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This report comprehensively summarizes the FHI/AIDSCAP program in Rwanda (1993-1997). The report includes a discussion of background and context, as well as accomplishments, constraints, implementation and management issues, outcomes, and lessons learned and recommendations for each of two components.
Table of Contents I. Country Program Description C. Accomplishments and Outcomes
D. Implementation and Management Issues II. Lessons Learned and Recommendations III. Refugee Intervention in Tanzania IV. Subproject Highlights I. Country Program Description (continued) C. Accomplishments and Outcomes 1. Introduction When AIDSCAP's project activities were suspended in 1994, the AIDSCAP Country Office was fully operational. A expatriate Resident Advisor and an expatriate research specialist were in place as were the necessary local staff. Two subprojects were active; a subagreement and a task order being implemented by CARE and PSI, respectively. The subproject being implemented by CARE in eastern Rwanda had as its goal the reduction of the rate of increase in incidence of sexually-transmitted HIV in Byumba and Kibungo Prefectures through community-based intervention activities intended to reduce high-risk sexual behavior among targeted groups. The PSI Task Order was putting into place a nationwide condom social marketing program and was exceeding performance expectations. With AIDSCAP funding, PSI was expanding its social marketing operations to all urban centers. Three additional subprojects were under development and would have shortly been finalized. These included a BCC intervention with the Centre d'Information, de Documentation et de Counselling (CIDC), a subproject emphasizing STI case management using the syndromic approach with the Gitarama Health Region, and a capacity-building intervention with PNLS. In addition, a major intervention was planned to upgrade the clinical management of STIs in the city of Kigali. This was to include support to the Bilyogo Health Center as a practical training site for clinicians from other Kigali health centers. Rapid response funds (RRFs) were to be used to support Bilyogo's risk-reduction work with commercial sex workers. Other planned STI interventions included close collaboration with the Rwanda Integrated Maternal Health Project (RIM). Adoption of national guidelines for the management of STIs was considered a prerequisite for the upgrading of STI case management, as called for in both the RIM and AIDSCAP implementation plans. Operational research (OR) on the feasibility of using the syndromic approach to STI management was well underway in two RIM pilot clinics. Results of the OR were to be used to finalize primary care diagnostic and treatment algorithms for national use. A modified version of the algorithms used in the RIM pilot clinics was being adapted by the PNLS in collaboration with WHO/GPA, and negotiations were underway with the Belgian Cooperation for the supply of STI drugs. Development of training materials and training sessions were planned for the second half of the year. By April of 1994 work was well underway on the targeted intervention research (TIR), an ethnographic study of beliefs surrounding sexually transmitted diseases, and the University of Butare had been selected under the Thematic Grants Program to receive funds for a study on "Condom Use Promotion Among Men in Butare". In addition, CARE International, in collaboration with ACORD and the Protestant Council, submitted a proposal for expanded AIDS prevention activities in eastern Rwanda, to be funded under the Competitive Grants Program. Award of funds and commencement of project activities had been projected for June 1994. Human and financial resource constraints after the war called for a scaled down version of the AIDSCAP/Rwanda Program. The comprehensive targeted interventions, using the three-pronged approach of behavior change communication, increased accessibility and availability of condoms, and upgrading of STI services at clinics sites in selected population centers were retained. The behavioral research component was canceled as well as the nationwide KABP survey, which was to be implemented in concert with another USAID-funded project. The new proposed AIDSCAP/Rwanda management structure called for the deputy resident advisor to assume duties as Resident Advisor with close backstopping from AIDSCAP/Nairobi to rebuild the program in the shortest possible time. The program was officially re-launched on World AIDS Day with an intense fourteen-day mass media campaign implemented by CIDC with support from the country office. The theme "AIDS is still here despite the war" was supported by a poster, a radio cassette with AIDS prevention songs, and brochures. AIDS messages were broadcast from the back of a van where people could also get additional information, leaflets and condoms. Interviews and discussions focusing on HIV/AIDS prevention and condom use were aired on radio and TV stations in Kigali. Over the next couple of months, the AIDSCAP country and regional office staff worked intensively to prepare the necessary agreements and conduct preliminary training for subproject staff to effectively implement their respective activities. Key to the success of the AIDSCAP Program in Rwanda under the new government was support to the Ministry of Health through the PNLS to strengthen its ability to coordinate and monitor national AIDS prevention efforts. In addition, the adaptation of national STI treatment guidelines was crucial to implement the STI control program using the syndromic approach. In this last effort, AIDSCAP collaborated closely with the WHO, while the UNDP was providing technical assistance in IEC and organizational development to the PNLS. During the post-conflict period, starting December 1, 1994 through April, 1997, seven subprojects were completed: three with the Ministry of Health in collaboration with the PNLS, the Ministry of Defense and the Medical Health Region of Gitarama, two with the Centre d'Information, de Documentation et de Counselling (CIDC), and two with international NGOs. In addition RRFs were provided to four indigenous NGOs in Kigali for discreet interventions. 2. Accomplishments and Constraints The greatest post-conflict accomplishment was the speed with which AIDSCAP with assistance from USAID/Rwanda provided financial and technical support to reintroduce AIDS prevention activities to the population of Rwanda. It should be noted that given the difficult post-conflict situation, no other US development agencies were allowed or even ready to reinstate activities so soon after the war. The NGO community and the UN agencies were concentrating on emergency relief, including providing food, shelter, clean water and medical care as well as rebuilding of the country's infrastructure. The greatest constraints were the difficulties associated with the war. Civil war plagued the country intermittently from 1990 until mid-1993, when peace accords were signed between the warring factions. The events of April 1994 left the country and personal lives in shambles. Staff members of AIDSCAP and all of its implementing partners lost family, friends, and fellow staff members in the genocide that followed. One cannot overemphasize how difficult it was to restart project activities in such an environment of dramatic human suffering and loss. In addition, CARE, CIDC and PSI lost equipment of significant value including computers, audiovisual equipment, and vehicles. Neither CIDC nor PSI were able to reoccupy their previous offices, however, CIDC was able to find and reclaim some project documents and records, and PSI recovered over 100,000 Prudence condoms in their warehouse. The AIDSCAP office was found intact after the war, and space previously occupied by the RIM project was allocated to CIDC and PSI. Behavior Change Communication (BCC) Behavior change communication efforts constituted an important part of AIDSCAP's activities in Rwanda. A communication strategy promoting the modification of high risk behaviors at the individual and group levels and change in the associated social norms was central to the success of the AIDSCAP/Rwanda Program. The AIDSCAP behavior change and communication component in Rwanda took a dual strategic approach: national-level activities in developing and producing communication materials and programs, as well as integrated interventions at selected population centers emphasizing interpersonal communication with AIDSCAP target audiences. This strategy included risk assessment and behavior modification, consistent and proper use of condoms, reduced number of sexual partners, STI recognition and treatment, and partner notification. Examples of effective integration and reinforcing channels for behavior change communication included IEC and training strategies provided by the combined projects which worked through the PNLS, health educators, retailers, military health practitioners, women's associations, and community based condom sales/promotion agents. Training materials for STI/AIDS, as well as extensive IEC materials, have been continuously customized and refined according to the findings of ongoing qualitative research. Different materials have been developed and/or translated into the local language and made use of by various implementing partners. Because IEC efforts have constituted an important part of most AIDSCAP projects, behavior change materials have been carefully researched, tested, and refined. Formative research has been an important component of the country program and was conducted extensively by CIDC and CARE International. Materials and Messages Development CIDC was selected as the lead organization for the development of IEC materials and mass media communication in Rwanda. In this role, CIDC worked closely with the IEC unit of the PNLS and the other AIDSCAP implementing agencies. Inventory of Existing Materials As a first and important step, CIDC comprehensively documented, evaluated, and catalogued all IEC materials existing in the country prior the war. After such intense disruption, it was necessary to literally take stock, and to begin to piece together an IEC materials resource center. This assessment, which included a great deal of groundwork in locating various materials produced by different agencies, was clearly an effort of significance. All the agencies who had produced IEC materials were visited and information was compiled on type, language, target group, availability, etc. A comprehensive inventory of IEC materials was established, including posters, pamphlets, brochures, booklets, flip charts, slides, billboards, calendars, and audio and visual cassettes. This inventory provided an important baseline and reference point for the post-war development of IEC materials in Rwanda. For example, the 1995 inventory documented that at that time, there were no IEC materials specifically targeting the military, a large high-risk group in Rwanda, nor was there sufficient material for illiterate people. Training As part of the materials and messages development process, CIDC organized training and completed a variety of discrete studies to document, refine and inform their IEC efforts that complemented the objectives and activities of most other subprojects. In preparation for qualitative research to be conducted prior to the development of new materials and messages, a Formative Research Training was conducted in April 1995 for IEC and BCC officers from CIDC, PNLS and the Medical Health Regions of Kigali and Gitarama. Eleven officers were trained in Focus Group Discussion techniques, data analysis and report writing. Using the results of the FGDs held during this training and the results of the assessment and evaluation of existing IEC materials, a two-week IEC materials development workshop was held in September 1995 for 21 IEC officers representing CIDC, CARE International, PSI, the Gitarama and Kigali Health Regions, the PNLS and the Military. PATH, an AIDSCAP subcontractor, was the lead training agency, and it developed a Rwanda-specific training manual, consisting of seven modules addressing the theoretical and practical aspect for the development of appropriate materials and messages. Formative Research Following the training, formative research was conducted among the selected target groups. Focus Groups were conducted by CIDC among single women, married women and young adults. The formative research focused on "Appropriate IEC Strategies for Women in Rwanda". The objectives of this study were to gain an indication of the levels of knowledge of STIs and HIV among women, to identify those factors which influence the effectiveness of behavior change, to identify messages which respond to the needs of women, and to identify appropriate means that will permit women to more easily participate in STI/HIV prevention activities. This study constitutes an excellent piece of ethnographic research on single, married and widowed women in Rwanda, and the ways in which they can best be served by HIV/AIDS prevention activities. This study involved extensive use of data generated by focus group discussions. CIDC has done a commendable job of providing the appropriate formative and operations research results to help all the various implementing partners to better understand specific target groups and other sociocultural contexts within which activities have been implemented. By way of focus group discussions and ethnographic research, specific target groups have been carefully assessed and described in terms of their most important social, cultural, and economic characteristics. Messages designed to promote condom use, to influence sexual behavior and the associated social norms of each group have been adapted to these characteristics. CARE also put a tremendous amount of effort into informing their IEC/BCC efforts by way of focus group discussions. Sixteen different focus group discussions with a total of 144 single women and 30 focus group discussions with a total of 280 rural, urban, and semi-urban youth were conducted. Subjects explored include their reactions to various kinds of materials, determination of risk perception, perceptions of social norms, and self-efficacy, or the belief in one's ability to determine a course of action. CARE also teamed up with a local NGO, l'Association Rwandaise pour la Bien-Etre Familial (ARBEF), to conduct qualitative research for the design and development of a dramatic script for a package of new IEC materials: a video, comic book and radio soap opera. PSI also conducted FGDs as part of their market research to pre-test and evaluate advertising and promotion campaigns. Audience Research CIDC conducted audience research (quantitative and qualitative) to identify communication channels attractive to women and young people, and to determine the most appropriate times to air prevention messages. The utility of the radio in disseminating IEC messages is generally acknowledged in Africa, and Rwanda, with a strong oral tradition and low rates of literacy, especially among women, is no exception. CIDC surveyed 630 women and 630 youth in late 1995 followed by Focus Group Discussions. The study was designed to determine exactly when young people and women were most likely to listen to radio broadcasts, how specific prevention messages were being perceived, as well as how and when to reach these target groups most effectively. Researchers found that Radio Rwanda is the primary source of information about HIV for 63% of youth and 73.3% of women surveyed. The study also generated information allowing CIDC to refine the messages currently in circulation. Materials and Message Production Following the extensive training in formative research and IEC materials development, and using the results of their respective and shared formative research, CIDC, CARE International and PSI produced a variety of print and audio materials, mass and alternative media to reach the AIDSCAP target groups and the general public with a multitude and variety of messages designed to change attitudes (norms), improve health seeking behavior and support condom promotion and use. Print Materials The AIDSCAP Rwanda Program developed and distributed over 700,000 print materials over the life of its project. CIDC developed seven new print materials, targeting mainly youth and women. CIDC produced and distributed over 320,000 new and existing materials in support of its own and other projects. The PNLS, complementing the efforts of CIDC, ensured that the IEC materials were distributed throughout the country via the MEDIRESA to the 34 medical districts of Rwanda. These materials supported the STI syndromic management being implemented by the PNLS and the Gitarama STI projects. PSI, in support of its condom social marketing program produced over 122,000 posters, brochures, condom samplers, stickers, caps, T-shirt and plastic shopping bags that were distributed through its sales force, point-of-purchase, and special events. Four new IEC materials were developed and distributed during CARE's first phase: a traditional cloth (igitenge) imprinted with the theme of World AIDS Day 1995 ("Shared Rights and Responsibilities") and a package of three interrelated educational materials. Over 100,000 IEC materials were distributed by the CARE project in support of its peer education and community outreach work. The military project produced two posters and a comic book specifically targeting its soldiers. Over 16,000 new and existing IEC materials were distributed by health educators, military clinics and barracks in support of educational and prevention activities in 7 garrisons. Mass and Alternative Media The Rwanda AIDSCAP Program made extensive use of Mass and Alternative Media to reach both the general population and its specific target groups. Mass Media productions included billboards, soap operas, radio programs, jingles, songs, and video showings. Theater and drama were also extensively used to reach the general population and in-school youth. Although no readily measurable data is available as to the total number of people reached through mass and alternative media by the AIDSCAP Rwanda Program, data is available on the number of events held and programs aired. However, numbers of people attending certain events were collected where feasible. PSI's video adaptation of the AIDSTECH developed comic book "Emma Says" reached over 80,000 people participating in PSI's ciné-mobile presentations across villages, schools and military barracks in Rwanda. The title of PSI's locally produced video is a Kinyarwandan Proverb: "Ugira Umugira Inama Aba Agira Amana", or "One is fortunate to have a friend who gives you good advice".
Radio is the main vehicle for communication in Rwanda where no daily newspaper exists and the reach of weeklies is limited to urban areas and literate people. Government announcements, job advertisements, national and regional events, are all broadcast to the public by way of national Radio: Radio Rwanda. The AIDSCAP program used this medium extensively for discussions and debates on HIV/AIDS. PSI had a weekly radio program called "Prudence Time", and CIDC capitalized on a popular music program for youth "Disque Demandé" to broadcast prevention messages for young adults. Radio Rwanda aired 2,500 "song dedication" requests by Rwandan youngsters, each containing a prevention message, selected by the requester from a group of 6 messages developed by CIDC following its research among young adults. Drama was another medium that attracts people and a very useful tool to disseminate messages to selected target audiences. Plays were used as part of a larger program of HIV/AIDS education in 23 schools in the Kigali Prefecture. This program reached over 8,900 urban and rural in-school youth with prevention messages, followed by discussions on abstinence, fidelity and safer sex. A theater production, selected from among several during a contest, reached over 4,000 adults during 4 presentations. This play and a soap opera produced by CARE were also broadcast over the national radio where they reached an unknown number of people in Rwanda and Eastern Zaire. Thousands of people visited the Prudence Kiosk at the main roundabout in Kigali, where condoms and pop soda were sold well into the night. Festivals, fairs, talent and fashion shows, market day mobilizations, and World AIDS Day festivities attracted large crowds and exposed them to prevention messages using popular music, skits, games and contests. Behavior Change and Peer Education CIDC, CARE International and the Military projects implemented targeted interventions using peer education and community outreach approaches. The CIDC community-based intervention limited itself to the training of women leaders representing their "comité du secteur" from urban communities in and around Kigali as community educators. Sixty trained women leaders reached over 6,000 women during educational chats dealing not only with general knowledge about STIs and HIV, but also on the role of women in the fight against AIDS within their family and the community. CIDC staff worked with and held regular education sessions for over 2,500 rural Kigali women,-head-of-households. Health education was a major component of the BCC project for the military. Prior to the implementation of the program, Training of Trainers (TOT) workshops were held in French and English for master trainers. Over the course of the program, 468 community health workers were trained as peer educators who conducted over 1,800 formal educational sessions reaching close to 18,000 military personnel. The program developed two posters and one comic book specifically targeting military personnel to support the peer education efforts. Peer educators used a training manual developed by the AIDSCAP Cameroon Military Project as their guide. CARE International implemented the most comprehensive peer education project in the Gitarama Prefecture consisting of the delivery of IEC messages to specific target group audiences by a community-based network of volunteer peer educators. During the fourteen months of the project's first phase, peer education activities were operating in eight randomly-chosen communes in the prefecture. During this period trained peer educators using previously developed Peer Educator Manual and Flip Chart educated over 35,000 target group beneficiaries. The CARE IEC Team educated an additional 5,350 persons, mostly youth, in basic STI/HIV transmission and prevention methods during informal question and answer sessions after showing CARE's new video "Hitamo Igikwiye" along with "Silent Epidemic" - an educational video on STIs originally developed in Kenya with support from AIDSCAP, and translated into the local language, Kinyarwanda, by the CARE/Tanzania refugee project. In addition, the Gitarama STI project reached over 96,000 STI patients and antenatal women at primary health care centers with prevention messages, while they were waiting for services. Assessment and Evaluation of Messages and Materials Qualitative assessment of materials by CIDC The evaluation consisted of a series of Focus Groups to assess whether the target populations had been exposed to and correctly understood the various messages that had been developed by CIDC. A total of seven materials including two posters, two brochures, one billboard and the "song dedication card" were evaluated by 30 different focus groups, composed of the general public, women and youth. Research was conducted in Butare, Gikongoro and Gitarama Health Regions and a total of 305 people participated. Results from this research indicated that the majority of the people participating in the FGDs had seen one or more materials and/or listened to the dedication songs and messages. In addition the participants mentioned having seen CARE's comic book, PNLS leaflets, video productions and radio programs. All young urban adults in the FGDs were able to describe the youth poster and its message, and the majority of rural youngsters had seen the poster at kiosks, health centers or meeting places. In-school youth also reported having seen the poster at their school, during special seminars for youth, or during the World AIDS days. All young people interviewed had listened to the "Song Dedication" radio program and the majority could recite one or more of the six prevention messages. Focus group research found that half of the married couples interviewed who had seen the couples' poster felt fear of the disease and how it would affect their family. Others felt the necessity of dialogue within their family on the subject of AIDS and HIV, and some women said they worried about the behavior of their husbands after seeing the poster. The research also indicated that communication between spouses on the issues of AIDS and fidelity as advocated by the poster, takes place in very few families and more often as a result of the death of a family member or neighbor from AIDS. Internal and external evaluation of CARE IEC Materials and Messages In addition to the internal evaluation efforts CARE conducted to guide their project activities, an external evaluation of the project was conducted as part of the AIDSCAP-funded project in January, 1997. The focus of the evaluation was an examination of the appropriateness and sustainability of CARE's community-based volunteer peer education approach to STI/HIV prevention in Rwanda. The two-person team, consisting of a representative from the PNLS and an independent consultant, used qualitative questionnaires to guide interviews with various partners and beneficiaries. The evaluation team made a number of recommendations with regard to the IEC component of the project, including a call for wider distribution of educational materials beyond the peer education sessions through schools, associations, sports events, and/or vaccination campaigns. They noted that the radio program had been an effective mechanism for disseminating STI/HIV prevention messages, especially the radio soap opera. In more general terms, the evaluation documented a strong, positive reception to the peer education activities throughout Gitarama. The team recommended a continuation of project activities in the eight communes of Gitarama for a proposed second phase, with a focus on refining project messages and the use of more varied and participatory communication media. STI Activities STI control remains a neglected area in many African countries. Curable STIs (syphilis, chancroid, gonorrhea, chlamydial infection, trichomonas) are serious health problems due to their own morbidity, to the possible complications in women (PID, sterility), and to their implications for HIV infection. The prevention, and early diagnosis and treatment of curable STIs not only responds to immediately felt needs but also represents an important means of preventing HIV infection. Incidence and prevalence data for STIs in Rwanda, although underreported and incomplete, confirm the gravity of the problem. The high HIV prevalence among STI patients, in both urban and rural areas, indicates that STI patients are a high-risk group for HIV infection. Although the need to improve STI management was recognized at the national level before the war, implementation lagged behind, and STI management guidelines were not available to health workers in the field. After the war, the adoption of national treatment guidelines was viewed as an essential first step for the successful implementation of the STI component of the AIDSCAP/Rwanda Program. AIDSCAP had supported operational research in the implementation of improved STI services in two Rwandan health facilities prior to the war. The data from this experience were presented at a national consensus meeting organized by WHO and the PNLS in Kigali in March of 1995 and national guidelines for STI case management based on the syndromic approach were adopted. These guidelines are essential for effective, appropriate treatment of STIs as well as for standardizing antibiotic use. In addition to validating the proposed treatment guidelines, the pre-war operations research project at the two health facilities also looked at other opportunities for reducing the prevalence of STIs in the community. Partner referral was initiated to improve the referral and treatment of sexual partners of STI patients. After syndromic management of the presenting complaint, index patients received prevention education and condom demonstrations, and were urged to refer sexual partners to the health center for free examination. Referral cards were linked by code number to the symptomatic index patient. Although it was discovered that only 58% percent of index patients accepted partner referral cards, the referral rate for those who did accept cards was 45%. Partner referral worked best for regular partners, and women index patients, especially when pregnant, women were more successful in referring partners than men. It was clear from this research that efforts to improve the rate of partner referral should begin at the clinic level with improved counseling to convince more STI patients of the importance of partner referral. Postwar implementation of STI Case Management Prompt treatment of STIs, supplemented by counseling and partner referral, has been recognized as an important strategy to slow down the spread of HIV. AIDSCAP Rwanda therefore integrated the training of primary health care providers in STI case management into three of its subprojects. STI management programs were piloted by the PNLS, the Rwandan Patriotic Army (military), and the Gitarama Health Region HIV/AIDS Prevention Program. After the adaptation of National Treatment Guidelines in March of 1995, the PNLS, with financial support from WHO, conducted two one-week, back-to-back, (French and English) Training of Trainers (TOT) workshops in the use of the National Treatment Guidelines for STD Case Management. The workshops were conducted with technical assistance from AIDSCAP's STI subcontractor, the Institute of Tropical Medicine (ITM) in Belgium, the AIDSCAP Regional STD Officer, and the PNLS STD Unit chief. During the workshops, a core group of 38 medical staff from the 11 health regions and the military services were trained. Since July of 1995, the combined projects have trained 521 service providers in syndromic diagnosis and treatment of STIs, according to national Rwandan guidelines. Training also focused on partner referral as well as other elements of counseling, such as condom use, and compliance with taking full course of medicines. In addition, STI surveillance forms and patient encounter forms were introduced during the training sessions in order to facilitate subsequent supervision and evaluation of the program. The PNLS with technical assistance from the AIDSCAP Regional Office, also developed an STI manual, national diagnostic and treatment guidelines in pocket guide format, and a wall chart/poster version of the algorithms. The wall charts were distributed to all participating clinics together with the pocket guide for the providers. Evaluation of STI case management component An evaluation of STI case management was carried out in February of 1997 by ITM, in which a total of 14 health facilities were visited and 22 health care providers were interviewed. The World Health Organization has developed two programmatic indicators (PI6 and PI7) for assessing STI case management and these indicators are used by many AIDSCAP programs throughout the world. Prevention Indicator 6 (PI6) is the proportion of individuals presenting with STIs in health facilities who are assessed and treated in an appropriate way, that is, according to national standards. Prevention Indicator 7 (PI7) is the proportion of individuals presenting with STIs in health facilities who receive appropriate advice on condom use and partner notification. A protocol for assessing both indicators has been developed by WHO and is based on interviews with health care providers and observation of STI patient contacts. Patient observation can take a great deal of time, especially in areas of low STI prevalence. Because of time and budget limitations in Rwanda, evaluation of PI 6 and 7 was based on interviews with health care providers, who see a mean number of 32 STI patients per month. Interviews included the diagnosis and treatment of 3 hypothetical STI case studies, as well as a review of the STI surveillance forms, STI patient encounter forms and the patient registers. Evaluation of Prevention Indicator 6 The proportion of individuals attending health facilities with STIs who are examined and treated in an appropriate way (PI6), was assessed in Rwanda by reviewing a total of 163 STI cases from the patient registers of the health centers selected for evaluation. The type of treatment was classified by analyzing the prescription pattern for each patient and treatment was considered etiologic when only one antibiotic was prescribed and syndromic when two or more antibiotics were prescribed. In 21% of all cases, the treatment was not mentioned in the register. These were patients who were sent to the laboratory for examination and whose treatment was therefore not filled in. In those cases where the treatment was mentioned, a syndromic approach was used in 77%, 72% and 58% of STI cases in the Gitarama, PNLS and military projects respectively. Each drug prescribed was classified according to the national guidelines as treatment of first choice, alternative choice, or not recommended by the national guidelines. A correct drug choice was made in 94% of all drugs prescribed in Gitarama, in 74% of the drugs prescribed by the health care providers in the military project and in 46% of the drugs prescribed in PNLS project areas. The treatment of first choice for gonorrhea in Rwanda is norfloxacin, which was only available at 6 centers at the time of the evaluation. The price of norfloxacin is still high for a Rwandan patient (1 course: 500 FRw. = 1.7 US $) and some health centers have resorted to selling the whole syndromic treatment (norfloxacin + doxycycline) at the same price as an etiologic treatment (norfloxacin alone), in order to reduce the patients' financial barrier to syndromic treatment. A major constraint to the implementation of the STI Case management program were shortages or lack of appropriate STI drugs. The PNLS, through the Ministry of Health, had negotiated with the Belgian Cooperation, as part of their renewed development support to Rwanda, the supply of STI drugs for the next two years.. By May of 1997 the first shipment of drugs had not yet been received. The review of the patient registers was an efficient method of conducting a rapid assessment of PI 6 in the health care centers. However, it is not possible to assess correct diagnosis, including risk assessment, without observation of the STI encounters. Many health care providers were asking for laboratory examinations before treating STIs. Two problems were detected in this approach. Firstly, inappropriate laboratory methods were used, such as examination of a urine sample in the case of vaginal discharge. Secondly, health care providers were giving the results of the laboratory tests on the following day, which not only delayed the treatment of the STI unnecessarily but gave the patients the opportunity to decide not to return. Overall case management was considered correct if both the correct approach and the correct drugs were used. Cases where the treatment was not mentioned could not be classified and were therefore excluded from this analysis. Correct management was found in 93% of the STI cases in Gitarama Health Region, in 77% of the STI cases in Kigali Health Region, in 32% of the STI cases in Kibungo Health Region (total for PNLS project: 51%), and in 67% of the STI cases in the military health center. Evaluation of Prevention Indicator 7 PI 7 is the proportion of individuals attending health facilities with STIs who receive appropriate advice on condom use and on partner notification. Information on PI 7 was obtained in the interview with the health care providers. All health care providers reported that they were giving preventive messages to all STI patients. Some were experiencing difficulties in giving preventive messages to married women, and some found it time consuming to give preventive messages to all STI patients. Condoms were available in 11 of the 14 health centers visited but were not always given to all STI patients, even if available. The three centers at which condoms were not available are affiliated with the Catholic Church. Health care providers expressed reluctance to demonstrate and give condoms to married women, because these women are "not allowed to use condoms by their husbands." Partner notification was done by all health care workers, and the method most frequently used was contact slips. Partner treatment was experienced as the most difficult aspect of STI case management by the health care workers interviewed. Problems can arise when evaluating PI 7 by interviews because the health care providers can give the answers which they think should be given, and not the answers which reflect the true situation. Therefore, the results of the assessment of PI 7 should be viewed with caution. In addition, it was not possible to select a representative sample of the health care centers, because of security problems in Rwanda at the time of the assessment and because of time limitations. For example, only 1 health center from the military project was visited and a limited number of STI patients, all from the same health center, were evaluated. In general, for both PI6 and PI7, the most important comments and constraints given by those interviewed were:
The present methodology for assessing PI 6 and PI 7 is both rapid and relatively cheap and appears to be a good alternative to other, more time consuming methods involving patient observation. There is also potential for sustainability, if accompanied by adequate training and supervision. In terms of results, the evaluation was successful in producing not only empirical data for a comparison of the different site interventions, but also in generating the kind of qualitative assessment that is crucial in understanding the problems faced by health care providers. Condom programming
The condom component of the AIDSCAP project in Rwanda has placed emphasis on improving accessibility to and acceptability of condoms through condom social marketing activities supplemented by free distribution of condoms by CARE, the RPA, and STI treatment facilities. The condom programming strategy aimed to increase accessibility of condoms throughout the country, to educate Rwandans about HIV/AIDS and promote condoms as an effective prevention strategy. Over three million condoms were sold and over one million were distributed free of charge by CARE and the RPA. Despite periodic condom shortages, the social marketing project has been successful in fulfilling its objectives. By the end of August, 1996 Prudence Plus condoms were on sale in all eleven of the country's prefectures. Average national condom sales per month had reached 230,000, just ahead of its target of 225,000, with sales of over 300,000 recorded in April 1996. PSI opened approximately 1,500 new points-of-purchase (places where condoms are available). Additional outlets have been established by NGOs and by independent wholesalers working with the project. Increased accessibility of condoms has been achieved with 71% of condoms sold being purchased from four widely accessible outlet categories: boutiques/kiosks, clinics/health centers, pharmacies, and community based sales. PSI condom promotion activities included ciné-mobile presentations, concerts, live theater, "Soirees Prudence", a fashion show, two business fairs, one youth competition, and market day mobilizations. The Ciné-mobile presentations were especially well received and attracted on average 1,500 town and village people during each two-hour show. These participatory presentations were held at night in villages all over Rwanda. The equipment necessary for the presentation, including a portable generator and a closed circuit unit, were mounted on the back of a large four wheel drive, "a mobile video unit", hence the name Ciné-Mobile. The film presentations mixed popular music, short plays and skits on safer sex with messages on HIV and AIDS prevention by national and regional health and political authorities. The close-circuit unit made it possible to have village elders and community leaders participate in debates while being projected on the large screen in front of their constituents. PSI staff held live question-and-answer sessions with volunteers from the crowd projected on screen for everyone to follow. Prizes were awarded to participants who gave the correct answers. The Ciné-mobile was also used as a training tool, and to stimulate discussions among specific target groups such as military, youth and women. Social marketing of condoms has proven to be effective, despite the mass movement of people within and out of Rwanda and the physical destruction of the infrastructure. The private sector was one of the first components of the Rwandan society to reorganize itself. Social marketing principles thus made it possible to use one of the few functioning systems to make a needed health product available and condoms were purchased despite severe economic constraints. Prudence/Prudence Plus sales exceeded 3.15 million condoms under AIDSCAP financing. PSI also worked closely with the other AIDSCAP implementing agencies and provided training in condom use demonstrations, selling skills for community-based sales agents, condom use, and HIV/AIDS prevention techniques. CARE's HIV/AIDS Peer Education and the Gitarama Health Region STI projects in Gitarama also included condom components. A total of 138,561 condoms were distributed free by CARE. The vast majority of these - 132,061- distributed by the Peer Educators during their peer education sessions. The remaining 6,000 were distributed during World AIDS day activities in Gitarama and during IEC focus group discussions. Following a training conducted by PSI, over two thirds of the peer educators agreed to become community-based sales agents of Prudence Plus condoms. The sales figures for CARE's PE s and Gitarama's community based sales agents are included in the overall sales figures of PSI and are separate from the figures given for free distribution. In addition, government-provided condoms were distributed free of charge through the primary health clinics and military health centers. The military health centers and outlets distributed over 800,000 condoms to military personnel. Unfortunately, no accurate account could be provided by the participating STI and primary health clinics on the number of condoms they distributed to patients seeking STI care. Constraints included the periodic shortage of condoms and difficulties associated with the war. The civil war constrained activities and several areas of the country were off limits for extended periods of time, both before and after the war. In March 1995, when condom social marketing activities were restarted, approximately 140,000 condoms, left over from before the war, were available. These condoms had to be rationed over a period of five months until new condoms arrived and were repackaged. In addition to the condoms found in the PSI warehouse, the Government also found their stock of condoms intact. PSI convinced the PNLS to donate some of their USAID condoms for re-packing under the Prudence label while awaiting their first shipment to arrive. Other periods of rationing occurred from August to December, 1995 and again from January to March, 1996, when a 3 million condom order arrived late. Behavior research Behavior Research was a major component of the original AIDSCAP/Rwanda Program and a variety of research projects were part of the country program design. The AIDSCAP/Rwanda program was designed to rely on appropriate formative and operations research results to better understand specific target groups and other general sociocultural contexts within which activities would be implemented. Each target group, for example, was to be described in terms of its most salient social, cultural, and economic characteristics. In addition, the Thematic Grants Program was intended to provide for theory-based research and capacity building. Each research project was to focus on a theoretical, thematic, or disciplinary approach to AIDS prevention. Sizable grants of two to three years duration were earmarked to be awarded to teams consisting of a US researcher and Rwandan counterparts, in addition to specific practical and short term research. The objectives of this comprehensive research program were:
Prior to the renewed outbreak of hostilities in Rwanda in April 1994, behavioral research work was well underway on the "Targeted Intervention Research" or TIR, an ethnographic study of beliefs surrounding sexually transmitted disease. The AIDSCAP behavioral research specialist in Rwanda had constituted a technical advisory group (TAG) to supervise the field work. The TAG consisted of Rwandans involved in STI treatment and prevention and had already held several planning meetings. The head of this group, a researcher at the Université Nationale du Rwanda, and the AIDSCAP Behavioral Research Specialist, had just finished recruiting a team of a dozen survey researchers who were about to begin their training during the second week of April. The team had hoped to elicit information concerning local cognition of STIs in Rwanda and therapeutic decision making in STI treatment. A second research project, "Condom Use Promotion Among Men in Butare" under the core-funded Thematic Grants Program, had been approved to be conducted by a research team of the University Center of Public Health of Butare. The proposed study was a controlled trial of an intervention, using repeated cross-sectional surveys at three-month intervals to collect relevant data. The research would have targeted male patrons of bars in Butare and Gikongoro. In 12 bars a patron was to have been selected and trained as an intervention specialist, to convey information about AIDS, STIs and their prevention to other bar patrons. He would have also provided information about condoms and encouraged their use. Six bars in Butare were to have served as a control. At each cross-sectional survey a total of 900 bar customers would be interviewed. Other planned behavioral research included a study of sexual relationships and exchange in Rwanda, a study designed to gain insight in the life of female commercial sex workers, and in couple negotiation dynamics with regard to sex and possible STI-AIDS transmission. It was further planned to work with and train traditional Rwandan healers as STI and HIV/AIDS prevention educators. The research component was designed to support and guide AIDSCAP's intervention among target groups in Rwanda. By the Spring of 1995 when AIDSCAP/Rwanda intervention activities were finally being implemented, neither the human nor financial resources were available to implement the original behavioral research component. The expatriate behavior research specialist, who not only had extensive research experience in Rwanda, but also spoke Kinyarwanda, had returned to work and teach at a US University. On the Rwanda side, the University of Butare was still closed, and many of its staff lost in the genocide, displaced internally or out of the country. From the AIDSCAP side, the Behavioral Thematic and Competitive NGO Grants Programs funds had been awarded and no further grant moneys were available. A variety of other factors also contributed to the decision to cancel the behavioral research component, including the US Embassy's decision not to allow expatriates to bring their families, continued problems with internal security, and a wary population still recovering from civil strife. |
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