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This report comprehensively summarizes the FHI/AIDSCAP program in Senegal (1993-1997). The report includes a discussion of accomplishments, outcomes, implementation and management issues, as well as a series of lessons learned and recommendations.
Table of Contents I. Country Program Description C. Accomplishments and Outcomes D. Implementation and Management Issues II. Lessons Learned and Recommendations III. Subproject Highlights I. Country Program Description (continued) C. Accomplishments and Outcomes Introduction Although the AIDSCAP project in Senegal was designed for the five year period from 1993 to 1997, most prevention activities did not get underway until 1994 and some even later. The project targeted a variety of groups in the four priority regions where USAID works, and carried out a number of BCC and STI prevention activities, as well as condom distribution. The populations reached by these activities included women working in the non-formal sector (market women), youth, male workers (factory and transport), university and secondary school students, registered and clandestine CSWs, and clients of CSWs including STI patients, truck drivers and military personnel. Initial evaluation plans included a variety of approaches including 1) formative (qualitative) research with several of the aforementioned groups to help guide the design of interventions, 2) support to the national HIV sentinel surveillance system for the collection of HIV prevalence data in sentinel risk groups, and 3) pre- and post-KABP surveys in conjunction with several subprojects to measure changes in outcome indicators and 4) a country baseline assessment describing the status of interventions when the program was established. Regarding the third approach, it eventually became evident that due to the multitude of interventions being implemented by AIDSCAP among multiple target groups, as well as the overlap that existed with programs of other donors working with the same target groups, conducting individual KABP surveys to evaluate each project would not be feasible, nor would it yield the desired evaluation results that could attribute outcomes to specific interventions. Therefore it was decided to implement a Behavioral Surveillance Survey (BSS) system that would provide relevant data on behavioral outcomes in key target groups on a repeated basis. Although the BSS would not provide data for individual projects, it would be an invaluable diagnostic tool for understanding gaps in knowledge about different risk groups, and for monitoring changes in behaviors of those groups in geographic areas where AIDSCAP interventions were operational. The BSS groups were chosen to represent some of the groups being targeted by AIDSCAP. At present, one round of data collection has been completed with six target groups, and repeated data collection on these groups, as well as the integration of new groups into the surveillance system, is underway. Several outcome level indicators were outlined in the LogFrame (see below) and as the project evolved, AIDSCAP participated in the elaboration of a set of indicators for the USAID Results Packages under its Strategic Objective for Health (see below). The BSS was designed to provide data for these as well as other indicators that AIDSCAP has prioritized for measuring the stages of change related to HIV risk reduction. A separate survey was also conducted with providers of STI services to obtain data on the quality of STI services. Outcome Indicators
Process Indicators
Strategic Objectives and Intermediate Results Under the new USAID system of monitoring and evaluation of results packages, the mission specified three key intermediate results (KIRs) to be reached through the achievement of several intermediate results (IRs) by September 1998. The behavioral outcome indicators used to measure those results are as follows: Intermediate Result 1: Increased Access to STI/HIV-AIDS Services
Intermediate Result 2: Increased Demand for STI/HIV-AIDS Services
Intermediate Result 3: Increased Quality of STI/HIV-AIDS Services
Accomplishments and Constraints Behavior Change Communication The behavior change communication (BCC) component was one of the principal strategies of AIDSCAP due to the strong link between behavior practices and the transmission of STI/HIV/AIDS. The goal of the BCC interventions was to stabilize or reduce the STI/HIV/AIDS prevalence among target populations at intervention sites. Four objectives were identified in order to attain this goal:
Several types of activities were undertaken throughout the life of AIDSCAP/Senegal to achieve these objectives: training of peer educators; targeted education activities; monitoring and evaluation; development of material supports with AIDS prevention messages (brochures, posters, booklets, etc.); special events and conferences; and a mass media program including written and oral press. The primary target groups for the different interventions were:
Other groups such as clients of CSWs, and men and women with multiple partners, were also considered important target groups, however as they were difficult to identify and isolate, an accent was placed on interventions targeting the general population (for example, the mass media campaigns and special public events) in order to reach these groups. Several secondary target groups were also identified during the life of the project:
Accomplishments The BCC strategy was implemented primarily through subprojects executed by local NGOs and associations. Four subagreements, twelve letters of agreement (LOAs) and thirty-four rapid response funds (RRFs) were granted during the life of the project. The principal activities carried out were: capacity building, elaboration of IEC materials, targeted educational activities and the reinforcement of community participation. In order to develop and improve the capacity of communities to actively participate in the fight against AIDS and increase the capacity of individuals to adopt safer sexual behaviors, several types of training were conducted. Training of trainers workshops were held for health educators, secondary school teachers, social workers, pharmacists, pharmacy clerks and warehouse managers, and doctors and health care workers in the public and private sectors. These trainers in turn organized training sessions for peer educators who would conduct AIDS education activities in their communities. A training module was developed in French and in the national language, Wolof, and used to train a total of 1,022 peer educators. In addition, 120 monitors received training in the utilization of a training module in 6 local languages to include AIDS prevention information in literacy programs. The use of peer educators to conduct AIDS prevention education sessions and activities was one of the main strategies of the BCC component. Peer educators became recognized "experts" on AIDS within their peer groups and communities. They conducted education sessions using IEC materials, films, theater presentations and songs, and distributed condoms. Through these peer educators, AIDSCAP/Senegal was able to spread the message about AIDS to communities and target groups and incite their participation in the fight against AIDS. In addition, peer educators encouraged populations to modify their behavior in order to reduce the risk of infection and provided information and/or means to protect themselves (for example, information on where to go for treatment of STIs and condom distribution). The training of natural science teachers in secondary schools resulted in the training of peer educators in the schools and the creation of AIDS prevention centers in 25 schools where students, parents and teachers would have access to AIDS prevention information. The mass media campaign resulted in a total of 390 radio broadcasts and 259 published articles on AIDS issues, in addition to various radio spots which were created and broadcast throughout the life of the project. Three major events per year were also covered by local television and radio: World AIDS Day, Women & AIDS Week and Youth AIDS Week. In addition, 300 posters were placed on buses and 30 billboards created to reinforce AIDS awareness. African Consultants International (ACI) conducted a training workshop for 163 managers of local NGOs on the implication of HIV/AIDS on other sectors of development and the necessity to initiate AIDS prevention activities through existing programs. In addition, AIDSCAP supported 90 small associations with either financial support, and technical or material assistance to help them execute interventions within their communities. Throughout the life of AIDSCAP/Senegal a significant number of people were reached through different interventions and activities:
In addition, 10 members of the PNLS and doctors from the four Senegal program regions participated in various international conferences. Constraints 1. Subproject Documentation
2. Technical Assistance and Project Monitoring
3. Financial Management
4. Targeted Groups
Improved STI Service Delivery Programs Introduction The objectives of the STI program of the AIDSCAP/Senegal project were to:
Accomplishments An ethnographic study of local perceptions, attitudes and behaviors regarding STIs and STI treatment-seeking behavior was carried out by the University of Cheick Anta Diop in Dakar. This Targeted Intervention Research (TIR) on STIs in Senegal provided essential information on local terminology and beliefs about STIs, as well as about the attitudes of health workers and prevailing perceptions of health services in the community. As part of the baseline evaluation of STI case management (PI6/PI7), all public and private (Catholic and NGO) health facilities in six of Senegal's ten regions were enumerated. Estimates of STI patients seen per week, availability of clinical and laboratory equipment, as well as the number and type of training of health workers were documented. Practices that could discourage people from using services, such as prescription of unnecessary lab tests and medications, were also documented. In order to strengthen the capacity of public and private sector health care providers to diagnose and treat STIs, AIDSCAP/Senegal collaborated with the PNLS and other partners to develop and disseminate national guidelines for STI case management. Operations research to validate the Senegal national algorithms for women presenting to health facilities with vaginal discharge or lower abdominal pain was conducted in collaboration with the University of Washington. The majority of laboratory testing for the algorithm validation study, including a new technique for the culture of trichomonas vaginalis (TV pouch), was conducted at the National STD Reference Laboratory at the IHS. This study contributed information on the prevalence of gonorrhea, Chlamydia, syphilis and genital ulcers among women attending the study clinics, and on the usefulness of current guidelines for identifying STIs. Training modules, pocket guides and wall posters of the national STI guidelines were also developed in collaboration with the PNLS and disseminated to health facilities. A training of trainers workshop was held in Dakar in December 1996. Eight doctors were trained as trainer/evaluators for STI case management training. One thousand, one hundred and sixty-seven health workers were subsequently trained in STI case management; this included 781 nurses, 312 midwives, 38 doctors and 36 other health workers identified in a census of public and private sector health facilities in 6 regions. Forty-three nurses and doctors from 21 Catholic health posts were also trained in STI case management. Training in STI case management included modules on health education. Prevention methods, including condoms, compliance with recommended treatment and the importance of partner treatment were emphasized. Clinical and laboratory equipment was supplied to select public and private health facilities. The STI laboratory capability at 18 Catholic health posts was also upgraded, including training and provision of equipment and supplies. The upgraded health posts now have the capability to perform antenatal syphilis screening. Education, prevention counseling and the provision of condoms was integrated into STI services at the public and private health facilities participating in AIDSCAP subprojects. Peer educators selected from among community and religious leaders were trained in community sensitization about STI prevention and health care seeking behavior. In addition, two brochures on STI prevention and condom use were developed and distributed to health centers. Constraints Studies conducted under AIDSCAP showed a low utilization of health facilities for the treatment of STIs, especially by men. The total number of men (432) estimated to be seen weekly for STIs in the busiest health facilities in the 6 regions was less than 22 percent of the total estimate for women (2,050). Only 3 of 76 patients with STI-related symptoms observed during the PI6/PI7 evaluation were men. This confirms findings from the TIR as well as anecdotal information from health workers. Women appear to utilize services more regularly for pregnancy and reproductive health needs while men are believed to seek care from a variety of alternative sources. Condoms Introduction In Senegal, condoms have been distributed for many years, mainly for family planning (FP) purposes through family planning clinics. Aside from family planning facilities, only pharmacies are currently authorized to sell condoms as they are categorized as "para-pharmaceutical products". On the other hand, Senegal customs authorities consider condoms as "non-pharmaceutical products " and are therefore subject to customs duty. In 1990, a study conducted by ENDA-Santé showed that the following charges were placed on the importation of condoms: Table 2: Charges on the Importation of Condoms
As a result, the price paid by the consumer is much greater than the basic price of the condom. The same study showed that pharmacies in Dakar sold a total of twenty different brands of condoms. Another study conducted by AIDSCAP in 1994 showed that 22 out of 27 markets surveyed sold condoms, the prices of which ranged from 40 CFA to 125 CFA per condom (approximately $0.09 to $0.27). In 1989, the distribution of condoms was extended to AIDS prevention. During that year, a team from the WHO Global Program on AIDS (GPA) assessed that 2 million condoms were needed for AIDS prevention activities in 1990. It was recommended that one million of these condoms be provided by WHO/GPA, 500,000 by USAID and the remaining 500,000 by any other willing donor. Between 1989 and 1990, WHO alone supplied a total of 4.4 million condoms to the PNLS, however, thereafter stopped supplying condoms to Senegal all together. With the startup of the AIDSCAP project, USAID agreed to provide 1,750,000 condoms every year to the PNLS through the project. These condoms were to be distributed free of charge through institutions identified by the PNLS in all of the 10 regions of Senegal to targeted populations deemed to be at high risk. This agreement was made by USAID as a stopgap measure to deal with the issue of the availability of condoms for AIDS prevention until the Condom Social Marketing (CSM) pilot project under SOMARC began. The SOMARC project became operational in 1995 under the Child Survival/Family Planning project of USAID, with initial sales through pharmacies. This strategy of SOMARC has prevailed to date, with the result that condoms for AIDS prevention for the targeted populations have remained available only through the PNLS/AIDSCAP free distribution system. The PNLS/AIDSCAP Condom Distribution System The PNLS storekeeper for condom stock is based at the central warehouse of the Pharmacie Nationale d'Approvisionnement (PNA). The space occupied by the storekeeper was renovated by AIDSCAP with the addition of security fencing and locks, electrical repairs and pallets to stock condoms. A new quarterly distribution system was established to deliver condoms to the 10 regions of Senegal for specific institutions as determined by the PNLS. The storekeeper received condoms from the port, recorded the quantity on the inventory control card, and subsequently supplied condoms to the 10 regions and to major NGOs located in Dakar which operate at the national level, private enterprises, military installations, and the University of Dakar. The PNLS storekeeper supplied regions on a quarterly basis with predetermined quantities of condoms: 51,000 units/region for AIDSCAP regions and 48,000 for non-AIDSCAP regions. Dakar had a special allocation of 123,000 condoms per quarter. Upon receipt of condoms from the central warehouse storekeeper, the receiver at the regional level signed an issue voucher. At the same time the storekeeper collected a stock situation report. Each report had a list of predetermined high-risk groups or NGOs to be supplied by the region. At the regional level, the regional condom manager (head of the regional health education unit) kept an inventory control card and received from each recipient NGO or each health facility supplied by the region a quarterly stock situation report. At the district level, condoms continued to be available through the same channels as for family planning. The condom distribution and management at this level remained under the control of a Primary Health Care Supervisor and districts were supplied by the region on a monthly basis. At the district level all health facilities such as health centers, health posts, high-risk intervention sites and/or NGOs operating in the district were supplied. Each district commodities manager was given a monthly stock form at the time of condom delivery. The following target groups were identified as being at highest risk for HIV/STI infection by the PNLS and were therefore targeted by the free condoms distribution system: registered commercial sex workers and their partners frequenting STI clinics, university students, secondary school students, out-of-school youth, the military and the paramilitary.
Unlike other African countries, commercial sex work is "legal" or tolerated in Senegal. CSWs are registered with police authorities and are given cards stating their profession. They are required by law to submit these cards monthly for health checkups by the regional STI clinics. When a CSW is diagnosed with an STI, she is treated and her card withheld until she is considered cured. The CSWs not only benefit from STI treatment but are given counseling, provided AIDS education and are given free condoms, approximately 40 per month.
The University of Dakar has a population of 20,000 students and 5,000 personnel. Initially, the university received condoms through a subcontract signed with AIDSCAP. Under this subproject, each student received 20 condoms per month and each staff member received 10 condoms per month through the PNLS/AIDSCAP distribution system. However, the subcontract with the university was terminated on August 26, 1996 and some of the activities were reprogrammed under an ongoing AIDSCAP project implemented by Santé de la Famille (SANFAM). In addition to receiving family planning condoms, SANFAM was also listed among organizations receiving condoms in Dakar under the PNLS/AIDSCAP condom distribution system.
In some of the secondary schools, condoms are supplied through the family planning or the PNLS/AIDSCAP distribution systems. The management of the condoms is the responsibility of a medical assistant nurse who supplies 10 boxes of condoms per school per month. Each student may receive 10 free condoms upon request. In some of the schools, science teachers are also involved in condom distribution.
The NGOs and associations working with this target group received their supply of condoms from ENDA-Santé, an NGO who received 3,000 condoms per quarter from the PNLS/AIDSCAP distribution system.
The armed forces have always been considered a high-risk group in AIDS prevention programs because of the nature of their work and frequent movements within the country and internationally. In Senegal, the military comprises only the "gendarme" and military personnel. The other uniformed personnel are paramilitary -- firemen, national security personnel and interior ministry personnel. The PNLS/AIDSCAP condom distribution system targeted both groups. Constraints
Policy Dialogue Introduction The main purpose of policy dialogue is to create an environment which is favorable to AIDS interventions and which supports a program of AIDS prevention and control. This is accomplished, in part, by increasing the awareness of the AIDS epidemic among policy makers, resource holders and community leaders and increasing the understanding of the implications of the epidemic on social and economic development and the stability of the country. In addition, through policy dialogue, emphasis is placed on the urgency of establishing sustainable interventions to prevent and slow the transmission of HIV. Creating this positive environment means not only working with political, community, and traditional leaders, but also with other opinion leaders who influence the views and behaviors of the community. Senegal is a country in which the population is strongly influenced by its religious leaders. Ninety percent of the population is Muslim and five percent Catholic. The strength of the Muslim community reaches all aspects of the Senegalese culture, and even though the Catholic community is a minority, the Catholic church has a strong influence on the education of youth in schools. Overall, religion plays a significant role in Senegalese society and the important involvement of religious leaders in the fight against AIDS was identified at an early stage in the AIDSCAP/Senegal program. Four objectives were identified for policy dialogue in Senegal:
Accomplishments AIDSCAP supported African Consultants International (ACI) in the implementation of a study to assess the knowledge and attitudes of political and religious leaders concerning AIDS issues. The study provided adequate background information for AIDSCAP to collaborate with the PNLS and JAMRA, a local Islamic NGO working in AIDS prevention and social issues, in organizing a national seminar on AIDS and Religion. In addition, JAMRA executed a subproject under AIDSCAP to educate religious leaders and Koranic teachers on AIDS issues, in addition to the establishment of health kiosks for the provision of information on AIDS and other health issues. The first national Colloquium on AIDS and Religion was held in March 1995, during which Islamic religious leaders learned about HIV/AIDS and offered recommendations about their roles and responsibilities vis-à-vis HIV/AIDS. This meeting was the first of its kind in Africa and the first time in the history of Senegal that government and religious leaders met to exchange views on any subject. It was followed by a series of regional political seminars (see paragraph below on ACI) to inform political and religious leaders about HIV/AIDS. A second seminar, the Christian Response to AIDS, organized by the PNLS and SIDA Service, became a forum for active inter-religious discussions and debates on educating youth, ending discrimination against people infected with HIV, and the care of AIDS patients, among other issues. In addition, SIDA Service worked with the Christian community in the organization of education sessions. ACI also implemented under AIDSCAP six regional seminars for opinion leaders and facilitated a 2-day seminar led by the PNLS for the National Assembly educating 72 parliamentarians. By the end of the ACI subproject, both religious and political leaders were making public statements about the epidemic in their sermons and political activities; JAMRA and SIDA Service had grown into large, effective organizations; and 2 major seminars on Islam and AIDS and the Christian Response to AIDS had been organized in the country. Through the efforts of the PNLS, ACI, JAMRA, SIDA Service and other AIDSCAP partners and organizations working in AIDS prevention in Senegal, Senegal has moved from avoidance of political dialogue and only timid attempts to involve religious and political leaders, to an active, all-out effort to involve opinion leaders and decision makers from all levels of society in the search for responses to the AIDS epidemic. There has been a qualitative and quantitative change in the number of leaders involved and the frequency and intensity of public discussions of AIDS related issues. While this has yet to result in a clear national AIDS policy, and a well-coordinated multisectoral approach, much progress has been made in this direction. Constraints
Recommendations A feasible process for engaging persons who influence policy (or policy "influencers") and policy makers should be set out, including the identification of: 1) a key group or groups to facilitate interaction and involvements with "influencers" and policy makers; 2) methods for reaching, informing and fully engaging these groups; and 3) issues that can be effectively tackled, including prioritizing issues in terms of urgency and political feasibility. Without a defined group to facilitate policy development, policy work ends up being a set of scattered and probably unconnected events. |
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