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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) BCC Intervention With Armed Forces in Rwanda
Background and Scope of the Intervention This project with the Rwanda Patriotic Army (RPA) through PNLS was implemented between April 1, 1995 and April 30, 1997. The army is known to be a high risk group due to the mobility and young age of its members as well as to the subculture that exists within its ranks, which, even more than in the general male population, accepts having multiple sexual partners as desirable and as proof of "manliness". The purpose of the subproject was to change behavior of members of the RPA through the implementation of a peer education program which promotes partner reduction and increased condom use, and to further reduce the risk of HIV infection by improving STI case management through the introduction of the syndromic approach in army health facilities. Accomplishments The subproject resulted in the training of 384 health staff as peer educators and 84 health service providers in the syndromic approach for STI case management. The project reached over 18,000 soldiers, developed two posters and one comic book, specifically targeted to the military, and established 40 condom distribution points. In addition, 16,600 IEC materials and over 850,000 free condoms were distributed within the military. The 384 Peer Educators trained were recruited from among the army medical corps and community health educators. The cadre of persons trained included nurses, doctors and community health educators. These Educators organized over 1,800 educational sessions on HIV/AIDS/STI prevention and correct condom use, distributed materials and arranged for PSI to show awareness and prevention videos in their barracks. The "health educator guide", developed for the Cameroon Military Intervention was used by the Peer Educators as a guide for planning and conducting educational sessions. The PNLS with overall management responsibility for the project, played a large role in the training of the peer educators in communication skills and clinical staff in STI syndromic management. The evaluation of STI case management reported on earlier was only able to access one RPA clinic due to continued conflict and security reasons. Although it is not possible to generalize the performance in STI management from this one site, the weak results do indicate a need for further follow-up and supervision in this area. As part of the project, a baseline KABP survey was conducted among a selected group of military personnel. Given the short interval between the baseline survey and the end of project, no follow-up KABP was conducted. However, in order to have some indication of the project's impact, FGDs were carried out prior to the end of the project. The results of both of these studies are summarized on the next page. It is expected that funding for the RPA's AIDS prevention intervention will continue through a grant from the World Bank and that a follow-up KABP will form part of the intervention package. Important Constraints The high level of mobility of the RPA made it difficult to follow-up the peer educators for effective supervision. In addition, the high state of alert of the RPA throughout the project period due to internal and external security problems and the continued insurgence of Hutu rebels made it often difficult for soldiers to participate in educational sessions. The lack of a vehicle for the first year of the project delayed many planned activities. In the second year, USAID supplied a vehicle managed by the AIDSCAP country office to assist with the monitoring and supervision. Behavioral Data In July of 1995 a baseline KABP study was conducted among the members of five randomly chosen RPA brigades. The findings of the FGDs conducted in March of 1997 are summarized below:
Knowledge of STI/AIDS and risk perception The majority of soldiers interviewed were able to identify the major symptoms associated with urethritis and know that STIs are transmitted sexually. Very few of the soldiers interviewed named erroneous methods of transmission. Transmission through the sharing of toilet facilities with someone infected by an STI was the erroneous method most commonly mentioned. Young soldiers most often cited abstinence from sex as a method of prevention while older soldiers were more likely to mention condoms. All groups interviewed (soldiers, sub-officers and officers) were able to cite that the major methods of prevention were abstinence, monogamy, and condom use. However, the proportion of interviewees who could name all or many methods of prevention was quite low. HIV is as well known in the army as are other STIs. Most soldiers stated that sexual intercourse is one way or the only way to contract the HIV virus. The use of condoms during sex was the prevention method most frequently cited. A large number of the respondents felt that they were at risk of contracting HIV, but few recognized that this risk was related to their personal behavior. For the most part, they identified their major risk factor as that of being unsure of their partner's fidelity. Sexual Behavior and Access to Condoms Almost all the military personnel interviewed confirmed that the practice of having multiple sexual partners was common (the norm) within the army. A number of soldiers estimated that as many as three-quarters of their peers had many sexual partners. However, very few admitted to having many partners themselves. The reasons offered for the continuing practice of having multiple partners included the young age of soldiers, their mobility, and the low perception of risk most military personnel hold. All persons sampled nonetheless believed that soldiers have fewer partners today than soldiers have had historically. More than half of the discussants claimed to have used a condom at least once during their lives. Although some discussants claim to use condoms with all partners, most say they use them only with casual partners. Those who never or almost never use condoms give reasons for nonuse including the reduction of sexual pleasure, the reluctance or refusal of their partner, ignorance, or the desire to have children. Almost all discussants claimed to be able to easily obtain a condom when one was needed since they are distributed free of charge in their barracks. Exposure to the project The title "peer educator" is little known among military personnel. However, respondents reported that they had received information on AIDS from "Political Commissaries", often referred to as "PC" and/or medical personnel. Since the project's health educators were selected from among PCs and paramedical personnel, it is most probable that the PCs or nurses that the military report to have met with on HIV/AIDS issues are actually peer educators trained within the military project. The majority of discussants claimed to have seen education materials (mainly posters) on HIV/STI prevention, but quite often, this material was not directly targeted to military personnel. Overall, the military personnel claim that the information and education received from different sources has raised their awareness of the risks and dangers of AIDS and has changed sexual behavior (particularly by reducing number of sexual partners and increasing condom use). They expressed a desire for more educational material on AIDS/STI prevention targeted at them in particular. They also would like to see an increase in the activity of peer educators. Those who knew the peer educators found their activities to be useful. Lessons Learned and Recommendations
BCC Intervention with Armed Forces Summary of Achievements
Process Indicator Summary
Background and Scope of the Intervention While the PNLS was responsible for coordinating and monitoring communication activities at the national level, the Centre for Information, Documentation and Counseling (CIDC), served as executing agency for the production of media and materials to be used across projects. CIDC was created in 1988 -- originally established as the operational IEC unit of the PNLS -- it became autonomous in 1991. Prior to 1994 it received most of its funding and technical assistance from the Canadian Cooperation. The pre-war CIDC program included a voluntary testing and counseling center, counselor training and curricula development, written and audiovisual materials development, and mobilization of groups at risk, particularly women. With support from local and AIDSCAP technical specialists, the agency was responsible for drafting, pretesting, finalizing and arranging for production and distribution of project-wide materials and media, and for participating in regular planning and monitoring sessions with the PNLS and the AIDSCAP/Rwanda office. Given the post conflict urgency to resume STI and AIDS prevention activities, a short contract was signed with CIDC to allow it to launch a national mass media campaign on World AIDS Day in December 1994, while it also provided funds to prepare for the broader project to improve the quality of communication resources in Rwanda. The mass media campaign project started on December 1, 1994 and was completed by April 30, 1995. It was immediately followed by a broader communications program which ended on April 30, 1997. Mass Media Campaign A national mass media campaign was launched on World AIDS Day, December 1, 1994 in collaboration with the PNLS and the support of the AIDSCAP/Rwanda office to reintroduce AIDS and HIV issues to the post-war population. Using the theme, "AIDS is still here despite the war", the campaign targeted the general population, youth, and sexually active adults, promoting the use of condoms for all sexual encounters. CIDC completed all activities outlined in the short contract. These included the following:
Materials were most often distributed from the back of a van during market days, at rallies, group meetings, or at conferences so that discussion of the issues could take place. Lessons Learned and Recommendations The main lesson learned was that while media campaigns can be useful to introduce discussion of an issue or to complement other activities, they cannot be expected to create or sustain attitude or behavior change by themselves, and therefore need to be part of a larger integrated communication program. |
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