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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 (See Below) IV. Subproject Highlights III. Refugee Intervention in Tanzania A. Background When civil war broke out in the spring of 1994, it displaced over half of the Rwandan population internally and hundreds of thousands fled to neighboring countries, where diseases inevitably followed them into hastily constructed refugee camps, some of them less than 20 km from the Rwandan border. It is estimated that at the peak of the exodus more than two million Rwandans were living in refugee camps neighboring the country. With the continuation of hostilities and no immediate sight of a resolution to the Rwanda crisis, AIDSCAP was requested by USAID to support HIV/AIDS prevention programming to the Rwanda refugee population in Tanzania. Funds were shifted from the Rwanda Country Program to respond to the newly created needs of the Rwandan population in exile. Because of its experience in relief and previous HIV/AIDS prevention work in Rwanda, CARE International was selected by AIDSCAP as the lead agency to manage the intervention. AIDSCAP subcontractors, John Snow International (JSI) and Population Services International (PSI) were selected to provide additional assistance in needs assessment/evaluation and condom distribution and promotion, respectively. Only four months after the exodus began, CARE International implemented a broad-based HIV prevention project for refugees living in the CARE managed Benaco camp -- one of the first ever large-scale HIV/AIDS intervention program in a refugee camp. Benaco camp, in the Ngara District, only 18 kilometers from the Rwandan border, almost overnight became the second largest city in Tanzania. The conditions of refugee life greatly increased the risk of exposure to HIV and other sexually transmitted diseases (STIs). The destruction of social structures and unraveling of social mores, loss of home and income, overburdened health care resources, instant urbanization, overcrowding, and commercial sex trade, were just some of the factors that lead to increased risk-taking behavior. Women and adolescent refugees, vulnerable to violence, rape and coercive sex, were at especially high risk. Because so little research on AIDS prevention has been done within refugee settings, the pioneering work at Benaco and three other Ngara District camps offers valuable lessons on working with displaced populations under crisis conditions. The strategy designed to reach the refugee population was based on the CARE and AIDSCAP community-based AIDS prevention project in northern Rwanda, rudely interrupted by the 1994 conflict. The three major activities included: increasing the availability and accessibility of free condoms, community outreach education for STI/HIV prevention; and STI treatment and counseling. Funding of the first phase ended in November 1995. Funds from the Agency for International Development, the Africa Bureau in Washington, DC, enabled AIDSCAP to continue to support the program until the closure of the Tanzania refugee camps in December 1996. Based on the needs assessment and the results of the baseline survey, carried out by JSI, services for community outreach, STI treatment and condom promotion/distribution were initiated by CARE in cooperation with other relief agencies. The target population included all sexually active persons in the CARE-managed camp, with special efforts directed toward women without partners, young men and adolescents. Prompted by CARE, UNHCR implemented AIDS Strategy Meetings for a common approach to AIDS prevention with NGOs working in five camps in the Ngara region. 1. Community-Based Education CARE trained a network of over 100 community educators (ACEs) recruited from among the refugee population. There was roughly one ACE to every 1,000 adults. Aces were trained to provide STI/AIDS prevention education in one-on-one encounters and group sessions to members of their own communities and to make referrals for STI treatment in the privacy of the refugees' dwellings. Each ACE conducted on average five group sessions and six home visits per week. Family planning referrals were also made during the private home visits. Eleven supervisors monitored the activities of the Aces Supervisors collected and reviewed weekly activity reports which detailed the number and type of educational sessions, aggregated by age and sex. Supervisors also made home visits with Aces to assess their effectiveness at conveying information and distributing condoms. In this relatively closed environment, approximately 90% of the population was reached with HIV/STI prevention messages. Aces received two weeks of initial training and periodic refresher training. The training was carried out by four senior trainers under the supervision and direction of the project manager. The AIDSCAP Peer Education Training manuals were used as models. All training was conducted in Kinyarwanda. Cross-training of over 1,900 health workers from CARE and other NGOs occurred and over 1,000 community volunteers and scouts/peer educators joined project activities. 2. Counseling and STI Services Twenty trained counselors offered counseling services and conducted group community education sessions at the outpatient departments and maternal and child health clinics in three refugee camps. Records were kept of the number of people counseled, individually and in group, and by gender. Over the life of the project, over 300,000 people were reached through the counseling services. The project collaborated closely with the African Medical Research and Education Foundation (AMREF) to promote STI treatment through syndromic management. AMREF trained medical assistants, supplied drugs and sponsored a mass education campaign in the camps and the adjacent Tanzanian village, Kasulu. Each month, the clinics would provide information on the number of STI cases, by gender, and by new or repeat STIs. On average, over 1,000 people were diagnosed and treated each month. A major constraint was the chronic shortage of STI drugs. Four counselors had also been trained in rape crisis counseling and were members of the CARE Crisis Intervention Team (CIT). Counseling was often provided to victims of sexual violence and home visits were made to follow-up on initial case contact. To encourage men to seek treatment, counselors increased home visits and follow-up to couples with STIs. The counselors also played a large role in assisting rape victims with follow-up and medical procedures, collaboration with the CIT members in each camp. Counselors collaborated with health workers at the health clinics by conducting group education sessions during prenatal days. 3. Condom Promotion and Distribution In the first year of the project, PSI took the lead in recruiting and training a Condom Promotion Team (CPPs) who were responsible for condom promotion and distribution in the refugee camps. PSI also provided training for Aces and HITs. IEC materials developed jointly by CARE and PSI were distributed through the network set up by PSI, and condom dispenser boxes were placed throughout the camps. PSI also pursued an events-oriented strategy to maintain awareness and to promote condom use. This included the organization of sports events, usually soccer matches, which attracted large crowds. At such weekly matches, 1500 to 3000 condoms were distributed , and animators worked the crowds with megaphones, demonstrated correct condom use, and distributed educational leaflets along with condoms. After the completion of the PSI program in August 1995, CARE took over the condom distribution component and renamed the CPP team as the Special Events Team. The Team continued to organize large-scale community activities such as dance contests, athletic events, and concerts. Over the course of the 29 month intervention, over 4.5 million condoms were distributed and 250,000 pieces of materials were disseminated by the PSI CPP team in the first year. 4. Expansion of Activities After the first year, the AIDS/STI project activities and technical support were expanded to four Ngara District camps and five Karagwe District refugee camps. A special effort was made to address adolescents' and women without partners reproductive health needs through training of community peer educators (scouts), videos and education in primary and secondary schools, conferences with women and men on sexual violence, AIDS/STI prevention and women's rights. Children, including unaccompanied minors, participated in health fairs, sports carnivals, video shows, all incorporating AIDS/STI messages and other topics of reproductive health. A survey conducted in December 1995, among 360 adolescents aged 13-20 years old showed that over 90% of the adolescents surveyed had high knowledge on how to protect themselves from HIV, and, more importantly, 76% had never had sexual intercourse. The majority knew where they could get condoms if needed, from Aces and Hits or at the health clinics, and over 77% responded there was no problem using a condom if they had to. The 17 boys and 10 girls that had ever sought treatment for an STI, had done so at the health clinics in the camps. A home-based care component was added after the first year as more and more HIV-infected camp dwellers developed AIDS. Volunteers trained in home care regularly visited homebound refugees, bringing water, firewood and food. To avoid further stigmatization of people with AIDS -- a serious problem among Rwandan refugees -- the project did not single out AIDS patients; any ill or disabled person without family support could receive home-based care services. NGOs worked closely together to coordinate the distribution of clothes, blankets and cooking utensils, and helped a group of refugee women to start a kitchen to prepare food for those unable to cook for themselves. Formative Research was conducted for the duration of the project with women, unmarried mothers, youth, traditional healers, and men. Focus Groups were conducted to learn more about cultural barriers in creating prevention programs, special needs of specific groups such as women and youth, and ways to design or refine messages that address those needs. This research lead also to the development of support groups for women and young girls, who found strength by uniting with others suffering the same fate. The harshness of refugee life for women goes far beyond the backbreaking toil so familiar to African women. Many Rwandan women on both sides of the conflict were beaten, raped and tortured. This violence did not end when they reached the refugee camps. Women without male protectors (husbands, fathers, uncles) were particularly vulnerable in the camps. Women reported that men would walk into their huts at will, rape them and leave. When the camps were new, large communal latrines were built some distances from the dwellings. These structures, especially at night, became the site for many sexual assaults on women and girls.
Efforts by the project and other NGOs eventually resulted in having small four-family latrines built closer to the dwellings. Most relief agencies now agree on the need to involve women in the early stages of camp layout to improve security. The research also resulted in regular discussions among Ngara District camps project staff to seek solutions to violence against women. One outcome of these discussion was the formation of a crisis intervention team made up of refugee social workers, counselors and other volunteers who provide medical and legal assistance, and social support for victims of sexual assault. A baseline assessment and KABP survey was conducted by JSI in August-September 1994. The study population for the survey was approximately 100,000 Rwandan refugees in August, 1994, which increased to approximately 165,000 during the evaluation period. A total of 559 refugees (age 15 - 49) who had been living in the camps for at least two months were included in the baseline study. A follow-up survey was conducted in July of 1995, with 484 respondents. An end of project survey, to be conducted in February-March 1997 was canceled due to the closing of the refuge camps. Although the target population did not remain stable throughout the implementation period, baseline and follow-up respondents did remain comparable with respect to age, sex, education level and religion. A comparison of the two surveys documents program effects in several areas. AIDS prevention knowledge levels were already high before the intervention which may serve to explain why there were no significant changes in HIV prevention knowledge. At the time of the baseline measurement, 87% of the respondents could mention at least two effective ways to prevent HIV infection. This figure changed to 85% at follow-up, not a statistically significant difference. However, incorrect knowledge of HIV transmission declined during the intervention period, in all categories - touching or sharing utensils with people with AIDS (PWAs), public latrines, and mosquitoes. In addition, there was a statistically significant increase in the proportion of respondents aware that healthy looking people could carry HIV (from 81% to 87%). Despite what appear to be relatively high levels of knowledge and awareness, however, there were limited changes in at-risk behavior. No statistically significant changes were observed in "ever use" of condoms, which remained low at 37% for men (from a baseline of 35%) and 17% for women (from a baseline of 13%). Condom use during the most recent intercourse remained at the same low level of 16% for men, but increased from 5% to 17% for women. The low rate of condom usage cannot be explained in this case by a lack of condoms. Within a 12 month period, 1.4 million condoms were distributed and the surveys indicates that condom accessibility increased from 52% to 95% for men and from 42% to 85% for women, exceeding the targets set for the intervention. A total of 95% of all sexually active men and 85% of sexually active women reported having access to condoms. One alarming finding was that attitudes towards condoms became more negative during the intervention period. Among those who do not use condoms, as many as 82% do not propose the use of condoms to their partners because they feel condoms are associated with promiscuous behavior. This can be compared to 29% at baseline. Unfortunately, at the same time that the findings document low condom usage, they also reveal increases in sexual activity, especially with multiple partners. More women were found to be sexually active at the time of the follow-up study ( 87% versus 79% at baseline), and the proportion of women who had had more than one partner during the previous 2 months increased to 16% (from 2% at baseline). The proportion of men who had had more than one partner during the previous 2 months also increased to 23% (from 12% at baseline). Perhaps more significantly, changes in sexual partnerships changed during the intervention period. A total of 38% of the sample reported having changed sexual partners during the course of the last year, as compared to 23% the year before, significant at the 95% confidence level. There are a number of ways to interpret these results. New patterns of dependency and of distribution of wealth occurred in the refugee camps, especially during periods in which food distribution was insufficient for some groups. This may have had an impact on sexual networking. Also, there are several marked differences in the demographic variables at baseline and follow-up, which may provide clues to changes in sexual behavior. Many more women declared themselves head of household in the follow-up survey than in the baseline. For 19.3% of the women who participated in the follow-up survey, there were no male heads of household present, as compared to 11.8% in the baseline study, although this may be tied to efforts to obtain additional relief rations. This may also serve to explain the statistically significant shifts from "married with spouse" in the camp to "single" and "married with a spouse elsewhere". There is no question that the refugee environment changed rapidly during the first year of intervention, and changes in sexual behavior were motivated by a whole host of factors. The net effects of AIDS prevention interventions are difficult to untangle in the best and most stable of circumstances. It is especially difficult to do so in the context of a refugee setting. E. Recommendations and Constraints Working with refugees stretches the boundaries of traditional prevention programming. The project's experiences in the Ngara District offered numerous insights for future work with refugees, many of which can be summed up as follows:
Process Indicator Summary
Endnotes
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