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Final Report for the
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Table of Contents II. Background and Country Context III. Country Program Description A. Introduction
Country Program Description E. Subproject Highlights (Part 2) Technical Assistance to AIDSCAP/Nepal
Background The Program for Appropriate Technology in Health's (PATH) Senior Program Officer Scott Wittet served in the capacity of AIDSCAP/Nepal's Outreach Education Technical Advisor for the life of the project. Goal and Objectives The technical advisor's primary tasks were: 1) To assist General Welfare Pratisthan (GWP) and Lifesaving and Lifegiving Society (LALS) with planning, activity design and development and oversight on field implementation and IEC material design, development and use. Mr. Wittet was also tasked to resolve technical problems encountered during project implementation. 2) To provide consultation to the Nepal Project Monitor regarding the technical quality of instruments, materials, evaluations and technical reports associated with the Outreach Education subprojects. Accomplishments The PATH technical advisor completed four technical assistance visits to Nepal working directly with GWP and LALS at key points in subproject implementation. The first visit began at a critical time in subproject implementation startup with the design of the training curriculum for outreach educators and the development of outreach strategies for field startup The second visit came at a critical time as the GWP outreach staff were initiating actual field outreach following the completion of initial community assessments in the project area. Mr. Wittet assisted project management to make adjustments in outreach staffing with the recruitment of community health nurses to complement the outreach staff. Another major accomplishment was assistance to GWP in the development of an IEC strategy including the procurement of locally-produced IEC materials and the development of specialized IEC materials for targeted audiences. The third Nepal visit came at a critical time following the 1995 Program Review, which recommended that GWP better target outreach to the priority risk groups and move more quickly into peer education activities. The technical advisor worked with GWP and LALS to better strategize targeting CSWs and key clients in the nine-district area, and assisted with the development of the final peer education training curricula and implementation approaches. In addition, work on the completion of IEC materials focused on PATH's Risk Advisor methodologies continued with further pretesting and design of the Nepal-specific Village Risk Advisor materials. The PATH advisor's fourth and final visit came at a critical time in subproject implementation in July 1996. Mr. Wittet assisted AIDSCAP/Nepal facilitate a team planning workshop at Dhulikhel with all of AIDSCAP's implementing partners. This workshop presented the results of a quick qualitative study of the AIDSCAP interventions conducted by New ERA, and provided an opportunity for IAs to prioritize and share plans for future interventions to be funded through the FY97 project extension. The PATH advisor greatly assisted this process and later worked directly with GWP and LALS to finalize their extension plans, and prepare program budgets for their August amendments. Due to budgetary limitations, this was the final visit of the technical advisor to Nepal. Findings It is important to reassess approaches to outreach and peer education and the use of IEC materials on a regular basis to throughout the life of an outreach/behavioral change communications program. Lessons Learned and Recommendations Technical oversight on a regular basis from an advisor knowledgeable of local culture and a leader in the field of HIV/AIDS communications and approaches for the Asia Region provided AIDSCAP's implementing partners opportunities to make enormous accomplishments in community and interpersonal outreach education in Nepal's Central Region. FPAN/Chitwan STI Services Project
Background AIDSCAP aimed to reduce the HIV/AIDS epidemic in Nepal by targeting sex workers, transient groups and communities along the national highways in the central region of Nepal with interventions. These interventions focused on STI management, behavior change communication and condom promotion and distribution. Access to STI treatment in Nepal is low, for both men and women. In an effort to increase access to quality STI services, AIDSCAP collaborated with the Nepal Medical Association to provide STI management training to private providers, and with the Nepal Chemists and Druggists Association to target pharmacists and nontraditional providers. This project, implemented by the Family Planning Association of Nepal, complemented these efforts by integrating STI services into existing Maternal Child Health (MCH) services. Scope Of Work The purpose of this project was to improve women's access to comprehensive, quality STI services in the Terai districts of the central region. The project objectives were to:
For the successful implementation of the activities, FPAN collaborated closely with other AIDSCAP partners, especially GWP outreach staff, with whom monthly meetings were held to discuss HIV/STI education, patient referral, and follow up in the project communities. Management The project was implemented from January 1996 till July 1997. During the implementation of the project, several amendments to the subagreement were made to enable the services to be expanded to two other districts, and two outreach sites in Chitwan. A total of 19 staff worked in the project, of whom 8 were newly recruited, and 3 were full time employed in the STI project. FPAN contributed NRs. 97,000 towards the establishment of the revolving drug fund, and made the FPAN Chitwan building available for the project. Accomplishments 1. Integrating FP and STI services FPAN Chitwan branch recruited 8 female health workers, expanded the existing clinic facilities and opening hours, and set up monitoring systems, in preparation for STI service delivery. Several trainings were organized with the help of outside experts for all staff involved in the project. An orientation training on basic STI/HIV was followed by trainings on STI case management for paramedics, peer education for community workers, and inservice trainings for the new Janakpur and Hetauda staff. Based on the Chitwan success, FPAN started up STI services in two additional clinics in Janakpur and Hetauda. An inauguration workshop was held in June 1996, where the Health Minister inaugurated the integrated STI/FP services. Over the life of the project, 1,275 patients were treated for STIs in the FPAN clinics and outreach sites, of whom over 87 percent were female. 2. Health Education and IEC The Chitwan clinic established a special health education room with video facilities, under the guidance of a full time health educator. Printed IEC materials on basic STI, HIV and condom use were procured from AIDSCAP partners and elsewhere, and one special STI brochure was developed for the project. FPAN's community workers and women volunteers integrated disease prevention messages into their ongoing family planning and family health services at the community level and during home visits. Women assessed as vulnerable for STIs were not only referred to the FPAN clinic, but accompanied by the outreach worker who assured proper follow-up. 87,494 different types of IEC materials were distributed to clients in the clinics as well as the communities. 4,400 promotional condom wallets, developed by CRS, were provided to clients, as well as 16,246 free brandless condoms. All clients with STI symptoms or complaints were counseled according to national guidelines (the 4 C's). 3. Revolving Drug Fund FPAN headquarters contributed NRs. 97,000 towards a revolving drug fund. STI drugs were procured according to the national prescription guidelines with this seed money, and costs were recovered from patients by selling them for cost price plus 8 percent mark up, i.e. well below the retail price. 4. Lesson Learned Workshop A lessons learned workshop was organized in April 1997, where family planning managers and policy makers recommended further integration of STI services within MCH services, on the basis of experiences in the project. Constraints Constraints to efficient implementation were experienced through the lack of sufficient manpower, lack of staff development and clear job descriptions, for paid staff as well as volunteers. A car would have facilitated outreach and monitoring work in other districts. Findings and Results The project has contributed to improved access for women to STI services in the project area. Not only have we treated over a thousand STI cases, due to health education, the reported use of condoms in high risk sexual contacts among sex workers increased to 61 percent compared with 35 percent at baseline. Lessons Learned And Recommendations Many lessons were learned in the project. The main lesson is that integration of STI services into MCH services can increase the demand for both. Secondly, any revolving drug fund needs to be separate from the general office accounts. Thirdly, roles and responsibilities of staff and volunteers need to be specified at the outset of a project. Finally, the syndromic approach for STI management appears to be cheaper and better for patients, compared to current STI treatment in the private sector. Process Indicator Summary
Condom Promotion and Distribution Program
Background About one half of Nepal's population lives in the Terai, about 20 percent of the land area along the open border with India. In Nepal, those most at risk of HIV infection are those who engage in unprotected sex with multiple partners, in particular, commercial sex workers (CSWs) and their clients. Studies and migrant labor patterns show Indian transport and migrant workers and traders crossing the border into Nepal, and Nepalese labor returning from India across the border and working in this agricultural/industrial area engage in high-risk commercial sex in the border areas and along Nepal's major transport routes. Therefore this intervention targets CSWs and their clients in the Terai area of the Central Region as well as along the major transport routes. Nepal CRS Company is a nonprofit private social marketing organization in the health and family planning sector with the purpose of increasing awareness and use of health and family planning products. CRS uses modern marketing techniques through private sector infrastructure to complement and supplement national health and population programs. CRS redefined the product positioning strategy of both its brands of condoms, "Dhaal" and "Panther", from strictly a family planning product to an STI/AIDS prevention tool. Its promotional campaign includes such messages as "to protect from unwanted pregnancy and STI/HIV/AIDS" in each of its packets, as well as in radio spots, television commercials, print advertisements and training materials. Under an earlier subagreement with AIDSCAP (February 1994 - August 1996), CRS worked with The Futures Group to conduct market research, expand into new product areas and market niches, and improve product accessibility. Goals and Objectives The objectives of this project were to continue to expand the distribution and accessibility of the CRS brand condoms for disease prevention in an effort to strengthen sales and to influence consumer behaviors in 22 districts and most particularly in the nine districts of the Central Development Region from Naubise to Janakpur/Jaleshwor and Birgunj. Scope of Work To meet the objectives, CRS completed the following activities.
Accomplishments Training initiatives for condom distribution and expansion: Developed an STI/HIV/AIDS awareness training curriculum for retailers in Nepali and conducted 22 one-day workshops for 471 general outlet owners, nontraditional retailers (pan shops, tea stalls, liquor stores, general stores, grocery stores, and barber shops) and local community leaders. Special efforts were made to include women, one special session was organized for women retailers only, and a total of sixty women participated. Efforts were also made to include chemists and alternative health providers who were unable to participate in the NCDA trainings. Each workshop participant received a package of training materials including a retailer kit. Condom Social Marketing Training for NGOs: CRS revised the social marketing training curriculum and manual originally developed with Save the Children/U.S. and conducted three field trainings for NGO participants on how to integrate these strategies into ongoing disease prevention activities. A total of 84 (45 m ale and 40 female) participants were trained in the two-day workshops. An unanticipated activity was the follow-up trainings NGOs requested. Support Initiatives for Condom Distribution and Expansion: Ten shops participated in a pilot "rack space buying" program through which they were reimbursed for the exclusive use of space for condom product display for one month. This new approach increased condom visibility in highway nontraditional outlets. Additional efforts included a Condom Display Contest to create awareness of STI/HIV/AIDS and the availability of condoms in local, nontraditional outlets, as well as to destigmatize condom use. One hundred outlets participated. CRS distributed AIDSCAP condom promotional materials such as tin signs, mirrors, lamp shades, condom wallets, T-shirts and caps to all of its retail outlets. CRS opened and additional 88 nontraditional outlets in the Central Region. Support Initiatives for the Condom Multimedia Campaign: Video Van: CRS arranged thirteen video van shows on average per month (total 136 shows) for the public living and working in communities along the major transport routes. IEC activities: The film was viewed by approximately 87,125 people. For IEC activities, CRS developed and distributed 35,000 condom wallets, 4,000 tin signs, and 5,000 pocket calendars. Nine billboards and five kiosks were put up along the main highway. Radio: CRS launched a pilot radio program on HIV/AIDS over FM Kathmandu with eight programs aired from March to April 1997. Due its success, it became a regular program. Constraints
Lessons Learned and Recommendations NGO participants from previous condom social marketing workshops were confused about how to integrate distribution activities into their other activities. CRS learned to work with NGOs on how to start projects, initiate awareness programs, and incorporate health and family planning into regular activities. Condom use was a very sensitive and taboo subject. Even when retailers were convinced to stock condoms, within a few days they were not selling them or kept them out of view saying that customers were avoiding the stores due to condom visibility. Female retailers in particular were teased and ridiculed for selling condoms. Delay efforts to open condom outlets until there is a general acceptance of condom use among the public. This was demonstrated possible through the mass awareness and targeted area campaigns such as the condom multimedia campaign For increased female participation in trainings, it helps to have smaller arrangements in informal settings for "women only". Process Indicator Summary
Rapid Qualitative Assessment of AIDSCAP Behavior Change Among Commercial Sex Workers and Their Clients
Background This brief qualitative study was initiated in order to provide a quick mid-term assessment of project interventions on behavior change among CSWs and clients. This study was implemented in mid-1996 in order that the findings could be shared with project implementing parties to assist with their final workplans and interventions for the project extension period from August 27, 1996 through mid-1997. Study Goal and Objectives This study was a rapid qualitative assessment of the effects of the AIDSCAP/Nepal project on the knowledge levels and change of sexual behavior among CSWs and their clients along the transportation route from Naubise to Janakpur and Birgunj. The objectives were to:
The Research Methodology A sample of 25 CSWs (at least one from each area of the route) and 25 clients were selected and interviewed during a two-month period. Two separate questionnaires were used, one for each group in order to record background information, sexual behavior and exposure to STI/HIV infection, condom use and exposure to HIV prevention information. The study was designed to get as much qualitative information as possible from a small number of target groups. There is no statistical analysis of the data except the frequency of the responses. Research Results Most of the CSWs entered the profession between 13-20 years of age. The majority were married between ages 12 and 15 but only 25 percent were still living with their husbands. Half of them were illiterate and 36 percent had dependent children. Client ages ranged from 17 to 45. Almost all were literate, urban, and away from their families for extended periods of time. Occupations included truck drivers/assistants, migrant workers, rickshaw driver, civil servant, police, army, transport and industrial workers. Almost all of the CSWs and clients had heard of the AIDSCAP slogan "Condom Lagau, AIDS Bhagau" ("Lets wear a condom to drive away AIDS"). A fairly good number of CSWs and even more clients had heard or seen other AIDSCAP messages featuring Dhaaley Dai and Guruji Ra Antare. The majority understood the messages correctly Among the media channels, radio was the most popular source of information followed by billboards. Cinema and videovan shows were the next popular sources for AIDSCAP messages. The least mentioned source was street drama. Eight CSWs had received information from outreach workers. The study indicated that AIDSCAP messages had brought some awareness of AIDS to CSWs and clients. Some of the CSW and client responses were drawn directly from the contents of the AIDSCAP media messages. Most of the CSWs and clients said they did not feel they were at risk of AIDS, but this could be interpreted as "they have not been a victim of AIDS". Not all of those familiar with AIDS and methods of prevention were aware that one dies from AIDS. Few CSWs or clients could identify different STIs. Although six CSWs and four clients said they did not feel at risk of AIDS, more than these numbers practiced safe sex. Sixty percent of CSWs reported using condoms with clients. Initiation of the idea was split 50-50 between CSW and client. Sources of condoms were outreach workers, NGOs, chemists and health workers in that order. Three CSWs reported having clients who always used a condom and six reported clients who never used them. Seventeen (68 percent) clients said they had used condoms but on 44 percent used a condom with their last CSW encounter. Seven said they carried condoms with them and seven said they always used condoms with CSWs. Only two reported using a condom with their regular sex partner. Human Resource Development Assistance and HIV/AIDS/STI Outreach Training to General Welfare Pratisthan in Nepal, Phase III
Background LALS provides human resource development technical support to General Welfare Pratisthan to implement and manage the project "Outreach Education to Commercial Sex Workers and Clients/Transient Population Groups in Central Nepal" for HIV/AIDS & STI prevention and control. Phase III of this project builds on experience and lessons learned from Phase II (FCO 53431) implemented from November 1, 1995 to August 26, 1996. Accomplishments
Participation in:
Constraints These constraints are from all three phases of this project.
Recommendations These recommendations are from all three phases of this project.
Process Indicator Summary
AIDS Awareness and Condom Promotion, Stimulus Advertizers (P) Ltd.
Background Stimulus Advertizers Ltd. was involved in the development, management and implementation of the AIDSCAP AIDS Awareness and Condom Promotion Multimedia Campaign during Phase I of the project, as a subcontractor to The Futures Group International. The main focus of the campaign was on increased accessibility of condoms, correct and consistent use of condoms (particularly while engaging in high risk behavior) and increased HIV/AIDS prevention awareness. Goal and Objectives In Phase II, Stimulus was responsible for:
Accomplishments Stimulus organized, conducted, supervised, managed and implemented the following activities. The multimedia campaign launched in July 1995 was continued through April 1997. The Dhaaley Dai logo and Guruji Ra Antarey storyline were continued through a variety of media products via Nepal Television, Radio Nepal, FM Radio, Cinema Halls, TARANGA Street Drama, and other complementary print material distribution by AIDSCAP's implementing partners, which included comic books, posters, film banners, condom wallets, stickers and danglers. Sixty-one shows of the 49 minute version of Guruji Ra Antare film were shown by video vans operated by Nepal CRS Company. Approximately 41,900 viewers saw the film. The 19 minute edited version of the same film was shown at four cinema halls in the project area, free of cost every Saturday morning. Stimulus Advertizers subcontracted TARANGA, a local street drama group based in Hetauda to stage the street drama Guruji Ra Antare based on the film. Sixty-four shows were performed. For feedback purposes, questionnaires were filled out by some members of the audience after the show. Three of the shows were staged on 20th, 21st and 22nd December 1996 to coincide with the Nepal Jaycees 23rd National Convention in Narayangarh. Because a symposium on HIV/AIDS had been jointly organized by AIDSCAP and the Nepal Jaycees for the convention. The Stimulus Project Manager was one of the two coordinators of the symposium. The four radio spots - "At the Hospital", "Husband and Wife", Guruji Ra Antare and "Tea Shop" as well as the Dhaaley jingle were broadcast over Radio Nepal and FM Kathmandu. On World AIDS Day, the frequency of the radio spots was increased the day before and the day after. All six FM stations under FM Kathmandu aired the Dhaaley jingle, free of cost, twice on this day. The 60 second Dhaaley TV spot was telecast on Nepal Television per the regular media schedule. Extra spots were shown on Condom Day and World AIDS Day. The spot was also screened regularly thrice a day at five cinema halls in the project Area. One extra spot was screened on Saturday mornings before the Guruji and Antare film. During this period, 2,000 comic books, 300 Dhaaley posters and 20,000 condom wallets were printed for distribution by AIDSCAP partners in the Central Region. The major new activity for Phase II of this project was the production of a new video drama, three short videofillers and 2 radio spots. One 45-minute video film "Asha", three videofillers - "Raju", "Laxmi" and "Unite Against AIDS" and two radio spots "Raju" and "Laxmi" were completed. Deependra Gauchan of Sights and Sounds was contracted to produce the film and the three TV spots. Nepal Government censor clearance was given to the film and spots. The primary theme of "Asha" addresses the issues of fear in the general public regarding people living with AIDS. The film highlights three key messages :
The video-filler, "Raju" focuses on the young target group and their risk behavior. "Laxmi" is aimed at families and shows how AIDS can affect the equilibrium of an otherwise normal family. "Unite Against AIDS" is aimed at the general public and conveys that AIDS is a universal problem and can affect anyone. It encourages everyone to unite together against AIDS. The three fillers were telecast free of cost by Young Nepal Television and Image Channel Television starting May 1997. The scripts of "Raju" and "Laxmi" were adapted and improvised for two radio spots. They were broadcast over Radio Nepal, Hits FM 100, Music Nepal, Image Channel, Classic FM and Kantipur FM on the 29th and 30th of April 1997. The street drama group Taranga had suggested that it would be a good idea to incorporate the messages from Guruji Ra Antare with "Asha" so that issues of AIDS, as well as care and management could be tackled together. Unfortunately the film was not completed in time. With the purpose of getting broadcast censor clearance and permission, a Media Advisory Team was formed in December 1996. The team included representatives from Radio Nepal, Nepal Television (NTV), The National Centre for AIDS and STI Control (NCASC), the Ministry of Communication & Information, the Censor Board, the Nepal Contraceptive Retail Sales Company (CRS), General Welfare Pratisthan (GWP), Sights and Sounds, AIDSCAP and Stimulus. The team met three times during the project period to discuss and approve scripts for television and radio as well as to share views and give technical input on the film and videofillers. The " Stimulus Lessons Learned" Workshop was held on 23rd April 1997 at the Godavari Village Resort. The workshop was attended by 81 participants from the different media, donor agencies, NGOs and the government. The objectives of the workshop were as follows:
Process Indicator Summary
Chemists' STD Drug Dispensing Behavior and HIV Prevention Communication: An Impact Evaluation of Training Using Simulated STD Patients
Background In September 1995 an AIDSCAP/USAID internal review team visited Nepal. One of the review findings was to expand a planned qualitative assessment of chemist dispensing practices with a comprehensive quantitative pre- and post-evaluation of the impact of the Nepal Chemists and Druggists Association's (NCDA) training program for chemists on chemists' STI dispensing practices. The baseline survey was conducted in late 1995 (FCO 57425) and this impact survey was conducted approximately one year later in October and November 1996. Study Goal and Objectives This was a follow-up quantitative impact evaluation of chemists' dispensing practices after the implementation of the NCDA training. The objectives of the study were to examine how chemists served individuals presenting themselves with urethral discharge, to examine whether chemists recommended patient compliance, partner notification and physician referral to STI patients, to examine condom promotion by chemists to the patient, to better understand chemists' awareness of STI transmission and interrelations with STI/AIDS and to understand if the NCDA training approach adequately met the needs of dispensing chemists. These results were compared to the baseline study taken pre-NCDA training. The Research Methodology The methods used were an assessment of the chemists' dispensing practices using the simulated client approach (Mystery Shopper). Interviewers were trained to pose as individuals exhibiting symptoms of urethral discharge at the chemist shop. Following the interaction with a chemist, the interview team recorded the chemist's responses on a structured questionnaire. One hundred and sixty male chemists were interviewed by male simulated patients in late 1996 in the AIDSCAP project area. Research Results The results show that 81.3 percent of the chemists recommended medications to treat the STI. Approximately 45 percent of the chemists suggested the correct medications and correspondingly correct dosages for urethral discharge, compared to 0.8 percent of the chemists in the baseline study. In the follow-up study 23 percent of the total chemists suggested condom use to their patients, increasing from 14 percent in the baseline. While only 5 percent of the total chemists suggested STI treatment for partners in the baseline this increased to 21 percent in the follow-up survey. Three percent of chemists in the baseline advised their patients to consult with a physician if not cured by the treatment. This increased to 16 percent after training. The average cost of the suggested medications decreased from Nepali rupees 193 in the baseline to Nepali rupees 168 in the follow-up. Chemists retention of the training curriculum and prevention education messages substantially decreased after a period of three months following training participation. Those trained closer to the evaluation date had better understanding and retention. This suggests the need for ongoing refresher and follow-up training for chemists. An Evaluation of Interventions Targeted to Commercial Sex Workers and Sex Clients on the Land Transportation Routes From Janakpur and Birgunj to Naubise
Background In 1994 New ERA completed a baseline study of commercial sex workers and sex clients in the AIDSCAP, highway-project area from Naubise to Janakpur and Birgunj. This baseline study provided benchmark data against which future surveys could be compared in assessing the effectiveness of HIV/AIDS control interventions. New ERA was tasked to undertake the final follow-up evaluation study by AIDSCAP in October 1996. Study Goal and Objectives The main purpose of this study was to provide evaluation data on the variables knowledge, attitude and practice (KAP) among commercial sex workers and their clients after AIDSCAP project interventions. The net effect was been measured by comparing the results of the 1996 follow-up survey with the results of the 1994 baseline survey. The Research Methodology The methodology and instruments used in both of the surveys were similar, however some minor adjustments in the 1994 questionnaires were made in order to gather some specific information about the program. In both the surveys, information was collected along the highway route from Naubise to Janakpur and Birgunj as the project intervention area, and, for the control area, from the western part of Narayanghat to Butwal/Bhairahawa and east of Dhalkebar including Lahan, Itahari and Biratnagar. In the baseline study a total of 100 CSWs and 209 clients in the project area and 62 CSWs and 103 clients in the control area were interviewed. In the follow-up survey, 164 CSWs and 231 clients in the project area, and 112 CSWs and 157 clients in the control area were interviewed. The sex clients basically included transport workers, industrial workers, police/army, students and rickshaw pullers. Qualitative information was also collected in the project area from 12 CSWs, 12 truck drivers and 23 community leaders, mayors/politicians, representatives of transport associations and businessmen, and is presented in a separate report. Research Results Prior to project interventions CSWs reported chemists and retail shops as their major source for condoms. This changed with NGOs now reported as a major source. In the control area the major condom sources were chemists and government health facilities. Following interventions there was an increase in the proportion of CSWs providing condoms to their clients in the project area. This had slightly declined in the control area. The proportion of CSWs having seen, heard, or read condom advertisements increased in the project area while no change was reported by CSWs in the control area. Radio, television, billboards and NGOs were the major sources of condom advertisements and information for CSWs in the project area. In both the control and intervention areas a significant gain was seen in the role of television as a source of information. In both areas CSWs reported perceiving condom messages as promoting the condom for disease prevention. In the project area, CSWs reported use of the condom by their last client increasing from 35 to 61 percent. There was no significant change in the control area (48 to 49 percent). There was an increase in the proportion of CSWs requesting use of condoms from their clients in both the project and control areas. Specific condom promotion messages including Dhaaley Dai, Guruji Ra Antare" and "Condom Lagau AIDS Bhagau" reached a significant proportion of CSWs in both areas. Following interventions there was an increase in CSWs who had knowledge of HIV. There was a substantial decline in the proportion of CSWs having no awareness of measures to protect themselves from AIDS in both the project and control areas. More than one-fifth of the clients in the project area and three-tenths of the clients in the control area reported having sexual contact in India, suggesting high mobility among sex clients. The mean number of CSWs visited by clients during the last 12 months in both the project and control areas decreased substantially from 1994 to 1996. Condom use among clients in their last sexual encounter increased from 34 percent to 41 percent in the project area and from 21 percent to 40 percent in the control area. More clients reported that AIDS is transmitted if a condom is not used in both project and control areas. An overwhelming majority of clients in both areas reported condom use as the preventive measure from AIDS (54 percent and 83 percent). Clients in both areas were exposed to the specific Dhaaley Dai, Guruji Ra Antare and "Condom Lagau AIDS Bhagau" promotion messages. Almost every client who had seen advertisements about condoms reported knowing about HIV. Reported STI symptoms were slightly higher in the control area than the project area, and nearly 82 percent of clients with STI symptoms in the project area report seeking treatment. This figure was only 50 percent in the control area. In conclusion, HIV messages were successfully disseminated and understood by target populations. Condom use among CSWs in the project area increased twofold and did not change in the control area. Condom use among clients in both areas increased. This was perhaps due to significant travel of clients between areas and the impact of AIDSCAP's national condom media campaign NCDA Chemists Strengthening Project
Background The Nepal Chemists & Druggists Association (NCDA) organizes and runs the Orientation Training Program for Chemists for dispensing practices, but had not addressed STI/HIV/AIDS. Because HIV/AIDS and other sexually transmitted infections, are pandemic, NCDA decided to conduct training programs for chemists and health providers on STI prevention and control activities. The first project began in January 1995 through a subagreement with AIDSCAP. The NCDA/AIDSCAP project intervened in Nepal's Central Region highway periphery (from Dhading to Jaleswore). The intervention area reached the border to India. Goals and Objectives The goal of this new project (February 10 to May 15, 1997) was to strengthen the role of chemists and health care providers as prevention educators and condom promoters. It utilized the same curriculum, trainers, master trainers, resource persons and training methodology, as in the first project. In this current project, three follow-up two-day field trainings, one residential follow-up Workshop for Novice Trainers and nine one-day refresher trainings in the field were planned. Accomplishments NCDA conducted three, two-day follow-up field trainings for 78 novice trainers at Pokhara, Janakpur and Narayanghat. Pokhara was added because NCDA had pretested the curriculum there in 1995 One four-day residential follow-up Workshop for Novice Trainers was conducted at Dhulikhel for eighteen participants. During this workshop the one-day refresher training manual and the two-day field training curriculum were revised and finalized. Four one-day refresher workshops were conducted, giving experience to the recently trained novices, for 105 chemists and health providers. Five more were scheduled but not conducted due to lack of time. Process Indicator Summary
Area of Affinity: Nepal and India One outstanding example of collaborative effort is AIDSCAP's first full pilot cross-border intervention, the Nepal-India Area of Affinity (AOA) experience, supported with funding from the Asia Near-East Bureau. The Nepal-India AOA experience weaves together the Bhoruka AIDS Prevention Project (BAP), implemented by Bhoruka Public Welfare Trust with AIDSCAP/Nepal's outreach education subprojects implemented by General Welfare Pratisthan (GWP) and Lifesaving and Lifegiving Society (LALS) in the border communities of Raxaul and Birgunj. Bhoruka's project goal is to reduce the transmission of HIV/AIDS and STI infection among truck drivers and helpers along National Highway 28 in Northern India and it is GWP/LALS project goal to reduce high risk sexual behavior among commercial sex workers, their clients and other transient population groups in Nepal's Central region. The Raxaul-Birgunj collaboration has served as a most valuable model in HIV/AIDS prevention for the South Asia Region. The Nepal-India border experiment webs focused STI and HIV prevention efforts by GWP and LALS and their other Nepal-collaborating partners with the Bhoruka project and its 5-year experience in AIDS prevention in West Bengal. The Nepali and Indian partners have integrated behavior change communications, condom promotion and STI service activities on both sides of the border.
While international borders can be barriers to public health collaboration and coordination, the India-Nepal border at Birgunj-Raxaul has provided an opportunity for a long-term international partnership in HIV/AIDS prevention. This long-term partnership has been strengthened with the organization of a series of sharing meetings and workshops to further promote the South Asian border experiment. A tripartite workshop organized by BAP was held in Calcutta in April 1996, and was attended by project staff, AIDSCAP and USAID Missions from Nepal and India. A few representatives of Bangladesh's condom social marketing company also participated. This was followed by the "STI/HIV/AIDS Cross-Border Intervention Workshop -- Sharing the India-Nepal Experience" held at Raxaul, Bihar in December 1997 and jointly organized by the Nepal and India projects. The participants of this meeting representing Nepal and India jointly agreed to the importance of continuing and expanding collaborative cross-border STI/HIV/AIDS prevention and services interventions at the Birgunj/Raxaul border with the support of local communities, national and regional governments and international funding agencies. Two major recommendations from the December meeting were (1) to seek information and conduct mapping/analyses of other potential cross-border sites along the Nepal-India international border, and (2) to create a local consultative board for the Birgunj-Raxaul program to serve in an advisory role, to assess program accomplishments, to serve as community advocates and to assist with strategic planning and program monitoring. The Nepal-India Consultative Board was officially established in March 1997 at a gathering at Raxaul, and a second international meeting of Nepali and Indian officials was held in Delhi in April 1997. This meeting, "Workshop on India/Nepal Cross Border Intervention Strategy on HIV/AIDS" was attended by Nepali Ministry of Health and Immigration officials and Indian Health Ministry officials, and resulted in the identification of five primary cross-border sites along the Nepal-India border. The priority sites identified included:
This meeting affirmed future cooperation and collaboration between the governments of Nepal and India on cross-border planning, program and support. Nepal/Rapid Response Fund Grants
Project Goal/Objectives Operational support for the Committee to work as an IEC advocacy body; to provide technical support; to coordinate efforts among interested agencies for IEC development and production; to publicize IEC materials through the media; and to conduct other activities related to HIV/AIDS. RRF Accomplishments This grant provided shared-support along with SAVE the Children/US to the Committee to undertake NGO IEC coordination activities started initially by SAVE/US during the AmFAR project in 1994 and later supported by AIDSCAP through the SAVE agreement. This grant provided the Committee with essential support to begin to work as an independent body serving the IEC needs of NGOs working in HIV/AIDS. Funds allowed the Committee to convene regular Committee meetings, to hold special meetings, to provide review, feedback and pretesting assistance for IEC materials submitted by NGOs and INGOs, supported an IEC material development workshop, supported Condom Day and World AIDS Day functions, and supported the development and production of the Committee's brochure.
Project Goal/Objectives The objectives of this grant were to promote HIV/AIDS awareness among the Jaycees Community as part of its annual national convention. Specifically the Jaycees wanted to:
RRF Accomplishments This grant provided support to the Narayangarh Jaycees chapter to assist in the organization of a special symposium on HIV/AIDS and STIs Prevention and Control to be held as part of Jaycees' 23rd National Annual Convention hosted by the Narayangarh Chapter of Jaycees on December 21-23, 1996. The grant provided support for Jaycees to sponsor a major HIV/AIDS advocacy campaign as part of its national convention bringing together Jaycees members from 47 chapters nationwide. In addition to IEC distribution, media programs, an information booth and other IEC messages, the grant helped to support the costs of the souvenir kitbag containing a key HIV/AIDS prevention message. On December 22, Jaycees with additional technical assistance from AIDSCAP and the National Centre for AIDS and STI Control convened a special HIV/AIDS symposium attended by over 100 participants from 36 chapters. As part of the workshop the participants were asked to prepare working plans for HIV/AIDS prevention activities they would organize in their local chapters. Given the enthusiasm and interest shown by the Jaycees members AIDSCAP and its partners were oriented to a very active and motivated segment of society through the Jaycees national network.
Project Goal/Objectives: The objectives of this grant were to support a local library to serve as a community information resource and training center on HIV/AIDS for member of the local community. RRF Accomplishments: This grant allowed a small library based in Lalgadh to host community training on HIV/AIDS to for 10 community educators, conduct STI/HIV/AIDS orientation training to 379 students from three high schools, conduct training for 16 local hotel/motel and transport industry staff, undertake local outreach by NGO volunteers, and set up a library with books, pamphlets and information on AIDS prevention. This project worked closely with the local GWP team and received direct technical assistance from LALS.
Project Goal/Objectives: The objectives of this grant were to support the development of a local NGO to develop and implement HIV/AIDS Stage Show Entertainment to be performed in adjacent communities. RRF Accomplishments: Prior to the development of the stage show scripts, the NGO team participated in a 2-day HIV/AIDS orientation training with technical assistance from GWP and LALS. Following the training the NGO developed the script, made costumes and organized show rehearsals prior to the organization of five stage shows presenting HIV/AIDS prevention entertainment during the month of November 1996. In March 1997 an additional five shows were held. An estimated 4,500 persons attended the performances. A focus group discussion (FGD) was held in April 1997 with local leaders and NGOs to gain information on local interest in the stage show entertainment. The FGDs indicated that stage shows are an effective and educational form of entertainment for the local communities.
Project Goal/Objectives The objectives of this grant were to support the continuing efforts of an organized group of high school students to conduct HIV prevention activities for younger students in their community. The student group's motto is: "Consciousness on time is the effective vaccine of AIDS". RRF Accomplishments The student forum conducted two orientation trainings on HIV/AIDS with support of the grant. One training was held for members of the Student Forum itself as well as with other students at the local Trijudha High School for a two-day program. The second training, a one-day session, was held at a local agriculture office for teachers and students. Following these orientation trainings the forum sponsored a drawing competition and a quiz contest for high school level students. The forum also provided support for the purchase of HIV informational materials for a small library in Birgunj ward 12. With supplies provided by GWP the group distributed an average of 60 condoms each month and other brochures and materials through the library. Other activities undertaken with grant funds included local HIV/AIDS activities during Dasain, Condom Day and International Women's Day.
Project Goal/Objectives This grant provided resources to the Sri Ram Yuwa Committee to support some special HIV/AIDS trainings and a Drop-in Center for local members of the community at risk. RRF Accomplishments The NGO conducted an initial HIV/AIDS community educator training for 20 persons with technical assistance from GWP and LALS. With this background the NGO organized five special trainings. Two training sessions were held for 59 barbers at two locations. Later three trainings were organized for a total of 23 persons responsible for the tattooing of local women (Godna) with traditional tattoos. NGO volunteers conducted community outreach in the local areas and a Drop-in Information Center supplying condoms and IEC materials on STIs and HIV/AIDS was initiated. The club had hoped to integrate HIV/AIDS prevention messages into locally-held literacy classes but because there were no literacy programs ongoing at that time, the NGO organized small trainings for community clubs, training 168 persons in eight separate programs in Janakpur city.
Project Goal/Objectives The objectives of this grant were to support a locally established NGO in Hetauda city to integrate HIV education into literacy classes and discussions for women in neighboring village development committees (VDCs). RRF Accomplishments Twelve community educators from four neighboring VDCs were trained in HIV/AIDS orientation with assistance from LALS and GWP. This was followed by the organizing of brainstorming sessions with local NGOs, health and social workers in four VDCs. A total of 372 participants joined these sessions. The NGO also organized rallies on Condom Day and World AIDS Day, organized street dramas at two locations and conducted a total of 30 integrated literacy classes in the four targeted VDCs. These literacy classes were attended by approximately 775 students.
Project Goal/Objectives To support an established local NGOs' integration of AIDS education and local cultural programming in rural Dhading. RRF Accomplishments The NGO initiated activities with the training of 81 students, teachers and local social and health workers on issues of HIV/AIDS in three VDCs. Those trained then initiated outreach training in 27 nearby wards for a total of three months. During month 2 the NGO launched a special HIV/AIDS folk song program. In each VDC locals were motivated to join rehearsals for folk song programs delivering messages of HIV/AIDS and STI prevention. During the following month folk song displays were held in each VDC and follow-up programs were held. The NGO found the use of folk songs to be an effective way to deliver HIV and STI prevention messages in their local communities.
Project Goal/Objectives To provide support to Nepal Medical Association to sponsor a special Symposium on AIDS and STIs at the 18th All Nepal Medical Conference held in Nepalgunj, January 21-24, 1997. RRF Accomplishments Support for NMA's 1997 conference session on HIV/AIDS and STIs provided follow-up assistance to NMA in its effort to keep the issue of AIDS and STIs highly visible among the physician community in Nepal. Over 400 delegates attended the session and papers presented by Nepal's senior venereologist and project managers included topics of STI policy, the global and national situation of AIDS/STIs, STI service integration, STI case management training of doctors, STI prevalence in asymptomatic patients, and STIs among migrant labor in western Nepal. |
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