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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 1) Study of Sexual Networking in Five Urban Areas in the Nepal Terai
Background The AIDSCAP/Nepal strategic and implementation plan identified five major urban areas and adjacent satellite towns along the Nepal-India border as the geographic focus for project interventions. As there was very little documented data on the commercial sex industry in these border areas it was necessary as a first step to conduct a rapid assessment of sexual networking in this region of Nepal. Valley Research Group was contracted to manage the study in mid-1993 and the field work was conducted from August to October 1993. The assessment report was completed in 1994. Study Goal and Objectives This study is an assessment of the current "sexual networking" in five urban areas in the Terai region of Nepal (Biratnagar, Birgunj, Bhairahawa, Dhangadhi and Mahendranagar). These sites were targeted because of a high concentration of female CSWs, the mobility of the population and their socioeconomic representation of the whole country. The objective of the study was to provide a good understanding of the beliefs, attitudes, misconceptions, and behaviors of sexually active individuals with multiple partners before the implementation of a comprehensive HIV/AIDS prevention program. The Research Methodology Data were gathered on the socio-demographic profile of the CSWs and their clients, their numbers in each area, the organization of the sex industry, the degree of knowledge and prevalence of infection of STI/AIDS, the extent of condom use and the availability of potential health educators. A selected sample of 56 CSWs, 100 clients and 80 potential AIDS educators were interviewed through open-ended questionnaires by a team of six researchers. Although the number of CSWs was estimated at around 250 in the five localities at the time of the study, their population varied according to the extent of harassment by police and local residents. Research Results The results of the study show that the average age of CSWs was 24 years, with age ranging from 14 to 41. Seventy-five percent of the CSWs had no formal education, and 50 percent came from untouchable castes. The majority of these women were of the Badi caste, which accepts prostitution as a social norm. On average the women began to engage in commercial sex at around 20 years of age. Twenty-three of the 56 CSWs were married, 48 percent were separated from their husbands or widowed, and 37 percent had children to support. The main reason given for working as a CSW was poverty, and some of the Badi CSWs were encouraged to join the profession by their parents. The majority of the CSWs worked independently (68 percent). They had an average of 13 clients per month and earned an average monthly salary of USD $48. Knowledge about HIV/AIDS was greater among the Badi CSWs (67 percent) than among the other CSWs (32 percent). Condom use was greater among the Badi CSWs because prostitution was practiced openly and accepted. Other CSWs were reluctant to buy condoms for fear of being recognized as CSWs by shopkeepers and other customers. The clients of the CSWs, were mostly drivers and conductors and married (61 percent). They knew little about HIV/AIDS and 48 percent reported that they never used condoms during sexual intercourse. Forty-six percent reported a history of STI. Misperceptions regarding STI prevention prevailed, and the majority sought allopathic treatment. The potential AIDS educators were males over 30 years of age on average. They were primarily health workers and educators and were well educated. The majority of them (76 percent) knew that the best ways to prevent HIV infection are faithfulness to one partner and use of condoms. The majority of the NGOs (65 percent) surveyed agreed to go to the red light areas to educate the CSWs and their clients, and to distribute condoms. In conclusion, the study recommended a comprehensive AIDS education program in all five surveyed areas, the use of media, the expansion of STI treatment services and condom promotion. Nepal: Condom Social Marketing
Background Heterosexual transmission has been found to be the primary mode of HIV/AIDS transmission in Nepal. An assessment conducted in 1994 (Cox and Subedi) suggested a strong link between the commercial sex industry along the major transportation routes, linking India and urban centers in Nepal, and the rapid spread of HIV/AIDS in Nepal. In order to assist AIDSCAP in achieving its goal of reducing high risk behaviors among key target groups -- especially, commercial sex workers and their clients -- The Futures Group was subcontracted to manage a comprehensive subcomponent of the AIDSCAP/Nepal program.. At the start of this project, the consumer could be confident of finding condoms in pharmacy outlets, but not in general shops. A comprehensive census of retail outlets/mapping study conducted by CRS in the Central Region (9 districts) in 1994 indicated that while 95 percent of chemist shops carried condoms, few of the cold stores and pan shops did so. In urban markets, where chemist shops are concentrated, accessibility did not present the problem that it did for the rural consumer. While the nearest general shop might be quite close -- - the corner pan shop for instance -- the nearest chemist shop might be several kilometers distant. In addition to availability and accessibility, earlier research had indicated a concern that consumers and retailers often thought of condoms as embarrassing or improper, particularly in a non-medical setting. While condoms had been promoted for many years for family planning and accepted in pharmaceutical outlets and clinics, broader acceptance of the product in less traditional settings and for the purpose of disease prevention was yet to be established. Goals and Objectives The broad goals of this component were to:
In order to accomplish these objectives, The Futures Group subagreement focused on two broad strategic areas:
Implementation Condom Sales and Distribution Futures expanded on its existing partnership with Nepal CRS Company, the SOMARC project, to market a complete array of contraceptive products, including two brands of condoms (Dhaal and Panther),. In order to penetrate the rural markets, especially along the trucking route, Futures developed a subcontract with Nepal CRS Company to conduct the following activities.
As a result of these efforts, by December, 1995, Nepal CRS Company had opened almost 3,000 new outlets for condom sales along the trucking route area, more than 90 percent of which were non-pharmaceutical outlets. The result in consumer off-take was also impressive. Whereas the target set for condom sales was 4,000,000 units by August, 1996, condom sales by December, 1995 had already reached over 4,500,000 units in the target area. The challenge for the remainder of the project was to ensure that each of these newly created outlets, many selling only one dispenser per month, continued to stock condoms. Behavior Change Communication In addition, Futures subcontracted with local professional advertising and research firms -- Stimulus Advertizers and HIMAL Research -- to develop and implement an integrated multimedia marketing communications campaign for condom promotion targeted to populations "at risk", as well as promoting condom awareness and acceptance among the general population. A 3-pronged integrated multimedia communication campaign was developed to support the project, consisting of three interrelated components, utilizing appropriate (small and mass) media for each level of intervention:
The rationale for this integrated approach was based on the body of literature around the world on HIV/AIDS prevention which suggests that efforts to target, and therefore single out, a population most affected by the virus can be counterproductive. Therefore, Component I of this communications strategy was intended to set the stage and establish AIDS/HIV as a problem for all Nepalese and to provide information on protection and prevention. Components II and III addressed communities with specific prevention needs, such as clients of commercial sex workers. In order to unify the campaign, a simple, easy to understand logo was developed to serve as the HIV/AIDS awareness campaign identifier and was used on all communications and training material by the entire project. The logo -- a condom character holding a shield and warding off the virus -- was tested to ensure that it clearly conveyed the key message of the campaign and was understood by key target audiences, both literate and illiterate. The slogan selected to accompany the logo was, "Condom Lehgau, AIDS Behgau", which roughly translates to "Wear a condom, drive away AIDS". Since even the most valuable information is more likely to be noticed and retained when it is visually appealing, enjoyable, and simple to understand, all project communication materials were designed with this in mind. To avoid confusion and to ensure focus, all materials used consistent themes and visual images and these were adapted and designed to suit the specific media. For instance:
Results These integrated media activities combined with the distribution and sales efforts of Nepal CRS Company were effective in generating awareness and acceptance of the project's key message points and increasing the availability, accessibility, acceptance and use of condoms for HIV/AIDS prevention. Specifically:
Capacity Building In addition to these "bottom-line" indicators, the project was also successful in linking a broad coalition of governmental and nongovernmental partners around a central campaign theme and strategic focus. These included HMG's National Program; a variety of NGOs working in prevention -- such as GWP, Save the Children, and LALS; private sector agencies, most especially Stimulus Advertising which developed all of the campaign materials as well as their partners HIMAL research, Sight & Sounds productions and Taranga drama troupe; media communication agencies such as Kantipur, Nepal Television and Radio Nepal, all of whom were willing to use their media to publicize the issue. Process Indicator Summary
A Baseline Study of Commercial Sex Workers and Sex Clients on the Land Transportation Routes from Naubise to Janakpur and Birgunj
Background To identify needs and establish activity monitoring and evaluation criteria, a baseline study was called for providing benchmark data on CSW and client knowledge, attitude and sexual practices related to STIs/HIV/AIDS and condom use. Study Goal and Objectives The objective of this study was to collect benchmark data on commercial sexual interactions on the highway routes from Naubise to Janakpur and Birgunj. Specific objectives included:
The Research Methodology A control area was included in the study covering the sections of the national highway west of Narayanghat to Butwal and Bhairahawa and East of Dhalkebar. A reconnaissance survey was done as a first step, to identify the study population and recognize their working sites. Altogether, 100 female CSWs and 209 clients in the study area and 62 CSWs and 103 clients in the control area were selected and interviewed. The evaluation design consisted of a pre- and post-intervention data collection in both intervention and comparison sites. A number of approaches such as mystery client, snowball sampling, mystery CSWs, intercepting and screening, self administration of questionnaires and group approach were used in order to include a broad spectrum of the target population. The study was implemented by New ERA in late 1994. Research Results The results showed that the CSWs were young with an average age of 26 in both areas. Nearly 84-93 percent were married while 57-66 percent of their clients were married in the intervention and control areas respectively. The level of education was much higher among the clients (90-93 percent) than among the CSWs (40-44 percent) The knowledge of AIDS was higher among the clients than among the CSWs. Nine out of every ten clients in both study areas had heard of AIDS while only eight out of every ten CSWs in the project area and six out of every ten in the control area had ever heard of AIDS. About one-third of the CSWs in both areas had requested that their clients use condom for sex. Among those, 60 percent in the project area and 48 percent in the control area were refused condom use by their clients. The unavailability of condoms and sexual dissatisfaction were the major reasons cited for not always using a condom. In addition, a substantial proportion of CSWs and clients with previous STIs reported no treatment. In general the sources of information about HIV/AIDS were radio, friends/neighbors, posters/newspapers and billboards. Contact with social workers was limited in both areas. A Qualitative Study of Chemist Shops on the Land Transportation Routes from Naubise to Janakpur and Birgunj
Background To complete the situation analysis for AIDSCAP interventions along the transportation routes from Naubise to Janakpur and Birgunj, a brief qualitative study of chemist shop numbers and services was added to the baseline evaluation on CSW and client knowledge, attitude and sexual practices related to STI/HIV/AIDS and condoms use. Study Goal and Objectives This study was undertaken in order to assess the quality and quantity of services provided by chemists and chemist shops to STI customers. Another objective was to identify the types of STI patients and the magnitude of chemists' counseling and dispensing practices, and to estimate the quantity of condoms sold to the STI clients. The study would also provide baseline data for planning, implementing and evaluating AIDSCAP/Nepal interventions with chemists. The Research Methodology A total of 34 chemists from 21 chemist shops in 17 small towns or municipalities on the routes from Naubise to Janakpur and Birgunj were selected and interviewed for the study. The criteria guiding the choice of the chemist shops were the shop size, the number of clients visiting the shop, and the willingness to participate in the study. Research Results Out of the 34 chemists, 13 were trained as health personnel, 8 semi-trained and 13 untrained, and all but two were male. Among the 327 STI clients served by the 21 chemist shops in the last month, 40 percent were women. Among the STI clients 67 percent complained of genital discharge while the rest complained of genital sores. A variety of drugs such as quinolones, penicillins, norfloxacin, and alkalizing agents were dispensed to the clients complaining of genital discharge. While the clients with genital sores received mostly antiseptic ointment, penicillin injections, norfloxacin, ampicillin and ciprofloxacin were also dispensed as treatment. Half of chemists said they always advised clients (use of condom 77 percent, not to visit CSWs 55 percent, danger of AIDS 55 percent).The majority of chemists (71 percent) recommended the use of a condom for pre-exposure precaution. The 50 percent of STI clients not buying the full treatment gave cost as the reason. Only 10 percent or less of STI clients who purchased drugs also bought condoms. STI Case Management Training Workshops and Education Initiatives Support for Physicians
Background Since HIV/AIDS only recently (1988) appeared in Nepal and realizing the role of sexually transmitted infections (STIs) in the potential epidemic of HIV/AIDS in Nepal, it became apparent there was a need to improve the skills of physicians, regardless of their specialty, in the management of patients with STIs. The Nepal Medical Association (NMA) was subcontracted for this purpose. Goals and Objectives An expert working group was formed to oversee project activities. Objectives included: developing a training curriculum for general practitioners presenting the STI case management approach to the diagnosis and treatment of sexually transmitted infections; implementing trainings/workshops; and disseminating information to physicians on a broader basis. Implementation The training curriculum was developed by a curriculum development subcommittee of the expert working group. The curriculum was pretested as part of a five day workshop to train local facilitators in the use of the training methodology. The final curriculum was then revised prior to the start of field training. A final training package with overheads and slides was developed and produced. Two day workshops for general practitioners were conducted at three sites in the Central Development Region, at Chitwan, Birgunj and Janakpur. Fifty private clinic practitioners participated. Evaluations of the workshops assessed the doctors' improved knowledge and skills of the management of STI patients through a pre and post test questionnaire. The results of the assessments showed significant improvements in the doctors' knowledge, but little significant change in communication and counseling skills. A supportive activity to educate a wider audience of physicians about the case management approach to STI treatment in Nepal included the development and publishing of two informative articles in the Nepal Medical Association's quarterly journal. One was published in July 1995 and the other in October 1995. To reach a further audience of physicians in Nepal, an additional program on "STIs in Nepal" was organized as part of NMA's 17th All Nepal Medical Conference held at Butwal. Recommendations It is recommended that further efforts continue in promoting STI case management. Nepal's general practitioners need to be trained in communication and counseling skills and these doctors should be encouraged to maintain records of their experience with the management of STI patients. The dissemination of information on STIs and STI management needs to be further strengthened among the physician community. Process Indicator Summary
Outreach Education to Commercial Sex Workers and Clients/Transient Population Groups in Central Nepal
Background Baseline studies identified commercial sex workers (CSWs) and their clients as most vulnerable to HIV/STI infection in Nepal. AIDSCAP therefore developed an HIV prevention project targeting sex workers and transient groups along the major highways of Central Nepal. Strategic components were behavior change communication, condom use and availability, and STI management. AIDSCAP worked with several implementing agencies, complementing each others interventions in the project communities in 9 districts of the Central Region of Nepal. Established in 1992, General Welfare Pratisthan (GWP) is a nonprofit nongovernmental organization which started with work in social development, including HIV prevention amongst truckers and their sex partners. On the basis of its experience, strong commitment towards STI/HIV prevention and control, and institutional strength, AIDSCAP/FHI subcontracted with GWP for outreach education and community mobilization in the target communities and areas. Scope of Work The purpose of the GWP project, "Outreach Education to Commercial Sex Workers and Clients / Transient Population Groups in Central Nepal". was to reduce high risk sexual behavior among CSWs, their clients and other transient population groups in order to reduce the rate of sexually transmitted STI/HIV infection along Nepal's major transport routes in the central region. The project had four objectives.
Project Implementation Management Amendments in the subagreement accommodated for necessary modifications in budget, timeframe, staffing levels and LogFrame. Besides the central GWP office, 5 outreach teams and offices were established in the project areas, with one field office for day to day management. Technical assistance for capacity building of the GWP outreach staff was provided by Lifesaving and Life-giving Society (LALS) through regular on-site and central training, and the through Nepal country office. Accomplishments GWP has been playing the dual roles of undertaking the outreach intervention as well as enhancing the peer education capacity of the target communities. The major accomplishments at the end of the project include:
Constraints The main constraints experienced by GWP in the process of the outreach intervention are as follows:
Findings and Results The outreach intervention proved to be an important component for reducing high risk sexual behaviors. Quantitative indicators are the following, derived from internal assessments and the New Era baseline and follow up studies:
Besides, the effectiveness of the outreach intervention is indicated by the increasing demand of the target groups and the local community groups and organizations, and the many case studies in the field which indicate that people not only increased their knowledge, but more importantly changed their own and each others attitudes and behaviors. Lessons Learned/Recommendations On the basis of lessons learned during the implementation of the project, about effective HIV/AIDS/STD prevention and control, GWP has the following recommendations: As STDs are closely attached with HIV/AIDS, the STD component should be closely associated with the intervention activities:
Process Indicator Summary
Nepal Short-term Technical Assistance to Prepare Marketing Plan for Prepackaged STI Therapy
Background Population Services International (PSI) was identified as the partner to provide technical assistance should AIDSCAP/Nepal implement the proposed STI Prevention Marketing Pilot Project in Nepal. A PSI consultant visited Nepal in June-July 1996 to develop a marketing plan that identified elements necessary for the promotion and distribution of prepackaged STI therapy kit and an accompanying IEC campaign on STI prevention. The report was designed to assist AIDSCAP decision-makers in assessing the feasibility of an STI Prevention Marketing-Pre-Packaged Therapy Pilot Project to be implemented in Nepal during the final extension year of the AIDSCAP/Nepal project. The plan also undertook to provide recommendations for resources required to launch such a major new initiative. Project Goal and Objectives The objectives of this task order were: 1) to begin the solicitation of interest process that would identify a social marketing agency with whom to develop and market the PPT kit; 2) to conduct research for the development of:
3) to generate an overall consumer marketing strategy for the PPT kit; 4) to assist in the development of a protocol to assess the perception of the kit by providers and consumers at the close of the pilot project. Accomplishments PSI produced a final report on the feasibility of an SPM/PPT project in Nepal. Recommendations for project implementation were provided for the following areas: project design, marketing protocol, identification of social marketing organizations in Nepal, pricing, product contents, training and orientations, distribution, promotion and advertising, PPT workplan and PPT budget. The report also included a summary of organizations and individuals suggested to oversee and implement the research component of the project. Findings and Recommendations As a result of this feasibility study, PSI recommended that AIDSCAP undertake the SPM/PPT project in Nepal. Lessons Learned and Recommendations Implementation by AIDSCAP was only feasible through Nepal CRS Company. However, at the time, Nepal CRS Company was unable to carry out its basic social marketing services. As a result the proposed subproject was not funded for implementation in Nepal in 1996. Human Resource Development Assistance and HIV/AIDS/STI Outreach Training to General Welfare Pratisthan, Phase I
Background Established in August 1991, the Lifesaving and Lifegiving Society (LALS) is a nonprofit nongovernmental organization which primarily commenced its work with Injecting Drug Users (IDUs) and their sexual clients at the street level in the prevention of HIV/AIDS using a street-based, harm-reduction outreach model. On the basis of its outreach experience, AIDSCAP subcontracted LALS to provide human resource development technical support to General Welfare Pratisthan (GWP) by training their outreach staff and assisting them in developing peer educators. GWP manages the AIDSCAP project, "Outreach Education to Commercial Sex Workers and Clients/Transient Population Groups in Central Nepal." Outreach intervention requires manpower with the knowledge, skills, attitude, and experience to influence the changes in behavior of the target people. Implementation
Achievements Six male and six female outreach workers and four supervisors were trained in STI/HIV/AIDS awareness and communication skills followed by monthly inservice trainings. Materials developed included:
Process Indicator Summary
STI/HIV/AIDS Prevention Education Strengthening Initiatives for Chemists and Alternative Health Care Providers
Background More than of 90 percent of Nepal's twenty million population live in rural areas. There are approximately 1,500 registered doctors, i.e. a ratio of 13,333 population per doctor. But 99 percent of Nepal's doctors live in urban areas. Health posts provide primary services delivered by paramedics and nurses, but the ratio is one health post for 25,500 people. In urban areas a large number of chemists operate shops, whereas in village communities with no formal health services, there is usually at least one chemist shop in operation. In many communities the chemist shop serves as the only source of health care. Chemists shops are easily available, economical and provide timely service. The chemist is often the first and only point of encounter for modern health care in a Nepal village. The collective forum for chemists is Nepal Chemists and Druggists Association (NCDA). The NCDA conducts an orientation training program for drug retailers and wholesalers that provides basic information on common use of drugs, drug interactions, good dispensing practices, doses of drugs and side effects. But this training does not address Sexually Transmitted Infections (STIs) or HIV/AIDS. Goals and Objectives The goal of this project was to strengthen the role of chemists and alternative health care providers as prevention educator and condom promoters. The objectives were:
Implementation A Technical Advisory Group (TAG) was identified consisting of technocrats, bureaucrats, trainers, chemists and experts on health issues to serve on a steering committee for this project. The TAG formed a Curriculum Development Committee (CDC) to develop, in collaboration with NCDA, a draft curriculum for chemists and health providers on STIs/HIV/AIDS. Using the Nepal Medical Association STI Case Management training package as a base, the CDC began development of the curriculum specially for chemists. Because of the number of meetings required, the project coordinator drafted the curriculum in consultation with AIDSCAP and the STI Technical Advisor. The CDC finalized the curriculum and presented it to the TAG which approved it. The initial draft curriculum was in English, and later translated into Nepali for chemists in rural areas. The draft curriculum was first pretested with chemists and health providers from Pokhara (outside the intervention area). Three master trainers were then selected to conduct a residential 4-day training of trainers (TOT) in Nagarkot for 18 novice trainers from different parts of intervention area. The training and technical consultants assisted the Master Trainers. Ten field trainings for chemists from Dhading, Chitwan and Makawanpur were held in early 1996. The trainings were conducted by the coordinator, the core master trainer team and a novice trainer from the local area. An STI specialist served as the primary trainer for the syndromic approach in the majority of sessions. Feedback and lessons learned from the first TOT and the ten field trainings were incorporated in revisions to the training curriculum. Then a second 4-day residential TOT was held to develop the skills of 14 newly identified, potential novice trainers from parts of the intervention area not yet approached. Following the second TOT, the NCDA began a second phase of trainings in the districts from Makawanpur to Dhanusha. Due to the high demand for trainings one additional training was added to the budget through amendment. A total of eleven two-day trainings were held with 317 participants (97 percent male, 82 percent chemists, and 18 percent health care providers. During field training it was discovered that participants were sometimes confused about genital ulcers and discharges. So a slide presentation was developed on urethral discharge in men, vaginal discharge in women and genital ulcers in male genitalia and female genitalia had been shown. The slide session became the most interesting session for the participants. Results At the conclusion of the project in December 1996 the NCDA had trained a total of 631 chemists and other health providers through 22 field trainings in the Central Region. Of the total 10 percent were female and 21 percent also served as health providers in their communities (of the 192 health providers 70 percent were government service holders). Four trainers became master trainers and thirty-two zonal NCDA leaders participated in the TOT. The master trainers conducted ten field trainings from Naubise to Hetauda. Of the 262 trained, 21 percent were female and 79 percent male; 52 percent chemists and 48 percent health care providers. Training participants were provided with quantities of an STI/HIV/AIDS information brochures to distribute directly from their shops. Also an acrylic stand was provided to display the brochures. "STI/HIV/AIDS: Chemist and Community" was written from this project and published in the November 1996 issue of the British journal Reproductive Health Matters. Sixteen articles on STIs/HIV/AIDS in Nepal were published monthly in the NCDA bulletin To measure the impact of NCDA's pilot intervention, AIDSCAP and NCDA worked with New ERA to implement a post training impact study in late 1996 (FCO 54428) measuring changes in chemist dispensing practices. A pre-training baseline study (FCO 57425-2) had been conducted in 1995. The impact study results showed that:
For NCDA a project of this kind was new and the people involved were also working with HIV/AIDS issues for the first time. So, the lessons that we learned may not be lessons for others.
Process Indicator Summary
Nepal STI/HIV/AIDS Coordination and NGO Technical Support
Background The realization that Acquired Immune Deficiency Syndrome (AIDS) and Sexually Transmitted Infections (STIs) pose a major threat to Nepalese society caused a vast expansion of agencies involved in Human Immune-Deficiency Virus (HIV) and AIDS prevention activities over the past 3 years. During this time, problems emerged with coordination of activities and in quality control over project outputs. Goals and Objectives This project utilized Save the Children US's extensive experience in AIDS programming and in making strong institutional linkages with Nepali nongovernmental organizations (NGOs) to provide technical assistance and to enhance coordination and linkages among agencies who had been involved in HIV/AIDS prevention activities. This project expanded the geographical focus of the AIDSCAP/Nepal strategic plan beyond the Terai Central Development Region to include Kathmandu Valley and other development regions of Nepal. The purpose of this project was to enhance the capabilities of participating Nepalese NGOs to effectively implement STI/HIV prevention education and condom social marketing programs and to coordinate programs. At the output level, specific objectives of the project were:
Achievements This project was successful in bringing the NGOs closer in their work. Altogether, 12 NGOs collaborated 88 times for the IEC program and a total of 28,000 copies of various materials were sold though the committee mechanism by the NGOs. Although the six month project was lengthened into a total duration of 13.5 months, all the projected activities mentioned in the subgrant were successfully accomplished. In total 14 IEC Coordination Committee meetings were held and 43 different materials were reviewed. Four of these materials received intensive technical inputs from SC/US. In order to facilitate collective printing of materials and reduce unit costs, a material production plan was disseminated to 40 organizations. Through this project, HIV prevention counseling got a more formal introduction in Nepal. The printing of both English and Nepali versions of the HIV prevention training manual received wide applause from both NGO/INGO and government circles. The integration of the counseling checklist, supervision form and village risk advisor into the training manual is expected to have long term impact in these areas. Recommendations It is critical that technical and resource agencies continue to support and follow-up on fledgling counseling services that are just beginning to become a part of HIV/AIDS prevention programming in Nepal. This follow-up support should take place both at the central and field levels. Process Indicator Summary
A Baseline Study of Sexually Transmitted Disease (STD) Services Provided by Chemists in the Land Transportation Routes From Naubise to Janakpur to Birgunj
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 began in late 1995 prior to the startup of NCDA field trainings. Study Goals and Objectives This was a baseline quantitative survey of chemists' dispensing practices prior to the implementation of the NCDA training. The objectives of the study were to examine how chemists served individuals presenting themselves with urethral discharge, to provide information that would assist the NCDA in revising and strengthening its core training curriculum and materials, and to provide benchmark evaluation indicators. 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 during the period from early December 1995 through early January 1996 in the AIDSCAP project area. Research Results The results show that 81 percent of the chemists recommended medications to treat the STI. Only 0.8 percent of the chemists suggested the correct medications and correspondingly correct dosages for urethral discharge. Only 14 percent of the chemists suggested condom use to their patients, and 5 percent suggested partner treatment. Only three percent of the chemists advised their patients to consult with a physician if not cured by the recommended STI treatment. The average cost of the suggested medications was Nepali rupees 193 the cost of the appropriate medications was only Nrs 119. Human Resources Development Assistance and HIV/AIDS/STI/Outreach Training, Phase II
Background Phase I of the Human Resources Development Assistance and HIV/AIDS/STI/Outreach Training project was implemented between October 10, 1994 and October 31, 1995. Phase II builds on the Phase I accomplishments in developing management and training skills of General Welfare Pratisthan (GWP) staff for STI/HIV/AIDS outreach education focusing on peer education and targeted interventions. Goals and Objectives The objectives of Phase II of this project were:
Accomplishments Peer Educator Facilitators Training: Peer educator facilitators training curriculum, and materials were developed. These were used in training workshops for outreach staff on identifying, recruiting, training, supporting and sustaining peer educators for STI/HIV/AIDS. Peer Education Training: Designed a peer education training package. LALS and GWP worked together in orienting and training peer educators/potential peer educators. More than 300 people were trained in 15 workshops. Inservice Session: Inservice sessions on outreach and field issues were provided during field visits. Whenever necessary, new training modules were designed. Specialized Counseling and Interpersonal Communication Training: A training course was designed and conducted to develop the counseling and interpersonal communication skills of staff during the project 10 month period were from GWP, FPAN, CRS, Taranga/Stimulus, and BAP/India. Orientation of the Outreach Staff on STI Case Management: Orientation was provided so that all outreach staff would be able to identify STI patients, explore their STI case history, refer them to the appropriate STI treatment centers, and provide STI prevention education and follow-up to the STI treatment. Syndromic STI Case Management Training: LALS organized and managed training for paramedical staff of GWP and Chitwan FPAN STI clinic on syndromic STI case management. All outreach staff were provided the basic concept of the syndromic approach of STI case management. Orientation, Outreach Education & Behavior Change Communication Training: The training was designed and conducted for the outreach staff who joined the project after the first orientation training at January, 1995. All new staff of GWP who joined the project at a later stage and the field staffs of CRS, FPAN, and Taranga Street Drama were also trained. Reorientation was provided for those trained in January 1995 International Study Tour: LALS planned, co-coordinated, organized and managed an International Study Tour to STI/HIV/AIDS projects in Calcutta/West Bengal of India for GWP/LALS/NCDA/CRS staffs in February, 1996. Field Visits: LALS paid regular visits to field-based outreach education sites, overseeing and monitoring the outreach activities, often participating in outreach interventions together with the field staff. The field visits by LALS included diagnosing the needs and carrying out non-formal, field-based practical trainings, inservice sessions and exercises. LALS developed field visit checklists for LALS staff. Coordination and Networking Activities: Regular and direct communications with the GWP management helped both LALS and GWP in reviewing, planning and implementing the activities. The communication with AIDSCAP was maintained through meetings and reports. Documentation and Reporting: The documentation and reporting was an important component of informing GWP, AIDSCAP and interested agencies about the status of project activities, awareness of problem situations and the process of improvement, and accomplishments. Unanticipated Accomplishments: Accomplishments not defined by the scope of work: Village Risk Advisor: The Village Risk Advisor, the HIV/AIDS risk assessment and counseling tool designed in collaboration with PATH was improved and translated into Nepali language. The tool was adapted for inclusion in the counseling manuals produced by GWP/AIDSCAP and Save/US. All GWP field staff were trained in the use of the tool. Cross Border Program: Worked with GWP in cross border program Bhoruka/Raxaul. Basic Orientation on STI/HIV/AIDS Outreach Education/Behavior Change Communication: The basic orientation on STI/HIV/AIDS Outreach Education & Behavior Change Communication was organized by LALS in May, 1996 for the GWP, CRS, FPAN, and Taranga staffs at the request of participant agencies and AIDSCAP. Trainings for RRF Recipient NGOs: LALS/GWP staffs were involved in orienting and training NGO staffs to implement Rapid Respond Fund (RRF) activities. The RRF encouraged linkages and integration of STI/HIV prevention initiatives into NGO ongoing community programs. Rapid Internal Assessment of GWP/AIDSCAP Outreach Intervention: To measure the effectiveness of the GWP strategy, process, outcome/impact, a rapid internal assessment of outreach intervention was undertaken. LALS provided technical support in designing, preparing, undertaking, interpreting, and analyzing the study. 24 CSWs and 105 CSWs' clients were interviewed. Recommendations
Process Indicator Summary
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