|
Programs |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
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 Project Outcomes Biologic/impact The epidemic in Senegal has, for the moment, been less catastrophic than that of some other countries in Africa. The number of officially declared AIDS cases was 2,168 in December, 1996 and as of June, 1997 there were a reported 80,000 HIV infections. Although it appeared at one point in time that HIV levels might be rising, HIV sentinel surveillance data collected since 1989 in Dakar, Kaolack and Ziguinchor, and since 1993 in Thies and Mbour continue to document low levels of HIV-1 and HIV-2 (i.e. below 1 percent) in pregnant women, as compared with other African countries. These low levels of HIV infection are undoubtedly due, at least in part, to the information and education campaign instituted early in the epidemic by the Ministry of Health. Despite this positive indication, there are still enough potentially threatening signs to warn against complacency. Among these are the continued high levels of HIV-1 infection in TB and hospital patients, between 5 and 15 percent in Dakar and even higher in Kaolack and Thies. Particularly alarming is the prevalence of HIV-1 in commercial sex workers, which ranged between 10 percent in Kaolack and Ziguinchor to nearly 16 percent in Mbour in 1995. Data on STI prevalence continues to be scarce in Senegal, making it difficult to assess progress in this area. Although STI trends can provide an indication of the short and medium term effects of prevention programs, there is currently no STI surveillance system in place in Senegal that would facilitate the estimation of the incidence of STIs such as gonorrhea and Chlamydia. STIs are generally under-recognized in Senegal, despite significant levels in selected, albeit non-representative, groups. A study carried out in 1990 in Dakar showed that 30 percent of women had trichomonas, 13 percent Chlamydia., 2 percent gonorrhea, and 7 percent had a positive serological test for syphilis. Among prostitutes, the prevalence of trichomonas was 46 percent, Chlamydia. 20 percent, gonorrhea 16 percent, and 29 percent had a positive serological test for syphilis.
Behavioral Outcomes Sources of Quantitative Data Although the majority of behavioral data was provided by the BSS, there are a few sources of quantitative data that were collected near enough to the beginning of AIDSCAP that they can be useful in helping to determine baseline levels of certain indicators. They include the Demographic Health Survey (DHS) from 1992, which was a household-level general population survey focusing on family planning but including some knowledge-related questions about HIV and STIs, and a survey carried out under one of AIDSCAP's rapid response fund projects, APROSOR. This study was completed in 1995 and consisted of a series of 6 KABP surveys done in a rural area of Thies. The first round of data from the BSS was collected in January and February in these target groups:
Source of Qualitative Data In addition to these quantitative surveys, a number of qualitative studies were conducted by AIDSCAP including:
Outcome data During the years of the AIDSCAP project, awareness about HIV and AIDS increased, as did knowledge about HIV prevention and use and availability of condoms. Improvements in the quality of STI case management were also achieved. The behavioral data presented in this section is organized according to categories and related stages of change: 1) awareness about HIV and AIDS, 2) knowledge related to HIV and AIDS, 3) risk perception and readiness to adopt low-risk behaviors, and 4) actions already taken to reduce risk or maintain low-risk. Situating the target groups according to these stages over time is helpful in assessing the process of change. Data from the BSS is summarized in Table 6 located at the end of this section. Although subsequent rounds of data for measuring change are not yet available, the attainment of certain indicators is already evident. 1. Awareness The willingness to engage in risk-reducing behaviors presupposes a basic awareness about the existence and the nature of HIV. AIDSCAP has used two indicators to look at levels of awareness.
Although the data are not from a representative sample, 17 percent of persons interviewed during the TIR study in 1994 stated that AIDS could not exist without symptoms. Only one of 38 respondents answered that it was impossible to know if a person was infected. Data from the BSS in 1997 indicate that between 10 and 30 percent of respondents, depending upon the target group, do not know that a person can look healthy and still be infected with HIV (see section 1.1 of Table 6) with CSWs and workers being the least aware, therefore there is still progress to be made in this area.
The only available baseline data for this indicator was from the APROSOR survey conducted in 1995 in a rural area of Thies, which showed that 89 percent of respondents believed that "the people in their village believe that AIDS exists". BSS findings indicate that less than 10 percent of respondents in most target groups, doubt the existence of AIDS. The exception is a subset of male university students (13 percent), who do doubt the existence of AIDS. Focus group discussions conducted in late 1996 indicated that they hold the popular belief that AIDS may be a conspiracy of westerners who want to keep people from having sex and children. Other skeptics find it difficult to fully accept something which they cannot see. One focus group participant (Qualitative evaluation of radio campaign, Diop, 1996) noted that people "want to see an AIDS patient, even if he has a mask on, or some reports which talk about the evolution of the disease, and the process of wasting, because we have heard enough about AIDS but we have not seen it." 2. Knowledge Before one can take action to reduce risk, one must not only recognize that there is a problem, but also have knowledge of the options available. Although baseline data from the same target groups as the BSS is not available, it appears that during the time that AIDSCAP has been conducting IEC activities, knowledge of modes of HIV prevention and availability of condoms has skyrocketed.
The 1992 DHS general population survey found that only 6 percent of women aged 15-49 (countrywide) knew that condoms can prevent AIDS. Thirty-two percent of women and 29 percent of men cited two or more things they could do to "protect themselves from HIV/AIDS". When it came to particular methods of avoiding infection, female respondents from the DHS survey appeared to be more aware of or to lay more stress upon fidelity, abstinence, and avoiding CSWs as effective means. Men on the other hand, were more conscious of the role of the condom in affording protection. In the 1997 BSS, the evidence is convincing that the goal of 80-90 percent knowledge of two modes of prevention has been largely achieved. More than 90 percent of respondents in all target groups knew two or more modes of prevention (responses were prompted).
Despite the high levels of knowledge about how to prevent HIV, there are still a lot of false beliefs about how one can be protected from HIV transmission. These false beliefs undoubtedly have an influence on risk perception and attitudes toward people with AIDS. Data from the APROSOR survey in 1995 and the BSS survey in 1997 indicated the following false beliefs: Table 3: Data from APROSOR and BSS survey, indicating false HIV prevention beliefs
The 1992 DHS survey indicated that 26 percent of women (overall for the country) knew where to procure a condom. The 1997 BSS showed that the availability of condoms has expanded greatly, with between 85 percent and 99 percent of all target groups reporting that they could easily procure a condom (see section 2.2 of Table 6). One focus group participant among a study with market women (Needs Assessment of Market Women's Associations, 1995) stated that: "Before people had a lot of complexes to even buy [condoms]. They would hide if buying them. Now they are sold outside, it is because they are very common." Thus although the goal of an 80 percent increase in the number of persons who report being able to obtain a condom could not be measured because follow-up data are not yet available, it seems clear that this indicator is already at a sufficiently high level in the target groups that were measured.
One knowledge area where there still seems to be a lot of room for improvement is that of knowledge of the signs and symptoms of STIs. While it is true that many people, especially women, are asymptomatic for STIs, it is clear from research that people do not associate the more obvious signs of STIs with a condition that might necessitate medical care. Findings from the TIR in 1994 indicated that "56 percent of respondents stated that STIs could not exist without some sort of symptoms".
Only 20-40 percent of men could cite two signs and symptoms of male STIs and only 16-40 percent of women could cite two signs of female STIs. Female knowledge of male signs and male knowledge of female signs was even lower. 3. Perceptions Perception influences peoples attitudes and also their behaviors. The process of perceiving allows individuals to receive information, to understand and appreciate that information, and to form an opinion and be prepared to respond to the information. Before a person can choose to reduce their personal risk of becoming HIV infected, they must first perceive that they are at risk, and understand the factors that put them at risk. The two indicators chosen for this section are perception of risk and intent to change. The objective of the risk perception indicator is to attempt to measure the percent of individuals who can both a) state the level of their personal risk of becoming infected with HIV and b) have an appropriate justification for their stated risk level. (Note: the justification is intended to be appropriate to the stated risk level which may or may not correlate with the actual risk based on behaviors). Both qualitative and quantitative information provide evidence that many people do not feel personally threatened by AIDS. This is likely to be due to the low levels of HIV in the general population and the fact that most people don't know anyone who has AIDS. In the TIR in 1994 "HIV/AIDS was cited by only 13 people (out of 253) as being a common illness, indicating that the community does not consider AIDS to be a common illness." In the CRWRC Needs Assessment of Market Women's Associations, it was stated that "most market women have not internalized the risks of HIV infection. When questioned about general life concerns, and more specifically about health concerns, no market women spoke of AIDS or STIs". Indeed the findings of the BSS were that the majority of people in virtually all of the groups surveyed perceive that they are presently "at no risk" of becoming infected with HIV.
The percent of respondents who could both state their risk of becoming infected, and who had an appropriate justification was as follows:
A high proportion of people who perceive that they are not at risk, actually did have an appropriate justification for the response. Among the much smaller group of people who perceive their risk to be moderate or high, the justifications for this perception were frequently not appropriate.
Although this indicator is an important part of the "ready for action" stage, the data from this round of the BSS were unfortunately incomplete so no data will be available until the next round. 4. Action
Studies in Senegal have shown an early age of first sexual contact. According to the BSS, 66 percent of male secondary school students are sexually active and 25 percent of them had their first sexual encounter before the age of 15. Among male university students, 82 percent are sexually active, but only 14 percent claim to have had their first sexual encounter before the age of 15. While this difference could indicate that young men are increasingly becoming sexually active at an earlier age, these two groups are not entirely comparable, since the likelihood of these two groups becoming sexually active at the same age may not be the same. Three quarters of the male students had sex for the first time with someone their own age or younger. Among female elementary school students, 10 percent are sexually active but only 2 percent claim to have started sexual activity below the age of 15. Twenty-one percent of female university students are sexually active, with 1 percent claiming to have had their first encounter before the age of 15. The majority (84 percent of secondary school females and 76 percent of female university students) had their first sexual activity with partners who were older than they were.
From the TIR in 1994 "One constraint to partner notification identified was a lack of communication between sex partners, as well as suspicion of infidelity". Although frank discussion of sexual issues is clearly still difficult, there are indications that such openness is becoming more acceptable. In a focus group discussion with truck drivers (Qualitative research with 4 target groups, EPS, 1994), one participant states: "I discuss HIV with my fiancee, who is always telling me to pay attention and reminding me about the existence of HIV ." Sexual Partners Percent who had at least 1 non-regular sex partner in the last 12 months (PI4) Data from the BSS indicate that 28 percent of male workers, 11 percent of male university students and 11 percent of male secondary school students reported having had sex with at least one non-regular partner (occasional or CSW) during the past 12 months. (Only a small fraction of these were with CSWs, 2.5 percent of male workers and less than 1 percent of male students). While this is less than what has been reported in some other countries, it should be kept in mind that the groups surveyed during this first round of the BSS are not the highest risk groups (with the exception of CSWs). Future rounds of BSS will survey men in the informal sector including merchants and truck drivers, who are believed to be part of a more high-risk sexual network, along with clandestine sex workers and some women in the informal sector (such as women working in the market place). Qualitative studies with market women indicated that "market women are generally at risk for HIV due to their own non-monogamous sexual behavior, low levels of condoms use, and certain sexual practices such as "safal" (see Needs Assessment of Market Women's Associations). In addition, women are well aware that they only have direct control over their own behavior. From the same assessment with market women, one woman states: "A woman can decide to be faithful and can be faithful, but she cannot follow her husband everywhere." (With only one round of data collected by the BSS thus far, it is not yet possible to measure the 50 percent decrease specified in the logframe for this indicator). Condom Use Judging from the data reported in the 1992 DHS and anecdotal data, condom use appears to have increased markedly during the past few years. Much more widespread availability of condoms combined with increasingly visible BCC messages through radio, television and billboards, seem to have had an impact on levels of condom use. In the 1992 DHS survey, only 3.6 percent of women and 10 percent of married men reported ever having used a condom (country wide). In the APROSOR survey in 1995, 22 percent of respondents said they had ever used a condom. Anecdotal information from the 1994 TIR indicated that condom use might be becoming more acceptable, which supports the 1997 BSS finding that many people are now using condoms during high-risk sex. Condom use during last sex act with non-regular partner (PI5) In the APROSOR KABP survey in 1995, 18 percent of respondents said they used a condom during their last sex act, although the type of partner was not specified. Data from the BSS shows condom use during the last sex act with an occasional partner to be between 67 percent and 81 percent for the male groups, thus the goal specified for this indicator of 70 percent has basically been achieved. Consistent condom use is almost as high, except among secondary school students (54 percent), where it appears that there is still much work to be done. CSWs report extremely high condom use both during last sex act and for "consistent use" with both regular and new clients. However, condom use by CSWs with their "regular" male partners (other than paying clients) is only around 50 percent. This is important information, since these men are not only in danger themselves, given the high HIV levels among CSWs, but also represent a bridge of infection to their other non-CSW partners. STI Case Management As part of the PNLS/AIDSCAP effort to train health workers from 6 regions in Senegal in STI case management, an evaluation was carried out from January to April 1997 to measure baseline levels of indicators related to STI case management (PI6&7 defined below) and to measure any changes that took place in the short term after training. Ninety-seven percent of health care workers in six of the ten regions were trained in the use of STI treatment algorithms (PI6) and prevention education and counseling methods (PI7). The USAID Results Package specifies that the level of 60 percent in both of these indicators is to be achieved by the fall of 1998.
Two methods of obtaining data on PI6 & 7 were used: 1) direct observations of providers interacting with their patients, and 2) interviews with the providers. The indicators were measured in only two of the six regions before the training, and in all six regions after the training. Table 4: Observations
As illustrated in Table 4, using the strict criteria of WHO during observations, the baseline level of PI6 was 11 percent and basically there was no improvement at follow-up (12 percent). However, significant improvement occurred in two of the three areas that are components of PI6, i.e. examination and treatment. For PI7 the baseline level was 2.9 percent and the follow-up level was 22 percent, therefore there was significant improvement. These indicators, however, are still far from the 1998 goal of 60 percent. Table 5: Interviews
Providers performed better during interviews. The baseline for PI6 was 4.6 percent with an increase to 19.2 percent at follow-up. Similarly, the already high levels for PI7 at baseline, 83.1 percent, increased significantly to 94.3 percent at follow-up. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
