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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 IV. Subproject Highlights (continued) Strengthening of BCC Activities in Rwanda
Background and Scope of Intervention The broader communications project was implemented for 24 months from May 1, 1995 until April 30, 1997. The purpose of the project was to reduce high-risk sexual behavior for STI/HIV/AIDS among targeted groups. To reach its purpose, the subproject was tasked with conducting formative research with selected projects' targeted groups, assessing and developing materials for targeted interpersonal and mass media interventions for use by projects and at a national level, developing and using alternative media for BCC interventions, and developing and demonstrating improved internal capacity to support counseling services at the Medical Health Region of Kigali. Accomplishments CIDC largely achieved its targets as outlined in the subproject document and summarized in the Process Indicator Summary. It exceeded its goal with regard to formative research and in so doing has provided a rich collection of ethnographic information on a number of target groups which will continue to be useful to all agencies working in the field of HIV prevention for some time to come. The main findings of these studies are also discussed in the Outcome Section of this document. Training and Capacity Building
Audience and Formative Research The assist in the development of appropriate materials, messages and channels for communication, four separate studies were carried out. While all four studies provide valuable additions to the database on sexual behavior, attitudes, and barriers to behavior change in Rwanda. The last two are particularly rich in content. The qualitative assessment of materials produced by CIDC found that the majority of persons interviewed in the target communities had seen the materials or heard the messages, and were able to correctly recall the messages contained in them. The four studies, which are described in the Accomplishments Section, are:
Print Material and Mass Media Using the results of the formative research, seven new print materials, 19 radio spots, and 15 radio programs were developed and broadcast. New print materials included posters and brochures targeting women and youth. In addition, a billboard with a prevention message targeting the general public was erected in 36 urban or semi-urban locations around the country. Over the life of the project, over 320,000 copies of new and existing print materials were produced and distributed. The radio spots were aired over 800 times by Radio Rwanda, the main constraint being the expense for air time, which doubled over the life of the project. The radio programs concentrated on STI and HIV prevention and were held in collaboration with journalists from the PNLS and Radio Rwanda. During the live programs discussions focused on safer sex, the role of women in HIV prevention, and the perception of the population with regard to fidelity, condom use and abstinence. Radio, is the most extensively used form of communication in Rwanda, and its use ranges from public announcements by the government to advertisements of job vacancies in the private sector, in addition to providing entertainment for its listener public. From audience research with young men and women, CIDC learned what programs were attractive to young people and when they were most apt to listen. One very popular program with young people is called: "Disques Demandés". It broadcast four times a week at 6 o'clock in the evening, and will play your favorite song with a dedication to the person of your choice. In order to dedicate a song, one needs to go to the Radio Rwanda and fill out one of its: Carte de demande de disques de Radio Rwanda, and pay a small fee. CIDC printed up 2,500 "dedication cards", each with one of six STI/AIDS prevention and behavior change messages developed for and pre-tested with youth. CIDC also made arrangements with Radio Rwanda for a group discount for its 2,500 cards. The "cards", now called Carte de demande de chansons du CIDC, were available from Radio Rwanda for "free" to any young person showing up at the station. Cards could be filled out directly or taken home to be completed, and 50% of youth chose the latter. By completing and signing the card, they agreed to have their message and dedication read to the person(s) of their choice. The program was so popular that within two months 2,400 cards had been completed and returned to Radio Rwanda. Each year, CIDC also participated in the World AIDS day activities, a 15 day period of AIDS prevention activities held country wide. The activities included preparatory meetings with the PNLS and regional health authorities, participation in the actual activities such as marches, leading discussion groups, theater and film presentations and the production of special materials. CIDC also participated in the International Day of the Woman organized in Gitarama and the Exposition and Sales Fair in Kigali. Alternative media In September 1995 CIDC organized a contest for best drama conveying prevention messages. Twelve plays were presented, and the three best ones, chosen by a jury composed of experts in drama and AIDS, were awarded prizes. The winner, a play called "Icyicamahirwe" related the story of a young couple, and although the husband knew that he was infected, did not take any precautions nor tell his wife because he was afraid she would leave him. Subsequently both become ill with AIDS and some of their friends provide help and care. The play was adapted to be played in the four largest cities in the country and reached over 4,200 people. The play was also taped on audio cassette and aired on national radio. A second play was produced to create awareness and prevention for school youth. The play was created in support of an HIV/AIDS education program for youth in the Kigali Prefecture. Forty education sessions, consisting of an introduction to HIV/AIDS, the play, and a question and answer session, were held in 23 secondary schools and educated over 8,900 urban and rural pupils. The play concentrated on abstinence and delay of first intercourse, cautioned young girls not to accept gifts from older men or extra points on an exam from a teacher in exchange for sexual favors, peer pressure, how to avoid high risk situations, etc. A discussion guide was developed and used by both CIDC staff and CIDC trained teachers to conduct the question and answer sessions following the play. The play was also produced on audio cassette and distributed to NGOs and others working in AIDS prevention. Song Competition CIDC organized a competition with prizes for the best AIDS prevention songs. As a result of this competition, CIDC produced a audio cassette containing the nine winning songs with themes centered around: risk factors, prevention, dialogue on AIDS, and consequences of high risk behavior. Fifteen hundred copies were distributed to bars, hotels, beauty shops, health educators, market stalls, NGOs, the PNLS, regional and local medical health authorities. Community-based education Formative research also indicated that women were interested in learning more about HIV/AIDS and how to protect themselves through community or neighborhood gatherings by and for women. To meet this need, CIDC trained 60 elected "women community leaders" (a community structure put in place by the Ministry for the Promotion of the Family and Women), in HIV and STI prevention. In turn, these 60 leaders educated over 5,600 women in their communities through participatory educational chats on AIDS and STI prevention. In addition, CIDC staff reached over 2,500 women, heads of household, in rural Kigali through educational sessions dealing with women and AIDS, the role of women in AIDS prevention, issues revolving around fidelity and condom use within marriage. Collaboration with the PNLS and support to selected Health Regions The CIDC worked closely with the PNLS IEC unit and was an active participant in the IEC subcommittee meetings. The PNLS ensured that materials produced by the CIDC were distributed through its Focal Point HIV Prevention Specialists at the Health Regions to participating health clinics and community-based projects. CIDC also worked closely with the PNLS to provide training in HIV/STI prevention counseling for staff of the Kigali and Gitarama Health Regions. CIDC materials are found countrywide, most materials found in rural areas and clinics originated from CIDC. For most of the post-war period, with the exception of PSI and a few NGOs (who normally rely heavily on expatriate assistance), CIDC was the only local organization developing and distributing materials. CIDC also provided support to the Kigali Health Region to build their capacity to set up counseling services. Prior to the war with technical assistance from the Canadian Government CIDC had drafted a counseling manual. This manual was finalized with the assistance of the original consultant and 55 copies were produced and 47 distributed among the trainees. In addition to the 23 counselors trained during the TOT workshop, CIDC staff trained 56 nurses and social workers in counseling; and, on how to organize and conduct groups sessions to discuss STI/HIV/AIDS. Individual CIDC counselors continued to provide counseling services to HIV+ people through the Kigali Health Region Medical Services. Important Constraints During the war, CIDC lost most of its equipment and its offices. Some staff members did not survive the war. The shortage of equipment available for rental from the private sector resulted in delays in the production of audio materials. The new prices for radio time also became prohibitive. While the qualitative evaluation found that CIDC materials had been seen and understood by communities throughout Rwanda, as is most often the case with projects producing IEC materials, it is not possible to measure to what extent the materials contributed to any significant degree to attitude or behavior change. Behavioral Data The subproject outputs did not include the collection of quantitative data for evaluation purposes. As discussed earlier, the CIDC project undertook valuable ethnographic research and conducted an assessment and evaluation of the IEC materials developed and distributed as part of the AIDSCAP Program. Since the research studies were described earlier in this report, the discussion will be limited to highlights which reflect on the HIV/AIDS program as a whole. The findings of the formative research on appropriate strategies for reaching women include some significant ones which validate findings of the CARE KABP and FGDs. For example, young women still found many barriers to condom use. These included lack of access and knowledge about condoms (as in the CARE study sample, many young rural women had never even seen a condom). Many also held misconceptions about condoms and expressed the view that condoms were for "high class" people to use. The very particular needs of widows also came to light - the desire to have children even in the absence of a husband outweighs the desire to reduce risk by a long measure. Those women who are married recognized that due to the gender imbalance (60-40 in favor of women) and the desire of widowed women to have children it was extremely likely that their husbands would have other partners and thus expose themselves and their spouses to risk of STIs and HIV. Poverty and the need to survive by exchanging sex for gifts or cash also put women at high risk. As was found in other studies (CARE, RPA, PSI), most Rwandans have a very low perception of personal risk. Lessons Learned and Recommendations
Future projects involving IEC materials should integrate ways of measuring whether the materials in any way contributed to attitude or behavior change. While any such measurement is likely to be imperfect, it could nonetheless help project planners and implementers in assessing the impact of their programs. CIDC: Strengthening of BCC Activities in Rwanda Summary of Achievements
Process Indicator Summary
Gitarama Health Region STI/AIDS Prevention
Background and Scope of Intervention This subproject was operational from September 1, 1995 through April 30, 1997. The goal of the project was to stabilize or decrease STI prevalence in population centers in Gitarama Prefecture. The project was complementary to the Peer Education Project implemented by CARE International. The purpose was to reduce high risk sexual behavior among targeted groups in the Prefecture. The expected project outputs were:
Principal Accomplishments During the twenty months of project activity, 105 service providers were trained by core trainers from the Gitarama medical health region (previously trained in Kigali at a TOT workshop) on STI case management using the syndromic approach, partner referral and condom use. The syndromic approach was introduced and practiced in 35 health facilities in the Gitarama Medical Region. An STI monitoring system was established at each facility and monthly supervisory visits were conducted at all sites. An evaluation of the STI case management component of the AIDSCAP Rwanda Program found the decentralized approach used in Gitarama to be the most effective among the three STI projects implemented in Rwanda. The model used in Gitarama, which involved decentralization of training, supervision and decision-making and support for these activities, resulted in 93% percent of STI cases being correctly managed according to national treatment guidelines1. Sixty-eight service providers participated in a refresher course to motivate them and keep their skills up-to-date. In addition:
Important Constraints Some medical personnel are resistant to abandoning the laboratory-based approach to STI case management, and others were not enthusiastic about having a new approach piloted in their region while other regions were still using the etiologic method2. The "communication" section of the STI training manual and the record-keeping system need improvement. No reliable record was kept of condoms distributed free through the public health services, nor is there a centralized record of the number of STI patients presenting and treated. While such data does exist in patient registers at each facility, the project did not include a component intended to update this recording system and to put in place a system of compiling this information by the MEDIRESA's office. The shortage of clinical personnel also constrained activities, and at the end of the project, it was still felt that supervision and monitoring of all activities could use improvement. Although the Belgian Government had pledged to meet Rwanda's needs for STI drugs, by the end of the AIDSCAP Program, the supply system was not yet in place, meaning that drugs were not always available to patients otherwise correctly diagnosed. Without drugs, STI management of any type cannot maximize its potential effectiveness. Behavioral Data The subproject did not include the collection of behavioral data, since the collection of behavioral data was under the Scope of Work of the CARE Gitarama project. The CARE project team shared the results of their KABP and FGDs with the STI project team. Lessons Learned and Recommendations
Some thought needs to be given to putting in place reliable records of condom distribution. It would have been useful had service delivery points kept reliable records of free condoms distributed to STI patients. Gitarama Health Region STI/AIDS Prevention Summary of Achievements
* materials provided by CIDC Process Indicator Summary
PATH provided technical assistance in IEC materials development to the Rwanda country office. Specifically, PATH assisted CIDC in the developing the curriculum for the training workshop in IEC materials development. Subsequently, PATH assisted CIDC in using the curriculum to convene a ten-day workshop for 21 persons from selected NGOs. Background and Scope of the Intervention Four small projects were funded using the "Rapid Response" mechanism. The four organizations receiving funds through this channel were CARITAS, the Bilyogo Health Center, the Rafiki Club, and Cor Unum. All four of these organizations are in some way affiliated with the Catholic church and have many years of experience working with disadvantaged groups in Kigali city. Accomplishments CARITAS's activities involved the training of 15 "house mothers" to care for children orphaned by HIV/AIDS, as well as the training of 500 HIV positive people in HIV prevention and basic counseling for persons with HIV/AIDS. The project was intended to help seropositive individuals to network with others sharing the same experiences and to have access to emotional support that would help them not only to live more positive lives, but to help others in the community. During the life of the project 485 persons with AIDS were trained (15 less than planned). Activities are continuing with funding from other sources, including the German and British affiliates of CARITAS. While the persons living with AIDS have not formed a formal association, CARITAS continues to invite them to periodic meetings and conduct home visits. The Bilyogo Health Center's approach was more medical. Fifty-nine commercial sex workers were recruited to the project on a voluntary basis; the target had been forty. Each volunteer was first examined for STIs and treated if necessary. During the six month life of the activity, the women were tested on a monthly basis and were given treatment at 50% of the regular cost. A support group was formed and the women met every Thursday afternoon for education and discussion sessions. These sessions covered topics such as condoms and how to negotiate with clients for their use. Condoms were made available to the women through PSI, whose personnel trained the women in condom sales. A total of 15,472 condoms were sold by the women (these are counted in PSI's overall sales). The women did remain involved in the project activities and present for STI treatment. In light of the short life of the project, it is difficult to make conclusions about longer term risk behavior or about improved health-seeking behavior. The Rafiki Club is a social center which has been active in the Nyamirambo neighborhood of Kigali for twenty years. Through the organization of sports, games, and cultural activities, it reaches out to high-risk youth. Its premises were completely looted during the war, but the Club continues to rebuild and to reach the 3,000 youth who are currently registered with it. This small project was meant to expand activities to include educational sessions on HIV/AIDS and STI prevention. The Club worked closely with the Bilyogo Health Center on medical issues and clinical referrals. Funds were used to refurbish its training hall, purchase simple audiovisual equipment, and to pay for the costs of organizing monthly meetings for different youth target groups. A government-salaried "Assistante Sociale" was also involved with the project and was able to conduct home visits as follow up to the monthly meetings. A total of 2,300 young people participated in the awareness/sensitization activities. Cor Unum is a not-for-profit NGO created in 1991 with the goal of assisting disadvantaged families living in Kimisagara and Cyahafi areas of Kigali. This project targeted 100 women at high risk of HIV/AIDS/STIs using a peer education approach. The volunteer peer educators were chosen from among women in the area and were involved in income-generating activities. One hundred twenty-eight women are now working in eight income-generating groups. Thirteen peer educators were selected and trained. Each was supervised by an "Assistante Sociale". Each peer educator devoted at least one hour per week on prevention activities with women in their home areas. The peer educators met monthly over the six month life of the project . During these meetings they shared experienced and were given refresher training and encouragement. The sessions held by the peer educators are summarized below.
Other activities were carried out during La Quinzaine du Sida, two weeks of activities following World AIDS Day; an additional 36 sessions were held and attended by 281 persons. The groups are still active although their funding ended some time ago. Lessons Learned and Recommendations There exists significant potential for extending reach with low-cost BCC/STI programs to the urban grassroots level through indigenous, NGOs. Many small scale NGOs with low overhead costs continue to operate in Kigali and with small amounts of support could help to link up prevention and treatment programs. All of the NGOs receiving support from the RRF were somehow affiliated to the Catholic Church. This affiliation did not, in most cases, discourage them from including condom promotion as part of their package of interventions. Three of the four organizations specifically mentioned condoms as an important element of their prevention activities. Endnotes
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