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Final Report for the
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Table of Contents I. Executive Summary (See Below) II. Background and Country Context III. Country Program Description A. Introduction Executive Summary In late March 1993 a total of 188 persons with HIV infection had been reported to His Majesty's Government's (HMG) National AIDS Prevention and Control Project (NAPCP). As of January 1997 the National Centre for AIDS and STD Control (NCASC) officially reported 480 HIV infections; this increased to 647 as of mid-1997, with 136 cumulative AIDS cases. While no specific studies were available to estimate how incomplete, inaccurate or delayed the official reports might have been, given the limited HIV/AIDS surveillance system in place, the actual number of AIDS cases might have been 5 to 10 times the reported number and the actual number of HIV infections prevalent in Nepal might have been 20 to 30 fold greater than the detected number. As of early 1997 it was projected that there were from 15,000 - 20,000 HIV infected persons in Nepal with a large proportion (up to 50 percent) of those infections acquired in India. Although the actual number of infected persons was estimated to be much higher at the start of the AIDSCAP Project, it appeared that Nepal was in its early stages of the global HIV/AIDS pandemic. This situation presented a real opportunity to contain the spread of HIV infection with a series of targeted interventions in selected areas and among populations at risk. At the request of the USAID Mission in Nepal, an AIDSCAP team visited Nepal to review the HIV/AIDS epidemiological situation and propose a series of interventions for USAID support. A strategic and implementation plan to conduct a comprehensive set of interventions targeting high risk behavior among commercial sex workers (CSWs) and their clients. In August 1993, A Memorandum of Understanding between USAID, NAPCP and Family Health International's (FHI) AIDSCAP project was signed launching USAID's commitment to support a series of prevention interventions to be managed through AIDSCAP. The goal of the project was to reduce the rate of sexually transmitted HIV infection in Nepal's Terai region. The project purpose was to reduce sexually transmitted infections (STIs) among core groups in this region through the following HIV/AIDS control strategies:
The interventions were planned to be integrated and coordinated with HMG's Medium Term Plan and implemented primarily through a series of subagreements with non-governmental organizations, associations, and private sector firms. In addition to the project's primary interventions the strategy called for policy and condom initiatives which would have a national impact. The strategic plan was initially supported by USAID, with special HIV/AIDS program funding from USAID's Asia Near East Bureau, and later support coming directly from USAID/Nepal Mission funds. Prior to the design and startup of project interventions, AIDSCAP/Nepal initiated a formative research study, Sexual Networking in Five Urban Areas in the Nepal Terai to confirm the need for the planned targeted interventions, the targeted groups and the project's geographical focus. The rapid assessment highlighted the realities of an underground commercial sex industry in the border areas and the high mobility of CSWs and client demand along Nepal's major transport highways leading to India. The AIDSCAP project strategy was then adapted to focus on a Central Region project area covering 435 kilometers of highway from Naubise to Janakpur and Birgunj -- adjacent to the nation's primary access route and urban centers leading to and from India. AIDSCAP's primary target populations were individuals at highest risk: women engaging in commercial sex and men engaging in high-risk sexual practices, particularly transport workers, migrant laborers, businessmen, military, police and campus students. In early 1994 AIDSCAP initiated subproject development, and launched a series of mutually-reinforcing STI/HIV/AIDS interventions with non-governmental organizations, associations and private sector partners. Over the four years of the project, NGOs and private enterprises, with the assistance of AIDSCAP, strengthened their capacities in mobilizing communities in the fight against AIDS through enhanced training, media and materials development, sales promotion and management. Significant accomplishments included:
Increasing Access to STI Services In an effort to ensure access to effective STI services for patients at the first point of encounter with service providers, AIDSCAP worked to strengthen service delivery in the private sector with three partners: Nepal Medical Association (NMA), Nepal Chemists and Druggists Association (NCDA) and Family Planning Association of Nepal (FPAN). The NMA developed the first training curriculum for general practitioners in the STI syndromic management approach and trained 50 physicians in the project area. The NMA training package was specially adapted to suit the needs of local, community chemists serving patients in rural chemist shops. The NCDA trained 631 Central Region community chemists and health care providers in a 2-day basic STI prevention education curriculum. The NCDA also trained 32 chemists as novice trainers to assist with training sessions and follow-up programming through the NCDA zonal branches. FPAN's static family planning and maternal-child health clinic in Bharatpur, Chitwan was the site of FPAN's first pilot to integrate STI services (using the national STI case management guidelines) into a well-established family planning and health services clinic. In early 1997, FPAN expanded existing branch services in Hetauda and Janakpur to also include women's clinical health services. FPAN's experiences have demonstrated the fact that a minor investment in facilities and staff skills development can provide accessible and available, low-cost reproductive health services to marginalized women, housewives, unmarried women and their partners in the Central Region. Condom Expansion and Promotion In a concerted effort to increase the accessibility and demand for condoms -- particularly for STI/HIV disease prevention, AIDSCAP partnered with four private sector agencies. In collaboration with The Futures Group International's (TFGI) Social Marketing for Change (SOMARC) project, Nepal Contraceptive Retail Sales (CRS) Company Ltd. worked hard to expand its retail sales base beyond the traditional chemist sales outlets to include nontraditional outlets in tea shops, restaurants, lodges and general goods shops adjacent to the highway and in key urban areas. CRS later provided specialized trainings and sales promotions and incentives to the nontraditional retailers. As of mid-1997 CRS marketed condoms through 2,149 new nontraditional outlets in the project area, and reported an increase in condom sales from nearly 700,000 units in 1993 to over 1.5 million in 1995 in the project area. The increased demand for condoms was clearly influenced by a Kathmandu-based advertising firm, Stimulus Advertiser (P) LTD's, complementary condom promotion and communications interventions jointly planned with CRS, TFGI and AIDSCAP. In mid-1995 Stimulus launched a specially designed and tested national and regional "HIV/AIDS Awareness and Condom Promotion Multimedia Campaign". Based around a campaign logo and slogan, an animated condom character, Dhaaley Dai, encourages individuals to use condoms to drive away AIDS in a rhyming message: "Condom Lagau AIDS Bhagau." The second highlight of the campaign was the Guruji Ra Antare story featured in an enter-educate videodrama, street drama and comic book. In the Central Region the Dhaaley Dai and Guruji Ra Antare messages are promoted on signs, through live street drama, on national radio, on a television public service announcement, on banners, in local cinema halls, and through community activities implemented by General Welfare Pratisthan (GWP) outreach staff. Over 50,000 people in local communities attended CRS's videovan shows held monthly in the Central Region. Seventy-nine percent of CSWs and 93 percent of clients questioned in the Central Region could recall the campaign slogan. Behavior Change Communications The core of AIDSCAP's behavior change communications (BCC) strategy was to reduce the rate of sexually transmitted STI/HIV infection among CSWs and clients through targeted communication-change interventions. General Welfare Pratisthan (GWP) with technical assistance from Lifesaving and Lifegiving Society (LALS) managed a unique field-partnership to develop and implement community-based outreach education throughout the Central Region. Working in highway halting points along the 435 kilometer route, in urban centers, small communities and at the Birgunj-Raxaul border, GWP outreach education staff provided direct, interpersonal outreach to difficult-to-reach women working as sex workers and other marginalized women with multiple sex partners. At the same time the staff targeted a range of mobile clients including truck drivers, their assistants, military, police, students, migrant workers and other local groups with messages promoting condom use and safer sexual behaviors. Outreach staff of GWP and LALS achieved over 2,600 CSW and 36,500 client contacts. Among CSWs in the project area, 61 percent reported using a condom with their last client, compared to only 35 percent prior to the startup of outreach activities. As GWP staff demonstrated enhanced confidence and skills, NGOs began peer education initiatives with interested and motivated leaders from the target communities. Due to the conservative nature of the Central Region population, peer education was challenging; however, the experiences of delivering messages into the heart of the target communities was a most effective way to disseminate long-lasting prevention messages. To improve BCC effectiveness more efforts are needed to gain community ownership and participation in HIV/AIDS prevention planning and implementation. A talk radio program "CRS Hotline" was broadcast weekly on Kantipur FM radio. A health, AIDS or family planning expert fielded direct phone-in questions with most inquiries coming from adolescents. A 49-minute videodrama, "Asha" (Hope) along with complementary videofillers and radio messages were launched in April 1997. The "Asha" film debuted on national television on July 15 with the support of local private-sector sponsors. In the final year of the project, Stimulus Advertizers expanded its media strategy beyond prevention messages to touch on timely messages about people living with AIDS. Complementing targeted media messages with accessible condom products appeared to have a clear impact on condom demand in the Central Region. Process Indicator Summary
Lessons Learned and Recommendations
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