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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 the STI and IEC Monitoring Capabilities of PNLS
Background and Scope of Intervention The subproject "Strengthening of STI and IEC Monitoring Capabilities" of the PNLS was implemented between September 1, 1995 and April 30, 1997. The purpose of the project was to improve the quality of STI prevention and IEC programming at the national level. The subproject design emphasized three main outputs.
Accomplishments and Outcomes The PNLS played a pivotal role in the AIDSCAP project, firstly as the national AIDS and STI coordinating body, and secondly as the recipient of AIDSCAP technical and material assistance for institutional strengthening, enhancing technical capacity in STIs and IEC, and improving national STI control services. This component of the AIDSCAP project sought to improve the coordination and leadership role of the PNLS in HIV/STI prevention activities throughout Rwanda. This would be accomplished through improving specific technical skills of key PNLS staff in their respective areas of expertise, and through providing material assistance to improve the national STI and IEC coordination and monitoring capabilities of the PNLS. Improving STI Services and Management Prior to the war, AIDSCAP supported operational research in implementation of improved STI services in two Rwandan health facilities. The data from this experience was presented at a national consensus meeting held in Kigali in March of 1995 and national guidelines for STI case management based on the syndromic approach were subsequently adopted. This was followed by 2 one-week, back to back, (English and French) Training of Trainers workshops in the use of the National Guidelines organized by the PNLS and funded by WHO. The workshop was conducted with technical assistance from AIDSCAP, through its STI subcontractor, the Institute of Tropical Medicine (ITM), Antwerp, Belgium, the AIDSCAP Regional STD Officer, and the PNLS STD Unit Chief. During the workshops, a core of 38 medical personnel, at least two of each of the 11 prefectures, and from the Gitarama and Military subprojects, were trained. Improving STI services delivery was a crucial component of the AIDSCAP/Rwanda Program. In order to improve the management of patients presenting at health centers with STIs, a comprehensive training program in STI case management was implemented for public sector providers in 7 medical regions of the country. The Gitarama Region was targeted under a separate project, as were the armed forces (RPA). Under the supervision of the STD Unit Chief, 15 training sessions were conducted for 332 public clinic staff. Training include syndromic management according to national guidelines, counseling, partner referral, and condom demonstration and promotion. An STI case management manual was developed and subsequently produced, and 200 copies have been distributed to trainers, supervisors and the participating health centers for use in STI management. A STI pocket guide and a Treatment Algorithm Wall Chart/Poster were also produced and distributed for use by the health care providers and participating clinics. To strengthen the capacity of the PNLS to monitor STI case management provided by the trained health workers, and to monitor and evaluate STI trends, a program of supervision and surveillance was established. A system of regular supervision was in place and a simple form for record collection was developed for use at the clinics. An evaluation using a modified version of collecting data on prevention indicators 6 and 7 (PI6 and 7) was undertaken by ITM in February of 1997 and PNLS staff were given preliminary training on how to use this method of evaluation of STI case management. Evaluation results are discussed in detail in the STI section of this report. However, it is worth noting that the assessment also included key informant interviews with seven supervisors and trainers. The interviews showed that there was little compliance with completion of the additional forms introduced by the project. The health care providers explained that these forms represented extra work during the patient visits, and that this information was readily available in the patient register. The trainers also indicated that the STI training manual needed to be revised and updated to include sections on condoms and communication. In order to strengthen the institutional capacity of the STI unit at the PNLS, the unit chief participated in several AIDSCAP-sponsored trainings. This included a two-week STD Managers course in Nairobi, organized by AIDSCAP in collaboration with the European Community. Topics covered in this course included principles of STI control, STIs and reproductive health, STI case management (program management, health education, supply logistics, training & supervision, surveillance, monitoring and evaluation). The STI chief also benefited from a one-week study tour in Uganda, visiting STI/AIDS programs, STI sentinel sites and various institutions dealing with STI/AIDS control. The aim was to learn from Uganda's experience since Rwanda faces the same challenges and had similar problems of war and social strife. To support the syndromic approach, it is important for drugs recommended in national treatment guidelines to be periodically evaluated to ensure that (1) recommended drugs are still effective, (2) treatment guidelines are updated and, (3) effective drugs are added to the essential drug list. In anticipation of donor funding to conduct such an antibiotic sensitivity study, the senior laboratory technician from the reference laboratory at the Central Hospital Kigali was trained at ITM in Belgium in new laboratory methods for evaluating STI drug resistance. The aim was to provide the PNLS with the skills to conduct studies of this nature in collaboration with the main referral hospital in Kigali. The results of such a study will allow the STI unit within the PNLS to refine the guidelines for STI diagnosis and treatment. Coordination and management of IEC activities The main task of the PNLS IEC Unit was to coordinate and monitor communication activities at the national level. This was accomplished through convening regular IEC planning meetings; maintaining a resource center for HIV/STI materials; establishing an HIV/STI clearing house, producing a quarterly newsletter, and disseminating information to the regions through the MEDIRESA to maximize reach of media and materials development. The PNLS worked closely with CIDC to ensure that the materials produced by the latter reached the Medical Health Regions, which were in turn responsible for distribution to their respective health clinics and community-based workers. IEC Subcommittee Meetings -- The PNLS IEC unit ensured that regular IEC subcommittee coordination meetings were held, six over the life of the project. The IEC subcommittee included representatives from the PNLS, CIDC, WHO and other donors and implementing agencies providing funds or conducting IEC activities in the country. The purpose of these meetings was to plan coordinated execution of IEC interventions in order to avoid duplication of effort, particularly in relation to materials development, and to exchange ideas and solve problems encountered. The subcommittee was also very active in planning and implementing World AIDS Day activities countrywide. Training -- As part of the capacity building of the PNLS professional staff, the IEC unit chief was sent for a four-week intensive training course in "Sexuality Education, HIV/AIDS Prevention & Reproductive Health Care" at the Margaret Sanger Center International, USA. He also participated in the Third USAID HIV/AIDS Prevention conference in Washington. With technical and material assistance from the AIDSCAP/AFRO BCC Officers, the PNLS organized a workshop for Rwandan print and broadcast journalists to improve the reporting on HIV and STIs in the country. The workshop was held in Kigali and 38 public and private sector journalists took part. PNLS IEC unit staff also participated in the formative research and IEC materials development workshops organized by the CIDC with support from AIDSCAP Resource Center and HIV/AIDS Clearing House -- Prior to the war, the PNLS, with assistance from the Canadian Government, had established a database of all HIV/AIDS and STI materials available in the country. The PNLS lost all its equipment during the looting that followed the civil war. However, part of the information data base had been recovered since it was backed-up on diskettes. In addition, a large part of the materials (books, magazines) located at the PNLS and Butare university libraries have been recovered as well. Under this project, AIDSCAP provided computer equipment and financial assistance to complete the inventory of all available materials in the country. The PNLS Information Specialist traveled to the regional documentation center located in Butare and assessed the status of the center. He also conducted bibliographic research in Butare and Kigali and entered the data into the new database. By month six of the project, the first clearing house catalogue "Documentation sur le Vih/Sida au Rwanda, Volume 1, 2, 3", was updated and printed, with a limited distribution to international and local NGOs, donors and researchers. AIDSCAP also provided additional library materials such as AIDS and STI reference books, videos, and journal subscriptions, in addition to office and library supplies. HIV newsletter -- Prior to the war, the HIV/STI newsletter was supported with funds from the Canadian Government. The current newsletter "CARREFOUR SIDA" has been published 3 times. It provides its readers with the latest statistics of HIV and AIDS in the country and the latest information on AIDS and STI research. It also provides space for guest contributors. A total of 4000 copies were printed and distributed with AIDSCAP funding. World AIDS Day and regional activities -- Each year in Rwanda, the first two weeks of December are devoted to "La Quinzaine du SIDA". The period begins with World AIDS Day activities on the first of December and the activities; parades, radio shows, song festivals, theater etc., continue for two full weeks all over the country. The World AIDS Day activities are coordinated centrally by the PNLS. In September of each year the PNLS convenes a meeting of all national and international organizations (WHO, UNDP, CARE, PSI, AIDSCAP, CIDC, MEDIRESA) working in AIDS prevention to plan for the World AIDS fortnight. Regional activities -- To support decentralization, and to ensure that activities are carried out at the prefecture level, an HIV/AIDS focal person/specialist has been identified and trained at each prefectures' headquarters, to assist the Regional Medical Director (MEDIRESA) in coordinating and monitoring HIV/AIDS prevention activities in their respective regions. The PNLS organized a workshop in Kigali to train 27 "Focal Point HIV Prevention Specialists" in the management, organization and monitoring of AIDS prevention activities. The "focal point person" in each prefecture worked very closely with the MEDIRESA and the respective units at the PNLS to ensure that all activities in the prefecture were coordinated through the office of the MEDIRESA and also in concert with activities organized at the national level. This person was responsible for coordination with the IEC unit to ensure that IEC materials were received and distributed in a timely fashion, coordinate World AIDS Day activities and also keep informed of any other HIV and STI activities taking place in his or her region. Finally, the PNLS organized three information seminars for students of higher education on HIV/AIDS and STI prevention. The seminars were held at the National University of Rwanda in Butare, and in Kigali. Important Constraints
Lessons Learned and Recommendations
Summary of Achievements
Process Indicator Summary
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