable practical experience in how to discuss safe sex and STDs. They later presented results of this research at the Vancouver Conference, and student conferences in Nairobi and South Africa. This project is a model for using participatory research as a means of internalizing the need for AIDS prevention while reaching students with peer education.

Media Support: Theater and Mass Media

Media support at the national level included funding Miujiza Players for theater performances combined with interactive communication, multiplied through making videos of selected plays; a weekly newspaper column, AIDS WATCH; a weekly radio soap opera in local languages, Maajabu; and support for special events and community theater for World AIDS Day.

AIDSCAP funded a theater company of young actors, Miujiza Players, to develop and perform plays dealing with HIV/AIDS issues. The company focused its performances in the AIDSCAP target areas, appearing at worksites, educational, and community institutions in Mombasa, Nairobi, and Eldoret and the surrounding areas and later expanding its target audience to include military bases and prisons. Eight short plays and one full-length play were produced, and videos made of two of the short productions. Plays were pre-tested and new topics explored through ongoing focus groups with representatives of the target audience. The performances were followed by an interactive session, in which the audience was invited to comment on the characters and situations and ask questions of the players, and, when appropriate, condom demonstrations were given.

The Miujiza Players were trained in qualitative methodology and interactive communication skills by AIDSCAP. The qualitative end-of-project evaluation indicated that the performances were popular, and considered to facilitate discussion, heighten audiences' sense of the epidemic's relevance to their lives, and increase their sense of personal risk. As one of the Miujiza players noted, "There was a time if you mentioned something like 'stick to one partner' all the audience would laugh but nowadays when you say the same, they realize actually these people are teaching something sensible." Yet the evaluation also noted that the plays were best received at sites that had a peer education program. The Miujiza subproject is interesting as it raises questions about the trade-off between quality and standardization through using professional actors, and the high cost of supporting a professional team. It is unproved whether the positive results achieved by Miujiza could have been gained through other cheaper strategies.

Two mass media interventions were aimed at the general public. One, the weekly AIDS WATCH column in the Sunday Standard, was primarily intended to contribute to changing the climate of understanding and acceptance of the epidemic. AIDSCAP funded the column for two years, from its inception on March 27, 1994 to the final column on March 20, 1996, during which period over 100 columns appeared. Articles ranged from facts about AIDS, its transmission, treatment, and prevention, to personal stories of how the epidemic was affecting individuals and families. The Sunday Standard has sales of 70,000 and an estimated readership of 700,000: AIDS WATCH was voted one of its top five columns in a 1996 poll of readers. While it is difficult to measure the effect of this intervention, the large number of letters received from readers confirmed that it contributed to the growing acceptance of the reality of AIDS among the Kenyan public.

Elements in its success included the choice of columnist, Raphael Tuju, a well-known and credible public personality; the system of replying to all readers' letters and making referrals where needed; basing several columns on concerns raised by readers and printing readers' letters; and citing reputable authorities for information reported. The column succeeded in changing editorial policy on condoms. Before AIDS WATCH, the Standard editors restricted discussions and photos of condoms. AIDS WATCH made a deliberate effort to discuss condoms in the proper context which, by not creating resistance, led the way for other journalists to address the issue of condoms.

Maajabu's objective was to reach rural audiences to increase their awareness and understanding about HIV/AIDS. This weekly radio show was broadcast in five local languages, Swahili, Dhluo, Luhya, Kalenjin, and Kikuyu and ran for 62 episodes. Evaluation of this series indicated it was popular, listened to by all ages, and involved the audience in the dilemmas and personalities of the characters. As a means of monitoring listener response, the radio show included a prize competition. 27,000 letters were received from listeners, an average of over 2,000 a month, an astonishing response, particularly from a local language audience.

Finally, AIDSCAP supported a drama festival in connection with World AIDS Day. This event, begun in Nairobi, grew each year, from 15 groups in 1994 to over 175 expressing interest in performing in 1997. This popularity resulted in the event being reorganized as a national competition, with sub-contests in the regions. Prizes were offered in the categories of drama, dance, poetry, song, and oral narrative. Groups were trained in a short workshop in AIDS prevention, message development and communication, and performance skills, and then monitored in the rehearsal stage by the organizers. The festival organizers were good publicists and the event was used as a means to create awareness about the continuing impact of the epidemic. Groups were also expected to perform for their communities, not to develop performances purely for the festival. Management questions have, however, developed as the event has grown, since some groups now expect to be paid, which has created conflicts. Monitoring of the number of community performances was also difficult to carry out, so the extent to which this was a one-time contest, rather than an incentive to community outreach, is not known.

Supportive Interventions: Information Dissemination and Materials Development

A needs assessment by the Kenya AIDS NGOs Consortium had showed that, at the start of the AIDSCAP country program, NGOs lacked a central source of information on AIDS prevention and knowledge of materials development methodologies. In addition, few recent materials had been developed for Kenyan audiences. The AIDSCAP projects addressed these needs. AIDSCAP supported the NGO Consortium to develop a Resource Centre based in Nairobi, of AIDS and reproductive health materials. Starting from zero in September 1994, in two and a half years, the Consortium set up a fully staffed center which now has a solid collection of over 800 resources and handles an average of 250 inquiries per month. Those using the Resource Centre have included NGO staff, students, donors, journalists, even Members of Parliament. The collections include a wide range of newsletters on AIDS, reports, electronic databases (Popline, AIDS Impact Model, AIDS Information System and Internet access), training materials, posters, pamphlets and a large and much-used video collection. The Resource Centre has also set up a World Wide Web home page. Materials are available on loan, including loans to the districts. In addition, the Resource Centre has distributed 48,000 of the materials developed under the PATH materials development training project.

A detailed monitoring system was set up, which provides valuable information on the main areas of NGO interest. The recent end-of-project evaluation showed that the main reasons for seeking information were to support the development of IEC materials on HIV/AIDS (62% of polled users), followed by requests for information on counseling (32%) and training materials (28%). The evaluation also reported on overall user satisfaction with the timeliness and quality of Resource Centre services, one indication of which is the number of referrals made to the Centre (50% of respondents had been referred by other users). Much of this success is owed to the excellent technical assistance provided to the Consortium by the Appropriate Health Resources and Technologies Action Group (AHRTAG).

The materials produced by AIDSCAP were intended to fill gaps, particularly in materials designed specifically for Kenyan target groups. Eight materials, targeting men, urban and rural out-of-school youth, school-age children, and couples, were produced during the materials development training course given by Path/Kenya. The two-year course, organized in collaboration with the NGO Consortium, took participants from member NGOs of KANCO through a hands-on process of materials development. Participants found the skills valuable, particularly in helping them to develop materials in parallel projects (for example, the materials developed as part of the policy project for the Consortium). The materials themselves, developed through formative research, are in demand by other NGOs. Two of the posters were reproduced by the National AIDS/STD Control Programme to mark World AIDS Day 1996. The power of these materials was also indicated by the fact that they were among materials burnt in a protest by religious extremists against condoms and AIDS education for youth. Of interest is that following this much publicized burning, requests for copies of the materials increased dramatically.

Few materials were available on STDs. The country program also addressed this gap through funding PATH to develop a series of brochures on STDs for security guards. These were later adapted as part of a collection of materials distributed to peer educators in the workplace. The STD material was intended to improve treatment-seeking behavior for STDs. As the PATH intervention was only in place for a short time, a post-project evaluation was not appropriate. However, focus groups at the FPPS worksites suggested that STD treatment-seeking behavior had improved.

Working with the Churches

The target audience of church congregations was not envisaged in the AIDSCAP Country Office Strategic Plan and there was at first some skepticism at AIDSCAP Headquarters about addressing this audience, given the opposition of some churches to condom use. The MAP project, however, proved extremely successful. Baseline KABPs with churchgoing youth had shown that 49% were sexually active and that their preferred source of information on sexuality was their parents. Based on this information, MAP developed Growing Together: A Guide for Parents and Youth. The book was so popular that reprints were needed, to make a total of 11,000 copies printed. AIDSCAP also funded screenings of MAP's film, Springs of Life, in rural areas around the country through linking with a commercial mobile unit, and reached over 2 million people in the course of the project.

MAP also trained pastors in counseling and AIDS prevention through an effective approach that challenged pastors to apply their learning through developing projects at local level before returning for follow-up training. In the three months between the first and second training, at least 576 activities related to HIV/AIDS were carried out by 105 of the participants, with more than 56,400 persons reached by these activities. MAP also produced a manual for pastoral training institutions, which has been distributed by the Africa Inland Church (AIC) for use in its 23 colleges and is being considered by other churches.

As noted in the policy section below, churches had not been fully included in AIDS prevention efforts and were often reluctant to deal with the epidemic. When materials were produced that discussed AIDS in a religious context, church pastors were able to deal with their responsibility to provide leadership to their congregations. MAP's strategy for dealing with the condom issue during training was particularly effective. Trainees were able to join a group of their choice to discuss prevention approaches, one focusing on abstinence and monogamy, one on condom use. MAP emphasized that whatever decision an individual took on condoms, pastors should provide accurate information. Local leaders had a responsibility to avoid misinformation, such as that condoms were laced with HIV. Although these discussions were often difficult, MAP's trainings continued to attract pastors from all denominations. Given that 80% of the Kenyan public is Christian and the leading role of the churches at both national and local level, the Country Program considers it has demonstrated the importance of working with the Churches and the possibility of working with them within their own frame of reference.

Kenya: Religious Reversal

Kenyans and their clergy reacted to the first news of the AIDS epidemic not unlike the general public and clergy worldwide. They ignored it, dismissed it as the disease of the aberrant and immoral and/or reacted violently to suggestions about the use of condoms to prevent the spread of the disease saying it would encourage promiscuity. When Rev. Onyalo announced to his Kenyan congregation that as Christians they must show compassion for people with HIV/AIDS, help care for them, and encouraged his parishioners to protect themselves by avoiding extramarital and pre-marital sex, his congregation knew a great change had taken place. This breakthrough was the result of dissemination of an "awareness packet" by MAP International and funded by AIDSCAP. The packet included comprehensive sermon outlines with themes relevant to presentation of information about HIV/AIDS. MAP had had a decade of strong health care experience and work with churches in Africa. As part of its mission to sensitize, educate and train the clergy to alert the general public and support persons and families dealing with AIDS, MAP drew on data collected from surveys and focus group discussions to identify the issues which needed to be addressed in the packet. An intensive pastoral counseling training curriculum was designed and conducted over several months and pastoral counseling manuals were translated as appropriate and distributed to participating clergy. MAP also helped establish the Kenya Christian AIDS Network (KCAN) which stated as its guiding position the "commitment of churches to a ministry of Christian hope, reconciliation and healing in congregations and communities through prevention, education and care for persons (with AIDS) and families". MAP's research also identified the need as expressed by young people for more open communication with their parents about sex and AIDS. In response, MAP developed a guide on sex and AIDS education to facilitate parents and children "walking through" the information together.

Achievements, Constraints, and Indications for Future Activities

The program's achievements were considerable. Qualitative evaluation (carried out for most of the BCC interventions at end of project) indicated that the interventions were well received and were considered to be successful in changing attitudes and acting as a motivator for more open discussion about AIDS and sexual behavior.

Discussion between partners and between generations is an area in which one can deduce from AIDSCAP project reports both change and readiness for further change. Sub-projects at both the worksite and colleges reported their impressions of more open discussion between partners about sexual behavior. Worksite peer educators also reported being asked for advice by family and community members as well as at the worksite and requested guidance in how best to respond. The behavioral research studies confirmed that we now need to consider how to address this stage. Partners in the sexual re-negotiation study found barriers to discussing sexual behavior, partly because of an inadequate language to discuss sexuality and partly because of cultural norms that discourage that discussion. The mothers and daughters study found that both generations had difficulty in communicating with each other on sexuality, but that this tension lessened after the investigators had facilitated discussions with each group. The female condom study noted that, besides the fact that most women found the female condom an acceptable method of prevention, the process of introducing the device had helped to make discussion between partners easier. Future BCC interventions should be aware that AIDSCAP's experience shows we now need to find effective ways to further facilitate discussion. PATH, for example, designed a comic book, "Life, Love and AIDS" that brought to life the interactions and discussions between three couples dealing with HIV, showing both positive and abusive communication.

Another aspect that needs further investigation is understanding the role of tradition and cultural practices in the AIDS epidemic, particularly in rural areas. At present, there appear to be seriously discordant beliefs among some populations, who while knowing the facts about HIV, also interpret the cause of illness in terms of long held traditional beliefs. This was commented on by MAP International with reference to the belief in some areas that AIDS is a curse, sent as a punishment for not observing traditional practices (such as widow inheritance and sexual cleansing) which themselves may transmit HIV. We need to develop ways of addressing these issues in terms and through leaders that are acceptable to the community.

A constraint on AIDSCAP interventions was the relatively weak links between some BCC interventions. Some projects collaborated well, for example, PATH's production of materials for the FPPS worksite intervention, PATH's collaboration with the NGO Consortium for training in materials development, and the links between MAP International and the Consortium to discuss each organization's plans to set up district resource points. But the sense of a coordinated BCC effort among the different implementing agencies was weak. This had been pointed out by the AIDSCAP Review Team in November 1995, and was never fully resolved. Feedback from the research projects came too late to be relevant to the mass media or interpersonal communication projects.

There were also weak linkages with PSI for the provision of socially marketed condoms. As noted below, in the condom section, this vulnerability resulted from structural causes. PSI in Kenya is a separately funded project. The AIDSCAP subprojects did not subcontract PSI to provide condoms to its projects but relied on informal working relationships with the PSI office. Though these were good, they depended on fitting into PSI's other priorities. In future it would be advisable to build contractual obligations into each subproject, to clarify expectations on both sides.

Yet, overall, the response of those at the sub-project level indicate that Country Office-funded BCC interventions were needed, appreciated, and successful. Asked what they would change in future project design, program managers only wished to extend their services to a wider range of communities or better target their interventions. As a respondent from MAP commented:

"I would love to take the project to more churches, more communities, more areas of Kenya ... there is need to reach people in a more in-depth way."

2b. Sexually Transmitted Diseases

It has now been established that effective STD case management reduces HIV transmission in addition to decreasing the often serious complications of STDs themselves. In Mwanza, Tanzania, the provision of improved STD case management at the primary health care level resulted in a 42% decrease in HIV transmission.

Health workers need the tools, including training and effective drugs, in order to contribute to STD/HIV control efforts. Standardized guidelines, and good monitoring and supervision systems, are necessary to assure quality and a consistent approach to STD case management.

A baseline assessment conducted by AIDSCAP/Kenya in 1994 revealed that national guidelines for the syndromic management of STDs were in place in Kenya, that training curricula had been tested and used, and that a number of projects were engaged in training health workers in STD case management. Most training activity at the time targeted health workers in the public sector and Nairobi was better covered than more peripheral areas.

In order to avoid duplication of effort and concentrate on the strategic geographic areas designated for AIDSCAP concentration in Kenya, private sector health facilities in Mombasa, Eldoret and Nairobi were chosen as priority targets for AIDSCAP/Kenya training efforts. Close coordination with the Clinical Services Unit of NASCOP was maintained throughout to assure that AIDSCAP-supported training was integrated with national efforts. AIDSCAP was represented on the NASCOP committee that reviewed and made recommendations for revision of the national STD case management guidelines.

AIDSCAP/Kenya has supported training and supervision of health workers in STD case management through two subprojects. Family Planning Private Sector (FPPS) trained 402 health workers from FPPS-supported worksite clinics and public health facilities. The Moi University Department of Reproductive Health provided training and an innovative approach to supervision for 95 private practice nurses, clinical officers, and doctors working in individual private practice clinics.

Significant improvements were documented in the case management of health workers trained by the two subprojects (see individual subproject descriptions), and valuable insights gained into issues of importance when designing training programs and supervisory support for health workers in these sectors.

2c. Condoms

USAID has long been a major player in Kenya in supplying free condoms to public and private sector clinics (mainly for family planning) and in directly supporting a condom social marketing project. Condoms distributed by the public sector increased from 9 million in 1989 to 45 million in 1994. Condoms sold in the private sector through USAID's social marketing program increased from 40,000 per month in 1989 to 500,000 per month in 1995. Condom distribution to target populations was therefore not a major focus of AIDSCAP-funded prevention interventions, though the need to link with existing sources of supply was expected of subprojects.

The November 1993 USAID/AIDSCAP "Strategic and Implementation Plan" articulated that "AIDSCAP [subprojects'] efforts will include increasing the demand for condoms among target groups which will rely in turn on socially-marketed condoms ... AIDSCAP will emphasize linkages with the PSI/CSM project when developing subagreements with implementing agencies... to expand the number of [condom] outlets". Six target groups, three "primary" and three "secondary", were identified for demand-creation attention.

By the time the Country Program reached its full momentum in September 1994, the primary condom-related mandate of AIDSCAP subprojects had been refined and reduced to "increase[ing] demand for condoms among the targeted populations" of workers at worksites, and STD and FP clinic attendees. Collaboration in assuring condom supply to the "worker" populations was assigned to AIDSCAP/ Kenya, PSI (not an AIDSCAP partner agency in Kenya), and other, unspecified "condom suppliers". Sources for condom supply for the second primary target population, STD patients, were not specified and only the need for "sufficient condoms" mentioned. No condom supply mechanisms or delivery responsibilities for the third primary target population - family planning clients - were assigned since it was assumed they would be supplied with condoms under the national Family Planning Logistics Management (FPLM) delivery system.

Promotion of condom use as a behavior change to avoid HIV/STD infection was included in sub-projects targeting worksites and university students (both managed by FPPS) and private security guards (implemented by PATH) and in a subproject to improve the skills of STD treatment providers (also managed by FPPS). Condom use was regularly featured, demonstrated, and discussed in general public theatrical presentations promoting behavior change (carried out by the AIDSCAP-funded Miujiza theater group), in the weekly AIDS WATCH column and in the Maajabu radio soap opera.

Worksite and Higher Education Interventions

Family Planning Private Sector (FPPS) conducted peer education for behavior change at 17 worksites in Mombasa, Nairobi, and Eldoret, as well as, under a separate contract, at nine institutions of higher education. Behavioral change messages included mention of condom use as part of an "A-B-C" (abstinence, behavior change, condoms) behavior change strategy, and condom use demonstrations were performed by peer educators as part of their outreach.

At many targeted commercial worksites and at most educational institutions, the health needs of workers and students were met by on-site clinics where many services, including free condom distribution, had been long established. This free, clinic-based distribution continued to be the primary source for condom supply under the two FPPS interventions. Most of these clinics were already linked into the MOH's regular condom supply network as "service delivery points". Worksites without on-site clinics were linked for service delivery, including condoms, by FPPS, under the AIDSCAP contract, to near-by companies with government-supplied clinics (and condoms) or to other FPPS-affiliated clinics in the area. In addition, at each worksite and some campuses, condom dispensers were placed at several other accessible points on-premises to encourage and facilitate uptake without requiring a clinic visit. Accessibility was also augmented by condoms supplied directly from some peer educators who sometimes carried their own stocks. In their end-of-project reports, FPPS reported that over 550,000 condoms were distributed through these channels to workers at worksites and over 350,000 to participating educational institutions. No data was collected to assess whether these figures represented increases in condom use or whether any increases were related to the interventions.

The subagreements called for FPPS to promote or (in the case of universities) facilitate the substitution of socially marketed condoms for the targeted populations. Peers were informed of the availability and price of the socially-marketed TRUST condom, sometimes given samples, and referred to the general types of outlets where TRUST condoms might be found.

A separate intervention, conducted by PATH and targeting security guards employed by security companies in Nairobi, aimed to increase HIV/STD awareness and condom use through special education sessions included in the general training program of new guards as well as in refresher courses for guards previously trained. Condom use demonstrations were included in these sessions. At PATH's request, PSI initially provided a leaflet with a sample TRUST condom and use illustrations which at least 2 (of 5) companies distributed in monthly pay envelopes. PATH has now produced a specially designed leaflet which addresses misinformation and fears about condom use and includes steps on proper use, but samples of the socially-marketed condom are no longer provided. According to PATH, companies proved resistant to selling socially-marketed condoms on their premises for fear of being accused of exploiting already poorly paid workers. Some companies offered free condoms, obtained from GOK stocks; most did not. The PATH training included, as well, mention of the types of outlets where TRUST condoms could generally be purchased. PSI provided PATH information to convey to companies' management on where TRUST condoms could be purchased by the companies at wholesale price for free (or re-sale) distribution to employees, but no company followed up and actually purchased condoms.

Future interventions might go a step further through working with PSI to identify possible condom sales locations near the intervention sites (for instance, worksites, security guard companies) and through giving the target audience precise information about where they might buy condoms.

STD Treatment-Related Interventions

In an effort to upgrade the care and management of STD patients, FPPS conducted a separate intervention to strengthen STD diagnostic and treatment services provided by FPPS and public sector FP providers in the Nairobi, Mombasa and Eldoret areas, and Moi University conducted a similar training program, targeting private medical practitioners, in the Eldoret area. The curriculum used in the trainings conducted by each subproject included sections on condoms as a means of preventing HIV/STD infection/re-infection and on condom use demonstration. HCPs were advised to assure that condoms were provided, post-treatment, to all patients, and that condom use demonstrations be given. An increase in condom distribution was included as a reportable output in the FPPS contract; no condom distribution data was required in the Moi University subagreement. Curiously, the FPPS project reported an overall lower level of condom distribution at the end of project. It is not clear whether this was related to supply or demand: the provision of free condoms at the clinic level is affected by numerous factors, including logistics and possible overstocks or stock-outs at clinics and it is not possible to attribute trends directly to the STD training. However, two indicators on condom use from the final evaluation of the FPPS project suggest that more work needs to be done to promote condoms: the number of trained personnel reporting giving out condoms and giving condom demonstrations was only in the 40% to 60% range.

Most clinics participating in the FPPS STD project relied on stocks available for free from FPPS supplies or GOK stores. For the private practitioners, it was hoped that links could be established between them and the wholesalers of TRUST condoms near participating clinics, but this proved difficult to put into practice.

The Country Office's primary role in helping to establish linkages among those AIDSCAP Implementing Agencies with a condom-supply mandate and external suppliers of condoms such as PSI's condom social marketing unit was to inform parties of the possibilities and desirability of cooperation and encourage each to pursue opportunities for collaboration directly. In retrospect, a more pro-active role may have been desirable, but it remains unclear what leverage would have been available to enforce such "extra-contractual" requirements.

2d. Policy and Sustainability

Policy development has been a successful component of the country program, both in terms of its depth and range. The Kenya country program provides the most extensive support to policy development of any AIDSCAP country program. The capacity of several organizations to engage in policy development has been significantly strengthened and the outcomes from AIDSCAP support have been tangible and specific.

AIDSCAP's Strategic and Implementation Plan outlined an output that would strengthen the "capacity of policy makers to exercise leadership roles in promoting HIV/AIDS and STD prevention." That outcome was achieved, but in ways that were somewhat different than had been envisioned in the Plan.

Strengthening Inputs into Policy Development

An initial policy assessment by AIDSCAP found that people in all sectors could cite a range of policy-related issues but were frustrated that those issues were not being discussed or addressed. As a result, AIDSCAP provided support to three organizations to facilitate debate and policy development around important issues. The first organization was the Kenya AIDS NGOs Consortium (KANCO) which over a two and a half years period conducted eight workshops with nearly 300 district, provincial and national leaders. The workshops contributed to a process of issue identification and prioritization, developing advocacy skills, and media training. A short list of priority issues were analyzed and presented as policy recommendations to both the group drafting national policy and to appropriate policy makers. Three of these issues were then developed as Policy Advocacy Papers: HIV/AIDS Education for Kenyan Youth, Removing Stigma and Development Appropriate IEC Strategies for STI Prevention and Control, and Discrimination of Persons Infected with or Affected by HIV and AIDS. An additional outcome of the workshops was the formation of over twenty local branches of KANCO.

The second organization was MAP International, supported to facilitate policy development with churches in Kenya. As part of the subagreement MAP conducted baseline research which showed a high proportion of church-going youth were sexually active and desired more information on sexuality from within their families and churches. MAP also contracted to train local clergy in pastoral counseling related to HIV/AIDS prevention, care and support. The training workshops provided a forum for clergy to express their concerns about the impact of the epidemic in their congregations and the absence of serious attention to the epidemic from the churches' leadership. These local clergy formed over 30 branches of the Kenya Christian AIDS Network, contributed to upward pressure on the churches' hierarchy and provided MAP with the impetus to combine the research findings with voices from the congregations to facilitate senior church leaders from Kenya's major denominations to sign and publicly commit to developing policies and strategies for their churches.

The formation of these NGO and church community-based networks to identify issues, facilitate local action, advocate for HIV/AIDS prevention and care, and contribute to a national understanding of the epidemic were not identified in the "Plan." However, their creation and contributions to changes in the policy environment have been significant. They have provided an organized structure for organizing and mobilizing scattered and quiet voices in a more focused way on policy issues. The networks represented a constituency which both KANCO and MAP could refer to when urging national leaders to respond more assertively to the epidemic. And the networks were a new source of information on the impact of the epidemic on households and communities, that information being utilized by KANCO staff in refining policy recommendations.

A third organization supported by AIDSCAP was the National AIDS Control Programme (renamed in 1996 to National AIDS and STD Control Programme--NASCOP). With technical assistance from The Futures Group, senior government officials were trained in making presentations with the AIDS Impact Model. The computer program combines epidemiologic and economic data to offer projections of the impact of AIDS on society. In addition, AIDSCAP supported the expansion of the HIV/AIDS sentinel surveillance system to cover eleven rural sites.

The Socio-Economic Impact of AIDS

Under AIDSTECH, a preliminary analysis of the socio-economic impact of AIDS in Kenya had been carried out, using secondary data. AIDSCAP developed new data on the macro-economic impact of HIV/AIDS on the national economy, the impact on specific commercial businesses and on households. The result was the publication of the most extensive study to date on the impact of HIV/AIDS in Kenya. Over twenty Kenyan and North American authors contributed chapters to AIDS in Kenya: Socioeconomic Impact and Policy Implications. The book was published in 1996, with an initial run of 2000 copies together with 5000 copies of a summary pamphlet. The official launch of the book in October 1996 included a keynote address by the Vice President of Kenya, the US Ambassador, the Director of Medical Services in the Ministry of Health, and the Representative to Kenya from the World Health Organization. Extensive media publicity--including citations to the book in editorials and articles for over two months--provided very high profile attention to the epidemic. Within days, the President of Kenya made his most pointed remarks to date, calling on churches, NGOs and other institutions to develop effective responses to HIV/AIDS. An additional 5000 copies of the book were printed early in 1997 to cope with demand. The NASCOP and KANCO became major disseminators of the book. UNFPA and UNDP planned to use the book in training activities.

AIDSCAP/HQ was commissioned by the Africa Bureau of USAID to develop materials on HIV/AIDS for use by and with the business community. Data for use in preparing the materials was collected in Kenya and a draft of the guide, known as Private Sector AIDS Policy (PSAP), was tested with business managers by Family Planning Private Sector (FPPS), one of the implementing agencies for AIDSCAP. Following field testing and revisions to the materials, FPPS provided training to business managers in Eldoret, the site for AIDSCAP's targeted business intervention, in development and implementation of workplace HIV/AIDS programs and policies. The PSAP materials also included two spreadsheets. Individual businesses can calculate the potential impact of HIV/AIDS on company profits and compare that figure with the cost of developing or expanding a set of workplace prevention interventions. The spreadsheets can be used on a recurrent basis to measure changes in both factors.

Building Organizational Sustainability

Building the capacity of IAs to sustain themselves as organizations and their HIV/AIDS prevention interventions was a part of design of the Implementation Plan. This occurred in several ways. First, on-going technical assistance was provided to the KANCO staff in designing and implementing a comprehensive approach to policy development. Second, FPPS received technical assistance in utilizing the PSAP materials with business managers. Third, an extensive review of financial, institutional and political aspects of the sustainability of each of the AIDSCAP IAs was carried out. An analysis of the costs of ten interventions was conducted and the results shared with all IAs during a capacity building workshop in February 1997. While none of the IAs could operate without external funding, it was clear that each had acquired and developed substantive components of sustainability. For example, KANCO is recognized by numerous external donors and the government as a major contributor to HIV/AIDS prevention and care efforts and its assistance has been sought by over five donors to implement their programs.

End-of-Project Assessment

Finally, an End-of-Project policy assessment was conducted to review changes that had occurred in the policy environment in the country over the nearly three years of AIDSCAP policy support. Among the changes noted in that assessment were:

Adoption by the Cabinet of a national HIV/AIDS prevention, care and mitigation policy, replacing ad hoc guidelines and responses;
Public commitment by senior church leaders to develop appropriate policy and program responses to the epidemic, thereby moving churches from institutions largely indifferent to the epidemic to ones in the mainstream of guiding the response;
Clearer and more frequent attention to HIV/AIDS by national political leaders, in contrast to a long period of denial;
Recognition by government policy makers that HIV/AIDS posed serious social and economic consequences for the country, as demonstrated by the inclusion of a chapter on HIV/AIDS in the seventh national development plan and the Vice President's keynote address launching AIDSCAP/USAID's book, AIDS in Kenya;
The development and strengthening of several AIDS related networks, where none had existed early in the mid-1990s;
An appreciation by local, district, and provincial authorities that they had the ability and right to discuss policy aspects of HIV/AIDS, in contrast to an earlier sense that policy only came from central authorities;
Stronger organizations, capable of carrying on the policy development process beyond the EOP;
A significant financial resource commitment by the country to HIV/AIDS prevention and care, in contrast to minimal contributions before the mid-1990s; and
Continued, but improved, media attention to the epidemic.

2e. Behavioral Research

AIDSCAP supported four research projects in Kenya. The two major studies, the HIV Counseling and Testing Efficacy study and that on the Female Condom as a Woman-Controlled Protective Method, were both part of multi-site interventions. Two additional studies were the Investigation of Strategies for Renegotiating Sexual Relationships and that on Mother-Daughter Communication: An Empowerment Tool for Women. All studies were implemented by local researchers, with back-up support from either AIDSCAP's Behavioral Research Unit or the AIDSCAP Women's Initiative as determined by the study's focus.

The underlying theme for all the research was investigations into interpersonal relationships and the strategies employable to enable behavior change in stable relationships. High risk groups were not a target. The unanswered questions of what is required to shift an ordinary relationship to one of minimal risk were the overpowering theme. Apart from focusing on male/female relationships (as illustrated by the female condom, sexual re-negotiation and counseling and testing studies), the mother/daughter study explored the generation gap and sought to identify information that could be used to break barriers at home, so that mothers can be seen as a reliable source of information in assisting their daughters to handle the AIDS epidemic.

The Kenya Association of Professional Counselors received funds through AIDSCAP/HQ to conduct a study to investigate strategies for renegotiating sexual relationships among stable heterosexual couples/partners in Kenya for changing high risk sexual behavior. The study revealed the need for an educational program on sexuality and sexual behavior for people in stable relationships, concentrating on dialogue, equality, condoms, and knowledge.

Another very important study was the counseling and testing research. As part of a multi-center randomized study of the efficacy of HIV counseling and testing, commissioned by AIDSCAP, the Kenya Association of Professional Counselors organized a self-standing counseling and testing research site at Kariobangi in Nairobi. More than 1500 people were recruited and followed for 12 months to determine the impact of HIV counseling and testing on behavior change among people seeking such services, document the social and psychological consequences of HIV counseling and testing, and evaluate the cost-effectiveness of HIV counseling and testing in the prevention of HIV transmission. Final outcomes of this study will be available in June 1998.

The research study on the female condom as a woman-controlled protective method sought to identify factors determining the use and non-use of the female condom, to determine ways in which introduction of the female condom would affect women's ability to negotiate protection against HIV and other STDs, and to explore the role of women?s groups in sustaining use of the female condom. The acceptability of the female condom was good. The proportion of women who liked using the female condom much increased during the study, with over 70% wishing to continue using it. The attitudes of male partners changed from resistance to acceptance. Most participants thought that the use of the device had a positive impact on male-female relationships: it gave them an opportunity to talk about sex and gave participants a sense of control. The few negative responses were at the initial stage and related to the experience needed to insert the device.

The Mothers/Daughters Communication project aimed at strengthening communication patterns between mothers and their daughters so that they acquire information and skills necessary for the prevention of STDs and HIV/AIDS. However, because of time factors, the study only completed the first phase which involved a qualitative needs assessment that included in-depth interviews and focus group discussions. The study results indicate a lack of effective information and skills for HIV/AIDS prevention. Mothers did not provide this information to their daughters and sons because the mothers themselves did not apply their knowledge to their own HIV/AIDS prevention behavior, and did not believe that condoms are protective. Communication patterns between mothers and daughters were poor, while those with sons were minimal. Although mothers and daughters expressed the desire to communicate, they experienced numerous obstacles in their efforts.

The results of the studies were intended to be used in providing a broad set of guidelines or frameworks within which behavior change strategies could be applied at programming level. Unfortunately, study results were completed too late to be disseminated to existing field interventions. However, the results should be useful to future interventions, assuming appropriate and timely dissemination of results. Future programs ought to consider the timing of behavioral research and build in a system for disseminating results, and reviewing and revising interventions based on those results.

2f. AIDSCAP Women's Initiative

Gender issues are clearly relevant to the design of AIDS prevention initiatives in Kenya. Sentinel surveillance data indicate that the peak age for infection in women occurs between the age of 15-29 and that women are increasingly infected at younger ages. Traditional attitudes, cultural taboos against discussing sexual issues, and the generally dominant role of males within partner relationships hinder women's attempts at negotiating safer sex and condom use and severely limit their ability to refuse sex. In addition, studies in Kenya indicate that young girls have inadequate information and skills on how to deal with physiological changes and the emerging sexuality characteristic of adolescence, and lack skills for negotiating healthy relationships. Should a woman want to protect herself, she is limited by the fact that woman-controlled devices for protection against HIV/STDs are virtually non-existent, since the female condom is not available in Kenya.

The AIDSCAP Women's Initiative was established at AIDSCAP Headquarters in 1993, in response to the increasing understanding of the role of gender issues in determining the ability to achieve the behavior change necessary for successful AIDS prevention. The objectives of gender-related activities in Kenya were to:

Sensitize key policymakers to gender issues and the need to address them in AIDS prevention
Sensitize Country Office and Implementing Agency staff to gender issues and the need to address them in AIDS prevention
Carry out selected projects to address gender concerns.

Activities centered around training and research. A team from Kenya participated in two regional workshops to train policymakers in gender issues, the first in October 1995 and the follow-up workshop in May 1996. At the first workshop, the team finalized the plan for a country activity to address gender issues at the worksite, through adding a gender component to the curriculum modules and training for peer educators at the workplace. A gender sensitization training was carried out for the implementers, FPPS.

Research projects specifically related to gender issues included the female condom study and the study on mother-daughter communication (see above).

Perhaps because the need to address gender issues as an aspect of AIDS prevention is still poorly understood, this was a difficult intervention to put in place. Some constraints arose from suspicion and resistance to "gender" projects. The initial interviews with company managers, for example, showed that gender issues were often seen as disruptive. Some FPPS staff, too, questioned the need for training in gender, however the workshop evaluation showed they felt their understanding of the issues had deepened. This kind of reaction underlines the need for training and educational interventions that address gender issues. See Section F: Non Subproject Highlights, for more details.

3. Project Outcomes

3a. Biologic/Impact

HIV Prevalence

NASCOP has been monitoring HIV prevalence in Kenya since 1990 among ante-natal clinic (ANC) attendees. Urban surveillance is conducted in 13 sites around the country. In 1994 and 1995, eleven additional peri-urban and rural sites were added. At ANC sites, blood is drawn and tested from 200-400 women attending the clinic for their first ante-natal visit during the last quarter of each year.

HIV prevalence among pregnant women in urban areas has been high since 1990 in Mombasa (10% in 1990-12.5% in 1995) and areas of Western Kenya around Lake Victoria, and along the road from the Ugandan border to Mombasa, including Nairobi. In the Western areas prevalence has increased from 1990 to 1995 from 17%-22% in Busia, and 19%-27.3% in Kisumu; while in Nakuru there has been a dramatic increase from 9.9% to 27.2% and in Nairobi from 5.8% to 24.6%. Peri-urban sites in areas of high urban prevalence show levels as high as the urban areas. Prevalence has remained lower (4.1-8.7%, both in 1995) in areas to the north and east of Nairobi; the two rural sites in Central and Eastern Kenya had prevalence of only 2% in 1994. The five-year trends suggest that prevalence may have reached a plateau level in some areas, such as Mombasa; however, areas in Central and Western Kenya, particularly the peri-urban sites surrounding urban centers, are still experiencing explosive growth in prevalence. There is no clear evidence yet of decreases in prevalence anywhere in the country.

During the past few years, it has become increasingly evident that not only are reliable and representative measures of HIV prevalence difficult to obtain, but interpretation is so problematic that their usefulness for evaluating HIV prevention programs and projects is of limited value. Changes in HIV prevalence may be indicative of the long term impact of multiple AIDS prevention efforts, but it is difficult to prove that observed decreases or stabilization in prevalence are the result of any one HIV prevention program. Other factors such as mortality, migration and saturation of the population at risk can also account for changes. In addition, even if decreases in prevalence do result from successful prevention programming, the decreases cannot be attributed to any single intervention. Trends are difficult to interpret without sufficient knowledge of the dynamics of the epidemic in a defined setting and/or control groups for comparative purposes. Nevertheless, tracking prevalence among key target groups will likely remain a priority in Kenya to monitor the epidemic's progress in key parts of the country. It is important to remember that prevalence data groups information from people recently infected together with that from people who have been infected for many years. As the epidemic progresses in countries like Kenya, HIV prevalence includes a larger proportion of long-standing infections which do not reflect recent changes in behavior, and will not tell us about how the virus is spreading right now.

STD Prevalence

Sexually transmitted infections including HIV are major causes of morbidity and mortality in Kenya as in other sub-Saharan countries. STDs are ranked fifth to seventh in relation to other causes of morbidity and constitute about 15% of outpatient consultations in government health facilities. This proportion is thought to be higher in private sector health facilities. However, relatively little data exist on STD prevalence, and virtually no data is available that enables STD prevalence to be tracked over time.

Data collected by the University of Nairobi in the early 1990s showed gonorrhea prevalence of 50% among commercial sex workers (1990), and 6-7% among pregnant women (1991). A study carried out by Maggwa et al in 1989-91 showed 3.2% of family planning clients were positive for gonorrhea. Chlamydia prevalence established in the same studies ranged from 25% (CSWs), to 7-9% (pregnant women); chancroid prevalence was 29% (CSWs) and 6% (pregnant women). Syphilis seroprevalence has increased in Nairobi since the early 1990s: it rose among pregnant women from 3% (1989) to 5% (1991) to 7% (1995). The most common STD syndrome seen in the integrated health facilities is urethral discharge closely followed up by vaginal discharge and genital ulcers (in both sexes).

3b. Behavioral Outcomes

Multiple quantitative and qualitative data points are available for the target populations reached by AIDSCAP programming. The Kenya Demographic and Health Survey (KDHS) was conducted in 1989 and 1993, and will be conducted again in 1998 with general population respondents nationwide. AIDSCAP's counseling and testing study site collected behavioral data on its cohort in 1997. Data on men and women in worksites, including security guards and factory workers were collected by consultants through the FPPS and PATH projects in 1995, 1996, and 1997. For higher education students, data were collected by FPPS in 1993, 1994, 1995, and 1997; and by AMSUNAAC on medical students, in 1994. MAP collected quantitative and qualitative data on church pastors and youth in 1994 and 1996. In 1996, the BCC Lessons Learned project collected qualitative data (individual interviews and focus group discussions) on project implementation and on people's perceptions of community norm change in sexual behavior with multiple target groups.

Qualitative data from interviews with target group members, peer educators and project managers from all subprojects suggest that people believe that Kenyans have better knowledge and awareness, are reducing partners, remaining abstinent, and/or using condoms more now than in the past. This perception exists despite the fact that respondents and participants also describe instances where people they know refuse to use condoms, persist in using ineffective treatments for STD symptoms, and continue to have unprotected sex with multiple partners. However, the perception "in the streets" seems to be that social norms are slowly changing and that the interventions (from AIDSCAP and other donors) have helped greatly to push that change along.

Behavioral Data Points for Target Populations
Reached Under AIDSCAP/Kenya

Target group	1989	1993	1994	1995	1996	1997
General population	KDHS	KDHS				C&T
Men and women in workplaces				Muttunga (KABP) Miujiza (KABP/FGDs)	Muttunga/FPPS (KABP/FGDs) Miujiza (KABP/FGDs) Muttunga/PATH (KABP/FGDs)	FPPS (FGDs/KIIs)
FP clients (FPPS clinics, men and women clients)		FPPS Wilson (FGDs)	FPPS Wilson (FGDs)
Higher education students		FPPS (KABP)	FPPS AMSU-NAAC (KABP)	FPPS (KABP)		FPPS (FGDs/KIIs)
Church pastors and youth			MAP (KABP) (FGDs)		MAP (KABP) (FGDs)
Multiple target groups					BCC LL (FGDs/KIIs)

Note: Studies not funded through AIDSCAP include the Kenya Demographic and Health Surveys (KDHSs) in 1989 and 1993, Wilson's FPPS analysis of data collected in 1993-94 FGDs, and the FPPS KABPs conducted with university students in 1993, 1994, and 1995. All other studies were funded through AIDSCAP/Kenya and implemented via the subproject implementing agencies or local contractors. The BCC Lessons Learned study included open-ended questions about project managers' and peer educators' perceptions of behavior change in their communities and among their target populations.

Some examples from the BCC Lessons Learned research are typical of qualitative comments made by people involved in AIDSCAP-sponsored interventions in Kenya:

"I really don't know the figures [but] I think with this intervention, I would say from my own observation and my interaction with people, they have reduced some of their high risk behavior that they used to have before...The only way I tell is when we have public lectures because I see a bigger crowd coming in and when we stop to talk to people, even on departmental level, people listen to you which was not really the case before. So you can tell really, there must be some awareness and people are getting more interested. ... Some of the people will talk about multiple partners and they will come along and say 'yes, we are zero grazing.' This means something is happening." [Program manager, Mombasa Polytechnic, 1996]

"We cannot be very accurate to tell you exactly how much impact we have had, but at least we have had some impact as a particular character [in the play] is disliked for particular reasons which you wanted them disliked or liked as was intended in the message. Then at least one can say there has been an impact... There has been change, especially in terms of beliefs. Attitudes towards having many sexual partners have changed. Generally attitudes have changed, but individual behavior is very difficult to change." [FGD participant, Miujiza Players, Nairobi, 1996]

"Within the churches the attitudes are at much different levels than they were two years ago. Practices, not yet! Let me just give an example: the reason why I was late for this meeting is because we were meeting with a doctor and also a member of one of the churches here in Nairobi. That is one of the churches we originally approached when we started this project. Now, two years later, they are coming up to us and saying 'help us design this'..." [Program manager, MAP International, Nairobi, 1996]

"I would say the reasons is because of people really coming out and talking in the open and talking continuously trying to tell people things, posting up materials and information for people to see. I think somebody being bombarded with all this information from all corners really is left with no choice but to join in." [Program manager, Mombasa Polytechnic, 1996]

Respondents cited several barriers/obstacles interfering with behavior change: 1) the general disbelief that HIV exists, 2) cultural constraints, including issues related to the status of women, 3) economics, 4) peer pressure, 5) lack of health education/information. The quotations below are typical of group discussions conducted under AIDSCAP to explore these issues.

Disbelief that HIV exists

"There are some employees who really up to now do not want to believe that this thing [AIDS] is there... They have heard about HIV but they do not want to agree that HIV is there.. Others say 'its just like malaria." [Worker, Bamburi Cement Factory, Mombasa, 1996)

"The church itself does not accept this and did not believe this. In most areas in Kenya AIDS cases were treated as malaria or a curse or a judgment or bewitching." [FGD participant, Miujiza Players, Nairobi, 1996]

Cultural Constraints

"I think one of the things that has come out most clearly and particularly from people in Western Kenya, and mostly from independent churches, is that culture is killing people. In the context of AIDS, there were cultural patterns that we needed to address in order to survive the AIDS crisis." [Program manager, MAP International, Nairobi, 1996)

"Also in the culture around here [Mombasa] a Muslim can divorce one wife and marry another one. In the line you never know who may be a carrier [of HIV] but to them it's like a way of life and a man is proud because he is allowed to marry up to four wives provided you get rid of the first one or you can retain all of them. But it's difficult to know who is going outside for sex." [Worker, Bamburi Cement Factory, Mombasa, 1996]

Economics

"I think they have just chosen to lead a careless life. Most of the time people urge that they have no other way for survival so the only way I can win my break is by this (selling sex) and even if I met death, the earlier the better they have that 'don't care attitude;' everybody fears death anyway." [Worker, Bamburi Cement Factory, Mombasa, 1996]

Peer Pressure - Expectations of Males

"In the Asian community the youngsters, the new generation, really look at sex like it's an 'in thing.' You know it's 'macho' now to go to bed with a woman. Even if it's going out for a social drink, you end up in the bedroom. The bottom line is that you will have sex. So, in the Asian community, before they were very strict but in the new generation it's different." [Worker, Bamburi Cement Factory, Mombasa, 1996]

"Of course you find it hard to change behaviors whatever they are. People don't want to believe that it would happen to them even if they know it could happen. To use a better word, say, 'Africanism.' One feels 'I must have sex.'" [FGD participant, Miujiza Players, Nairobi, 1996]

Lack of Health Education

"Another thing is this idea of saying 'I have to select the best." You can say, as a man, this girl works for this bank, she earns a lot of money, she is decent, she cannot have it [HIV/AIDS] or I can say, my house maid, she has been in my house for about six months and all this time she has not had sex, therefore she is safe because she does not move around. So I have sex with my housemaid, not knowing two years earlier she had contracted the disease. So the issue of trying to justify that this person can not have the disease is very common." [FGD participant, Miujiza Players, Nairobi, 1996]

"There are some things which are still not very clear. You come and tell people [about]Pearl Omega, well, people will not change their sexual habits because they know that they will get a dose from Prof. Obel and be treated. So, people have a hope of treatment. So, behavior change becomes secondary other than primary need. I read in a magazine that when this Prof. Obel came up with this thing [Pearl Omega] it actually pushed the HIV/AIDS campaign in Kenya into the limelight to come out and say 'I have got this thing' and to tell people what to do. [FGD participant, Miujiza Players, Nairobi, 1996]

Despite the absence of repeated cross-sectional quantitative surveys tracking changes over time in AIDS-related sexual behaviors in selected target groups, there remain quantitative data in Kenya that suggest the qualitative perceptions are grounded in reality. A challenge for future prevention programming is to develop a target group based behavioral tracking system in Kenya that is cost-effective, periodic, and designed to answer the most important outcome questions of all the international and indigenous HIV/AIDS prevention donor agencies in the country. The KDHS has begun to provide some general population, national level data on AIDS-related indicators, and these data are also reported below.

Knowledge

"I think there is a lot of misinformation and that is what we are addressing. When people have the accurate information, they are more likely to respond. I know when I went home I met some of the leaders in Makueni. One of pastors came to me and asked, is it true that our youth are sexually active? And he is asking out of shock that if this high percentage of youth in our churches are sexually active, we definitely have to do something about it. Those are facts that move them to respond. As a social scientist, I have been extremely surprised at the impact of good solid evidence and research and this motivation and information." [Program manager, MAP International, Nairobi, 1996]

Awareness of AIDS in Kenya is virtually universal by now. Rates of knowledge of the existence of AIDS have been over 90% for most of the life of the project.

Knowledge that an infected person can look healthy: Rates for this indicator have ranged from 88% of males and 76% of females in the 1993 KDHS (general population), to 77% in 1995 (worksite populations, no gender differences, with 15% not sure).

Knowing someone with AIDS/died of AIDS: Among the general population in 1993 (KDHS), 40% of males and 42% of females know either someone with AIDS or someone who has died of AIDS; regional differences were notable ranging from 31% of males in Eastern Province to 61% of males in Nyanza Province; and among females, from 32% in Eastern to 58% in Western Province. In 1995 among worksite populations, 66% knew someone with AIDS and 88% knew someone who had died of AIDS (no gender differences).

Knowledge of maternal/infant transmission: Prompted response to a question about maternal/infant transmission in the 1993 KDHS resulted in only 5% of men and 7% of women who knew that this mode of transmission was possible. In the KDHS, the higher the level of education, the more likely a respondent was to cite a correct channel of transmission of HIV. Unprompted mention of mother-to-infant as a way to transmit HIV was only 6.3% for males and 12.5% for females among worksite populations in 1995.

Misconceptions: In the 1993 KDHS, 59% of males and 55% of females believed that HIV could be transmitted by mosquitoes, and 37% of males and 32% of females believed kissing could transmit HIV. In 1995, AMREF's study of adolescents at truck stops in Kenya found that 37% thought that only ill-appearing patients could transmit HIV, and 43% thought that insects could transmit HIV. In 1996, during baseline research with security guards, researchers found that many guards believe that condoms burst during sex, reduce sexual enjoyment for both partners, cannot be used with regular partners, and are laced with HIV.

Knowledge of prevention methods: Unprompted mention of two or more ways to prevent HIV was 67% in 1995 (worksite populations, no gender differences). Church leaders and youth reached by MAP International reported increased knowledge of at least two correct prevention methods: both groups exceeded 80% at baseline in 1994 and increased by 15% at follow-up in 1996.

Participants in FGDs conducted by Miujiza Players cited abstinence as the best mode of prevention. A majority of both males and females cited being faithful to one partner as ideal. Similarly, baseline focus groups with male security guards in Nairobi revealed that almost all participants mentioned having sex with only one faithful partner and using condoms as the most effective strategies.

Unprompted mention of limiting sex to one faithful partner was 75% for males and 70% of females in the 1993 general population sample for the KDHS, and 80% for both genders in the worksite population in 1995.

Knowledge that condoms can prevent HIV infection: Unprompted mention of condoms as a prevention method has been 36% of males and 21% of females (general population, 1993 KDHS), and 43% for males and 49% for females (worksite populations, 1995). Prompted mention of condoms as a prevention method among medical students in Nairobi was 81% in 1995 (no gender disaggregation). Interestingly, in the 1994 FGDs, most people had heard of female condoms, but no one had seen one of them (Wilson 1994:5).

Risk assessment: In the 1993 KDHS (general population), 66% of males and 46% of females thought they might be at risk of acquiring HIV, while 10% of males and 19% of females were unable to state their risk. Of those who felt at risk, the vast majority think that their spouses or sexual partners are the means by which the virus might be transmitted to them (71% of men and 79% of women).

In the 1995 worksite population study, 62% of males and 66% of females said they had a moderate or good chance of catching HIV. 29% of males and 23% of females said they had no chance and 10% of males and 11% of females could not state their risk. The main reasons for stating no risk included not having had a blood transfusion (mentioned by 40% of males and 32% of females) and having sex with only one partner (mentioned by 36% of males and 30% of females). Additionally, 25% of females but only 4.6% of males mentioned "no sex". In that study, only 1.8% of males mentioned condom use with non-regular partners as a reason for low risk.

Reasons for thinking they have a moderate or good risk included unfaithful partner (or spouse has multiple partners) which was 70% for females and 56% for males, had injections (32% for both genders), had blood transfusion (21% for both genders), and current or previous multiple partners (23% for males and 8% for females).

Among Nairobi medical students in 1995, 35% thought they had no risk of contracting AIDS because of no blood transfusions (80%), not being sexually active (77%), no homosexual contact (74%), no injections (45%), used condoms (23%), and slept only with spouse (7%);

Participants in the counseling and testing study were asked about their risk reduction strategies during the past two months and about what they intended to do in the next two months: 20% of males and 17% of females mentioned abstaining from sex during the previous two months, and 21%/19% mentioned abstaining in the future. "Always use condoms" was mentioned by 8%/11% in the past, and 23%/32% for the future. Reducing partners was mentioned by 20%/17% in the past, and 35%/22% for the future. Having sex with only one partner was mentioned by 53%/66% in the past and 71%/76% for the future.

Participants in the AIDSCAP Women's Initiative (AWI) female condom study (all women) demonstrated significant increases in perceived need for self protection against STDs/HIV/AIDS between initial and final in-depth interviews. Percentages of participants responding "very much" increased among older high socioeconomic status (SES) women from 4-100%, among young high SES women from 84-100%, among young low SES women from 0-97% and among older low SES women from 0-87%.

During baseline research in 1996 with security guards, researchers found that the majority of guards had multiple sexual partners and were heavily engaging in casual sex. Despite the multiple partners, most guards did not perceive themselves to be at risk of contracting STDs and HIV. The majority said they felt safe because they "trust" their partners. Most guards do not use or like condoms. Those who did perceive risk, said their risk was due to inability to control the behavior of either their partners living upcountry or those they live with when they (the guards) are working at night, or their own behavior when exposed to the many prostitutes living in the slums where the guards live or to other partners who they seek out because their regular partners live far away.

In talking about taking chances and calculating risk, participants in FGDs conducted for the BCC Lessons Learned project suggested that fatalism played a role in preventing behavior change.

"The other thing is when somebody has been so much into moving around one is not sure of him/herself . They may say 'maybe I have it because I have been told that 10% of the people have it then I already have it, so no need to change.' " [Worker, Bamburi Cement Factory, Mombassa, 1996]

"For some people there is that element of believing that there is a chance that I might get it, or I might not get it. They are ready to gamble and take chances. They reason it's all in the hands of God: if I get it, fine I do not, I would not. So they definitely get infected." [FGD participant, Miujiza Players, Nairobi, 1996]

Sexual Partners

The 1993 KDHS asked general population respondents about the number of sexual partners in the six months before the survey; 32% of males and only 4% of females reported more than one partner. Respondents were also asked about number of lifetime partners; 87% of males and 51% of females reported more than one lifetime partner, which includes 62% of males reporting six or more lifetime partners, and 34% of females reporting 2-3 lifetime partners. Data on 200 male and female adolescents (aged 15-19) at the Malaba, Mashinari, and Sachangwan truck stops in Kenya, collected by AMREF and CAPS, San Francisco, revealed that 90% of the respondents reported prior sexual activity, with girls reporting a median of 15 lifetime sexual partners and boys reporting a median of 12 lifetime sexual partners.

Data from KABPs carried out for AIDSCAP subprojects confirmed that multiple partners are common among some target populations. Among Nairobi security guards from five companies, the FGD results confirmed that a substantial proportion of guards have multiple partners, related to the fact that half the guards are married but living apart from their spouses, who reside in villages far from Nairobi. The guards unanimously agreed that "sexual provocation, and the general attraction from the women, plays a major role in influencing the majority to have many partners. Similarly, alcohol seems to be closely related to sexual practice involving multiple partners." The 1995 study with worksite populations found that 66% of single/unmarried males and 69% of females reported regular partners. Among married respondents, 20% of males and 5.6% of females reported other regular partners.

Qualitative data from AIDSCAP interventions suggest, however, that the practice of having multiple partners is perceived to be changing. Among workers in worksites reached through FPPS interventions, FGD moderators were told that "women are saying that their men have changed. We have also noted that reduced multiple sexual partners have caused a decline as the VDRL cases at our FP clinic continue to drop." All target audience participants in FGDs conducted at the end of the project strongly agreed that HIV awareness is influencing workers' behavior. FGD participants in 1996 and 1997 perceived that some people are reducing partners in their communities and that many people's attitudes towards having sexual relations with multiple partners have changed.

"There was a time if you mentioned something like 'stick to one partner" the whole audience would laugh but nowadays when you say the same they realize actually these people are teaching something sensible." [FGD participant, Miujiza Players, Nairobi, 1996]

Among church youth reached by MAP International from 1994-96, the percentage of youth who decided to reduce numbers of partners as a way to reduce risk increased from 25-41% during the intervention.

Condom Use

"I think within the churches there is the message that behavioral change is absolutely necessary and that you can protect a young person with a condom but you need to protect them much better if they kind of have few sexual relations. So the messages are clear that what the church wants is not just to go out and give condoms to a thousand or two but to need to go beyond that and talk about changes in behavior to the adolescents level and at level of marriages. " [Program manager, MAP International, Nairobi, 1966]

"We have the students' dispensary which also keeps condoms for both students and staff. From what I have gathered from the dispensary is that now more people are going for them compared to the previous situation. And because we have also told people about it, I have heard people really inquiring can we have them stationed in a certain location which means they are willing to have them and use them." [FGD participant, Mombassa Polytechnic, 1996]

Condom Access: The number of condoms distributed free in Kenya has risen from 8 million in 1988 to over 90 million in 1996. In addition, 500,000 socially-marketed condoms per month were sold in 1995. Much work remains to be done and the potential market is by no means saturated.

In the 1995 study with worksite populations, respondents were asked if they needed a condom today, could they get one; 59% answered yes (no gender differences). Focus groups in 1994 and 1997 suggest condoms are well known, even by people who do not use them. In the 1996 study, workers, peer educators and managers all indicated that condoms are widely available, for both men and women, in the project sites.

The 1997 FGDs in worksites indicated that accessibility of condoms in the worksites was established in the course of FPPS's intervention, with dispensers providing condoms for sale. One FGD participant said:

"Condoms are available and are kept in every department in dispensers. The peer educators also distribute condoms from the manager's office."

The BCC Lessons Learned research suggested, however, that as condoms become more popular, access and availability become a problem:

"Condom availability is a major constraint. For example, when we give two boxes, we realize that they are not enough and people need more; they need a constant supply; they need a constant reminder that they need to use condoms always" [Program manager, Miujiza Players, Nairobi, 1996]

Female condoms remain unavailable to the general population in Kenya.

Ever been shown how to use a condom: In the 1995 study with worksite populations, respondents were asked if they had ever been shown how to use a condom; 58% of males had been shown compared to 49% of females. The same tendency to provide fewer condom demonstrations to females was seen in the evaluation of the FPPS STD training project, which reported that 75% of male STD patients received a condom demonstration, compared to 62% of women STD patients. None of the security guards reached through the PATH intervention had ever been shown how to use a condom, prior to the intervention.

Condom use with non-regular partners: In the 1995 study with worksite populations, 52% of males and 54% of females reported condom use at last sex act with a non-regular partner. Main reasons mentioned by males (female sample too small) for condom use were to prevent HIV/AIDS (49%), prevent STDs (43%) and prevent pregnancy (8.3%). Reasons for not using condoms with a non-regular partner (cited by males) included trust partner (44%), don't like them (19%) and not available (14%).

Condom use with regular partners: In the 1995 study with worksite populations, only 16% of males and 14% of females reported condom use at last sexual act with a regular partner. Reasons for condom use were about 60% to prevent pregnancy, 23% to prevent HIV/AIDS transmission, and 17% to prevent STDs. This low percentage is consistent with the continuing social norm in Kenya against condom use with a regular partner.

Condom use with any partner: KDHS results show that the number of men using condoms regularly more than doubled between 1989 and 1993 (from 3% to 7%) while the percentage of men who have used a condom at least once increased from 17 to 27% during the same period. The 1993 KDHS (general population) asked respondents who reported having had sex in the six months prior to the survey if they had used a condom with any of their partners; 20% of men and 6% of women said yes. The 1993 KDHS also reported that for both men and women condom use goes up with the number of partners - implying a degree of realistic risk assessment. The 1995 study of adolescents at truck stops (Nzyuko et al 1996) revealed that 54% of girls and 38% of boys reported ever use of condoms. Reasons given for non-use included not liking condoms (29%) and condoms not readily available (4.5%).

Focus groups among workers and students (1996, 1997) reported similar perceptions by participants that their peers were using condoms more, finding it easier to talk about condom use with their partners, and feeling less judgmental in their attitudes towards condoms.

"When we started, people feared asking for condoms, but these days they ask freely" [University peer educator, 1997].

"We realized in the beginning before we had peer education, no one was going for condoms but now we have to replenish the stock quite often, almost overnight. So it shows a demand and people have taken to our education." [FGD participant, Bamburi Cement Factory, Mombasa, 1996]

People have become more vocal on AIDS issues. In terms of using condoms there are times when we even don't have to give the condoms they actually ask for condoms. [FGD participant, Miujiza Players, Nairobi, 1996]

They (staff) take these condoms to their partners, or friends. They even say they carry condoms in their bags. They advise their friends to use condoms especially when they don't trust their partners. [FGD participant, Bamburi Cement Factory, Mombasa, 1996]

However, more intensive interventions are needed to promote risk assessment and condom use among groups at risk. Among medical students in 1995, 61% said they had sex recently without using a condom; reasons for not using condoms included not at risk (50%), condoms inaccessible (35%), and the belief that condoms are not effective (8%); 47% said they "did not think about discussing condom use before sex" and 19% said they "were too embarrassed to discuss it."

Few of the Nairobi security guards who participated in the FGDs in 1996 (at the beginning of the intervention) reported ever use of condoms with any partners. Although most guards knew that condoms could provide protection, the majority would not consent to use them. Reasons for non-use provided by those who had tried them ranged from "poor quality, dirty handling and disposal, bursting during use, being left within women' private parts, not being approved and appreciated by the female partners, and possible family misunderstandings" (if found with a condom, this would mean consent to be unfaithful to the partner). The majority of the guards participating in the FGDs felt that they would prefer to have sex with casual partners without condoms, regardless of who the partner was, and regardless of the risks involved. "There was general agreement among the guards that the issues of risk of infection with STDs and HIV/AIDS is not taken into consideration during sex." (Muttunga 1996:6) Because this intervention began late in the Kenya program, no end of project studies have been done.

The 1994 study with worksite populations interviewed both condom users and nonusers, and found that nonusers mentioned the use of condoms for preventing unwanted pregnancies much more frequently than did users. Both users and nonusers thought that most condom use is with partners other than spouses. Although the evaluation reveals a general positive attitude towards condom use, respondents in the various groups interviewed nevertheless said that some people feel that free condoms are laced with the AIDS virus, and hence prefer to buy TRUST condoms. On the other hand, one FGD participant in 1997 said that many more people are now using condoms and "they go like hot cakes" in the worksites. Peer educators said in 1997 that they have noticed many people asking them questions on the effectiveness of the condoms. Medical students in 1995 also said that free condoms were thought to be of inferior quality, as compared to purchased condoms.

Female condom acceptability: At present, the female condom is virtually unavailable in Kenya. AWI's qualitative study of the female condom introduced the device to a population of 106 women recruited through women's organizations. This research showed increased acceptance of the device across all socio-economic status (SES) levels and ages: those who reported liking the female condom "very much" increased significantly from 80-100% among young women of low SES, 70-94% among older women of low SES, and 32-71% among young women of high SES. 93% stated they were always satisfied with the device and 81% said they would continue to use it if it were available.

Strategies used by women to introduce use of the female condom included using pregnancy prevention as the entry point, rather than telling partners that they needed to use the device against HIV/AIDS. They told partners that doctors had recommended use of the female condom because the pill has negative side effects. This strategy was used most often by married women and those with permanent sexual partners. Some women used the device secretly when their partners were drunk, which worked as long as they inserted the condom early enough to absorb body heat prior to penile insertion. Other women reported simply asking partners to experiment and ultimately making a joint decision. Others gave their partners the brochures and left condoms where the men could see them and ask about them. Cooperative strategies were also used, such as using friends' partners to introduce the topic of using the female condom to a male partner. The level of acceptance by male partners was also high with only one man refusing to cooperate with his female partner in using the device.

Constraints and misconceptions: There remain difficulties impeding further improvements in both male and female condom use. The 1996 BCC Lessons Learned project found, from interviews with peer educators that women's fear of men, specifically women's discomfort initiating condom use, was a key obstacle to condom use. Women were fearful both in their personal relationships, as well as in the context of mixed-sex group discussions. In response to women's concerns, peer educators suggested working separately with members of a couple, and having single-sex groups.

"One problem facing the women is that when we talk about condom use, in the African culture, the wife is put down as submissive. So most of them, even if they take the condom, it's very hard for them to introduce them to their husband. So probably, it is better to talk to them sometimes in privacy and tell them how to handle their wives, because when they go home they won't find a lot of opposition. They [women] really fear either they are going to be kicked out or be told that they are not being submissive to their husbands. So there is that kind of fear so that even when you get that mother or woman set for condoms, she fears that she may not get a way of giving them to the husband. The problem is mainly with the workers [ladies] who are housed outside the company premise. Sometimes the husbands are very frank with us and they tell us that I don't have to use a condom with my wife but I take the condom at the end of the month or during advance because I want to go out with another woman." [FGD participant, Bamburi Cement Factory, Mombasa, 1996]

"The ladies hope that some time they will be in a group of their own, and actually not a man teaching them, but a lady. When the circulars are sent the majority who show up are men. Women tend to shy away. I think the reason why women shy off is because literally they feel we are pointing fingers at them. They (women) feel when they come into these meetings because they are having these kinds of pleasures (free sex), they feel that we are attacking them so they refrain from coming." [FGD participant, Bamburi Cement Factory, Mombasa, 1996]

How have you changed behavior? When asked whether they had changed their sexual behavior to avoid getting AIDS after receiving information, 84% of males and 76% of females mentioned they were sticking to one partner (worksites populations, 1995) while 12% of males and 17% of females said they were abstaining from sex.

The vast majority of participants in FGDs conducted by Miujiza Players felt that they had changed their sexual behavior over the past two years through the use of condoms and reduction in sexual partners. Among students in institutions of higher learning, results from FGDs suggest students are also modifying their sexual behavior in response to peer education activities by reducing numbers of partners, abstaining from sex, discussing HIV/AIDS more freely and using condoms. Reproductive health clubs for students have achieved greater visibility as a result of the intervention and are being sought out by other clubs and students for help.

Barriers to behavior change were also noted, however, particularly with the target group of security guards:

"While the majority of guards knew that they could generally protect themselves by being faithful to one partner, abstaining from sex and by condom use, they were unsure of how to effectively apply these strategies for prevention" [Muttunga, 1996].

Other strategies suggested by various guards in some but not all groups included the following:

avoid sharing piercing instruments
insist on tested blood for transfusion
avoid sex with prostitutes
avoid injections outside health care facilities and use only disposable needles and syringes
avoid traveling in overcrowded public service vehicles to reduce chances of being sexually aroused
abolish traditional circumcisions for men and women
encourage single persons to undergo HIV tests before marriage
control beer consumption as beer and sex are closely related
counsel bosses to stop seducing and sleeping with young girls and other women seeking employment and favors from them.

These kinds of strategies reflect some of the universally accepted prevention strategies, but also reflect many culture-specific strategies developed in the Kenya context. While point 5 may seem confusing to some readers, it would readily make sense to anyone who has spent any amount of time in a public taxi or minibus carrying two or three times more passengers than seats in the vehicle.

Attitudes: In one study, respondents were asked in 1995 (worksite populations) what they would be comfortable doing with HIV infected persons. Out of 13 different activities (including working together, shaking hands, sharing utensils, caring for patients, welcoming a family member with AIDS and others), percentages ranged from a low of 48% who said they would be willing to share eating utensils, to a high of 92% who said they would help the children of a dead AIDS patient. Only 31% said they thought an AIDS patient should be segregated.

3c. Additional Outcome Assessments

STD Case Management

AIDSCAP collaborated with FPPS and Moi University to provide training in syndromic STD case management using Kenya's national guidelines. (Refer to FCOs 51468 and 51475 in the subproject highlights section for more detail.) The projects demonstrated that training produces a difference in the quality and effectiveness of STD case management.

Over the course of the FPPS project, over 98% of patients with complaints or signs consistent with the common STD syndromes received an appropriate syndromic diagnosis. Overall, 32% of patients returned to the clinic for follow-up. Of these, 93% reported either cure or improvement. The proportion of returning patients reporting treatment failure decreased from 12% in 1995 to 5% in 1996 along with increased use of recommended drugs. Clinical failure rates were lowest for cervicitis (4%) and highest for genital ulcer disease (15%).

Overall, 69% of STD patients received a demonstration of how to use a condom and 55% took home condom samples. Men were significantly more likely than women to receive the demonstration (75% to 62%) and to take the condom samples (61% to 43%). Whether this is due to the unwillingness on the part of the health worker to bring up the subject of condoms with women, or to resistance from the women, is unclear.

Following health worker supervisor training, the use of first-line drugs increased from 38% before to 53% after. Similarly, more patients received appropriate co-treatment for their syndrome (from 79% before training to 83% after training).

Results from the Moi University project were similar, with the majority of patients being treated either according to the national guidelines or with an effective alternative. Results were poorest for vaginal discharge, where health workers were most likely to treat on clinical grounds. Over 80% of private practitioners reported having counseled patients. As with the FPPS project, male patients were more likely to be given condom demonstrations and condoms than women. Health workers reported giving condoms to 23% of men and 12% of women.

Media Outcome Assessments: Newspaper Column and Radio Shows

Newspaper column: A qualitative evaluation of the AIDS WATCH newspaper column was carried out by AIDSCAP, as part of a media evaluation in March 1997, one year after the column ended. The purpose of this evaluation was to determine to what extent the project objectives had been achieved, whether there is still a role for a newspaper column on HIV/AIDS, and what form such a column should take. Above all, the evaluation sought to determine the column's effectiveness in reaching the audiences and encouraging discussion about HIV/AIDS.

Two FGDs were held, one with young trainee journalists and the other with NGO program officers working on HIV/AIDS. In addition, four key informant interviews were held, including the two editors of The East African Standard responsible for the column, and the columnist himself.

All respondents thought that the column had effectively contributed to creating awareness, meeting informational needs, and creating positive attitudes and behavior in relation to HIV/AIDS. According to the communications students, the column created much more awareness in the urban areas about high risk sexual behavior, and the need to treat AIDS patients with care. Similarly, those interviewed indicated that the column succeeded in humanizing the AIDS epidemic, as the many people with HIV/AIDS who went public did so through the column. It was also reported that parents used the column to educate their children. Additionally, responses showed satisfaction with the way the column handled regional issues in multi-cultural Kenya.

The evaluation concluded that the column had addressed the project's objectives of broadening awareness about the impact of HIV/AIDS, humanizing AIDS, educating people on prevention and care, and correcting myths and misinformation. The respondents recommended considering reviving the column, and made recommendations to improve its effectiveness. More detail on the project appears in the subproject highlights section.

Radio soap opera: A year after the column ended, a qualitative evaluation of Maajabu was carried out by AIDSCAP in March and April 1997. The objectives were to assess the effectiveness of the project in reaching the audience, and fostering discussion about HIV/AIDS; and to assess whether the radio program should be repeated, and if so, whether and how the content should evolve. Eight focus groups discussions were held with representatives of the audience, selected with the collaboration of chiefs, from listeners in the rural areas visited. The FGDs were carried out with four language groups (all except Kikuyu), supplemented with four key informant interviews, with radio producers and project staff.

Participants in the FGDs indicated that they had learned important information from the program and found it interesting, entertaining, informative, true to life, and very enjoyable. Contrary to expectations that popular opinion supports careful censorship of program content, participants interviewed in the FGDs felt that all people, young and old, including house-girls, should be exposed to the program. Participants also indicated that discussions are usually held about the program by listeners with family members, friends, workmates, and neighbors. This positive response, one year after the program ended, confirmed the immediate evidence of listener approval during the program. Feedback from listeners during the broadcast period was overwhelming, with over 27,000 listeners writing to respond to a radio competition held in connection with the show. The overall consensus was that the program should be immediately reinstated, preferably as a new series.

Participants interviewed in the FGDs said that they had noted positive change in awareness, attitudes and behavior with regard to HIV/AIDS. They attributed some of these changes, including condom use and the reduction of non-regular partners to the radio program. However, participants were divided on whether attitudes towards the condom have changed for the better. Some said condom use had increased; while others felt that single people have resorted to abstinence, and the married to sticking to their partners. Other issues that emerged from the FGDs were the reluctance of men to use condoms, the persistent negative attitudes about condoms among church leaders, and the confidence in condoms that people gained from the condom advertisements. It is interesting that the condom advertisements were generally seen as being appropriate, though some of the women lamented that they had caused men to be unfaithful.

Final Report for theAIDSCAP Program in Kenya: Country Program Description

Final Report for the
AIDSCAP Program in Kenya: Country Program Description