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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 Executive Summary (See Below) 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 Executive Summary AIDSCAP's operations in Rwanda began in October 1993. By April of 1994 when the civil war broke out, the country office was staffed, two subprojects had started, three additional activities were about to be awarded funding, and several other interventions were at different stages of development. When AIDSCAP developed the country strategic document in May 1993, despite the uncertainty of political, social, and economic life in Rwanda, unique opportunities existed for a successful AIDS prevention project. A serosurveillance system was well-established, and the AIDSCAP program called for a nationwide KABP survey, which was expected to facilitate project evaluation and to provide crucial data that would demonstrate the efficacy of prevention interventions. Rwanda already had one of the highest HIV infection rates in the world. Particularly affected by HIV/AIDS were city dwellers whose prevalence rates in 1991 were reported at 27 percent. In the capital city of Kigali research indicated that 90 percent of mortality among women of reproductive age was due to AIDS. These data translated into severe social, economic consequences for Rwandan society as deaths from AIDS among economically productive, sexually-active adults result in serious stresses on extended families and communities including single parent households, orphans and economic hardship for survivors. Rwanda's small size and relatively good infrastructure favored the design of a program with national-level impact. Since the epidemic was largely an urban/periurban phenomenon it was thought to be possible to minimize the spread of the epidemic to the rural population. The Rwanda program was designed to contribute to the national efforts to reduce the rate of sexual transmission of HIV by building the capacity of governmental and nongovernmental organizations to implement AIDS prevention interventions. The AIDSCAP/Rwanda program was suspended with the outbreak of civil war in April 1994, as were all other USAID-funded activities. Concurrent with the civil breakdown was the beginning of a rapid and massive migration of Rwandans fleeing the violence, first into Tanzania and later into Zaire. Almost immediately, plans were developed to continue AIDS prevention activities with the refugee population and by the summer of 1994, a large part of the AIDSCAP/Rwanda resources and activities had been reoriented to the newly created needs of Rwandan refugees in Tanzania. When the political situation stabilized inside Rwanda, AIDSCAP reopened its office in Kigali in October 1994 and implemented a scaled-down version of its original program design. The AIDSCAP/Rwanda program consisted of two geographically distinct components: the AIDSCAP/Rwanda country program implemented by the AIDSCAP country office in Kigali, and the AIDSCAP intervention with Rwandan refugees in Tanzania managed by the AIDSCAP Regional Office in Nairobi. Both components focused on three mutually reinforcing strategies: controlling STIs; increasing access to and acceptability of condoms; and implementing communication strategies aimed at reducing high-risk behaviors. AIDSCAP/Rwanda Country Program The AIDSCAP/Rwanda program was implemented in collaboration with the PNLS with the help of several government and parastatal implementing agencies including the Medical Services of the Ministry of Defense, the Gitarama Health Region, and the Centre d'Information, Documentation, et de Counselling (CIDC), as well as international and local NGOs. The AIDSCAP/Rwanda program operated at the national and regional levels. National interventions included a condom social marketing program implemented by Population Services International (PSI), institutional strengthening of the PNLS with an emphasis on STI control using the syndromic approach, and, with CIDC, improving the quality of IEC programming focused on STI/HIV prevention. The geographically-focused and targeted activities included interventions with STI patients, youth, single and married women and military personnel. Refugees were reached under a separate community-based intervention at the Benako camp in the Ngara District of Tanzania. The behavior change communication strategy included formative and audience research to guide the interventions, the choice of communication channels, and the development of appropriate messages and materials on safe sex, condom use, abstinence and fidelity. The strategy also included training subproject staff and volunteers in the use of prevention messages, condom demonstrations, and important health-seeking behaviors. The AIDSCAP Rwanda program combined a variety of approaches to influence behavior change among its target populations, training over 6,000 peer, health and community outreach educators. The program used the peer educator approach with army personnel, young and single women, youth, and CSWs. Antenatal women and STI patients were reached at primary health clinics with prevention counseling provided by trained social workers and other health staff. Community-outreach programs worked through women, heads-of-household; elected women heads of sector, and community health volunteers to reach women, youth and CSWs. The combined programs reached over 800,000 people with IEC and prevention messages. Mass and alternative media were used extensively to support and reinforce the prevention messages being communicated through educational sessions and informal chats. These media included radio soap operas, music programs, radio talk shows, fashion shows, songs festivals, drama, skits and video presentations. A play specifically developed for young adults, including a discussion guide, was part of a HIV/AIDS prevention program introduced in 23 schools in the Kigali prefecture. Over 4,000 media messages were broadcast, reaching an unknown number of people in Rwanda. Over half a million educational materials were distributed in support of the IEC, condom and STI activities. In April 1995, national STI treatment guidelines were adopted by the PNLS using the results from pre-war operations research conducted by AIDSCAP and USAID's Rwanda Integrated Maternal Health Project. Subsequently, the Ministry of Health, with financial support from WHO and technical assistance from AIDSCAP, trained a core of 38 trainers in syndromic management, prevention counseling and partner referral. AIDSCAP supported three STI subprojects with the Gitarama Health Region, PNLS central and the military, which combined trained 521 service providers in syndromic diagnosis and treatment of STIs according to the national guidelines. Training also focused on partner referral as well as other elements of counseling, such as condom use, and compliance with taking a full course of drugs. Thirty-one trained social workers reached over 90,000 antenatal women and STI patients through group prevention counseling at primary health care centers. An AIDSCAP-supported evaluation of the STI component (PI 6 & 7) by the Institute of Tropical Medicine, Antwerp in February of 1997 revealed that the correct drug was prescribed for 94 percent of cases at the Gitarama Project site, for 74 percent of the cases at the military site, and for 46 percent of the cases at PNLS project areas. Correct case management was found in 93 percent of the STI cases in the Gitarama Health Region, in 77 percent of the STI cases in the Kigali Health Region, and in 67 percent of the cases in the military health center surveyed. Condoms were available in 11 of the 14 centers surveyed; the three centers were condoms were not available were affiliated with the Catholic church. The program developed a training manual on syndromic management, and an algorithm wall chart and pocket guide that were distributed to STI clinics and health care providers. Behavioral research data at the time of the program design showed that despite high knowledge of AIDS and its major modes of transmission, the use of condoms was low. Therefore, the condom programming strategy aimed to increase and improve condom accessibility throughout the country and to promote condom use as an effective means of preventing HIV transmission. Condoms were effectively marketed by PSI, with average national monthly sales reaching 230,000 by August 1996. A total of 1,500 new condom sales outlets were opened during the 19 months of post-war AIDSCAP support. Additional outlets were established by NGOs and independent wholesalers. Increased accessibility of condoms has been achieved with 71 percent of condoms being purchased from four widely accessible sales categories: boutiques/kiosks, clinic/health centers, pharmacies, and community-based sales distributors. In addition to the 3.15 million Prudence condoms sold by PSI, AIDSCAP distributed over one million condoms through its peer education, outreach and community-based subprojects. Social marketing of condoms has proven to be effective, despite the mass movement of people and the physical destruction of the infrastructure due to the war. The private sector was one of the first components of the Rwandan society to reorganize; social marketing principles 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. Under AIDSCAP, capacity-building among Rwandan NGOs and government institutions was achieved by developing a core staff capable of conducting formative and audience research, and of designing IEC materials based on accepted communication theories and practices. CIDC and other implementing partners now use a systematic process of audience segmentation and research to guide message development and involve their target audience in designing and pre-testing materials and messages. Training of trainers workshops in counseling, prevention communications, and STI syndromic management created a pool of trainers who are applying their technical expertise to train others. The Gitarama Health Region personnel, when interviewed as part of a key informant interview process, indicated that their capacity and skills in the syndromic management of STIs are a direct result of the AIDSCAP-funded training. In addition, the PI 6 & 7 evaluation of the STI intervention was largely positive. The health personnel also stated that within the context of the AIDSCAP project, improvements in management, budgeting, planning, information sharing and networking occurred within the region. Some of the most important lessons learned in implementing the country-based program were:
AIDSCAP Refugee Intervention in Tanzania The tragedy of the Rwandan civil war made it possible to implement the first ever large scale AIDS prevention program for refugees. By August 1994, AIDSCAP had established prevention activities for the Rwandan population living in refugee camps in northwestern Tanzania along Rwanda's eastern border. CARE International assisted by John Snow, Inc. and PSI, launched a community-based HIV/STI prevention program in the CARE-managed Benaco camp in Tanzania, home to a quarter million Rwandan refugees. The activities gradually expanded to three other refugee camps in the Ngara District. A combination of trained community educators , health information teams , crisis intervention teams, condom promotion teams, and counselors provided information and counseling to over 500,000 people. STI treatment was provided at most NGO-managed outpatient clinics by health care workers trained by AMREF; approximately 7,000 people were treated over the life of the project. A home-based care program was implemented for the sick, including people living with AIDS, and a group of women volunteers set up a soup kitchen to provide food for the homebound. The crisis intervention team was created to provide social, legal and medical support to women and young female victims of sexual violence. "Adolescent Health Days" were held to acquaint teenagers with the health services available to them. Thousands of youth were also targeted with messages, using traditional dance and songs, at sporting event half times. Not only did these events keep young people occupied, they served as an excellent venue to convey HIV/AIDS prevention messages. Working with refugees stretches the boundaries of traditional prevention programming. AIDSCAP's experiences in the Ngara District offered some important insights for future interventions with refugees, including the following:
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