Final Report for the
AIDSCAP Program in Mali
September 1992 to March 1995

This report comprehensively summarizes the FHI/AIDSCAP program in Mali (1992-1995). The report lists program accomplishments, outcomes and lessons learned.

Executive Summary

Introduction

The first AIDS case was diagnosed in Mali in 1985 and within 10 years, 2,600 cases had been reported to the Ministry of Health. Survey data in 1992 showed that HIV infection levels were from one to five percent in the general population. In all regions, except Sikasso, infection levels were higher among females than males. HIV prevalence among prostitutes surveyed ranged from 16 percent in Gao to 74 percent in the capital city of Bamako and the regions bordering Côte d'Ivoire.

In 1990, USAID supported the National AIDS Control Program (NACP) to continue a pilot intervention for brothel-based sex workers in Bamako which had been initiated by FHI in 1988. FHI/AIDSTECH, in collaboration with the National AIDS Control Program, then implemented a two-year education and condom distribution project aimed to educate sex workers and potential clients, about the spread of AIDS and how to reduce personal risk for infection. Encouraged by evaluation results which indicated significant gains in knowledge and reported condom use, USAID supported FHI/AIDSCAP in implementing an expanded intervention from September 1992 through March 1995.

Under AIDSCAP, project education and condom promotion activities were expanded to include additional target groups and geographical areas. Consistent with earlier interventions, the objective of AIDSCAP in Mali was to reduce the sexual transmission of HIV by reducing high-risk sexual behaviors, providing STI control for selected groups, and increasing condom use in: brothel-based sex workers, residing in approximately 15 brothels in the participating cities of Bamako, Segou, and Sikasso; clandestine sex workers; male bar patrons; male taxi drivers; workers and their families; military men; and members of the general population, especially youth and women. The program also included the funding and training of local nongovernmental organizations (NGOs) to run HIV/AIDS prevention projects in various districts and shantytowns of Bamako. By the end of the project 15 NGO projects had received both technical and financial assistance.

Accomplishments

The AIDSCAP program in Mali had many achievements in its two-and-a-half years of operation. Its approach can be characterized as innovative in this predominantly Muslim country, in which taboos on sex-related subjects are still very strong and the media play only a minor role in the fight against AIDS. The project was known for its frank discussions of high-risk sexual behavior and its demonstrations and promotion of correct condom use. Although the project cannot claim to have reached the majority of WMPs in Bamako through its peer education program, it established direct, warm, and lasting relationships with a substantial number of WMPs working in brothels (averaging 150 at any given time) and with streetwalkers (averaging about 50 at any given time).

In a country where condom use has been very low, the project raised the level of condom awareness and use and paved the way for the social marketing project implemented by SOMARC in Mali. The project distributed over 2 million free condoms. During the end-of-project survey, 85 percent of project beneficiaries declared they would continue to use condoms even though they would have to pay for them.

Many of the small, indigenous NGOs that started HIV/AIDS interventions under the AIDSCAP small grants program have since received long-term funding for activities in HIV/AIDS prevention and/or family planning through the Groups Pivot et Survie de l'Enfant, a USAID-funded NGO umbrella organization, and Plan International, which is also funded by USAID. The training and experience received by these NGOs facilitated their entry to larger funded projects. The combined NGO projects reached over 3,000 people in greater Bamako. In addition, NGO staff and local youth were trained as AIDS educators by AIDSCAP project staff.

The AIDSCAP program, in collaboration with both national and international governmental and nongovernmental organizations, contributed to enhanced awareness of the existence and the dangers of HIV/AIDS among a large proportion of primarily urban Malians. Through its free distribution of over 2 million condoms, the program tackled existing prejudices and taboos and created a climate in which safe sex is increasingly negotiable. The quality of the project's relationship with WMPs made the use of condoms a group-enforced standard code of behavior among them.

A knowledge, attitudes, beliefs, and practices (KABP) survey conducted at the end of the project found that:

• Knowledge about HIV/AIDS and its transmission and prevention was very high among all target groups: 94 to 95 percent
• Reported condom use among brothel-based WMPs with their clients was close to 100 percent in Bamako, although reported condom use with regular partners remained at between 30 to 40 percent. Reported condom use with last non-regular partner by bar patrons and transport workers was 65 percent.
• There was a remarkable decrease in STI prevalence among the brothel-based WMPs.

Lessons Learned

A number of important lessons were learned during the project. These include:

• Regular partners of commercial sex workers are not perceived as sources of infection; therefore, appropriate messages need to be developed to target regular partners of WMPs to use condoms and to convince WMPs of the importance of using condoms with their regular partners as a source of STIs.
• Once sensitized, people at risk are willing to pay for condoms.
• Future STI prevalence studies should target boyfriends (or nonpaying clients) and clients of CSWs to establish boyfriends as a source of STI infection and verify claims of condom use with clients.