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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 (See Below) E. Non-Subproject Highlights (See Below) II. Lessons Learned and Recommendations III. Subproject Highlights I. Country Program Description (continued) D. Implementation and Management Issues Introduction In 1992, an AIDSCAP implementation team conducted an evaluation in Senegal to assess the situation and to design an HIV/AIDS prevention and control project that could address the unmet needs of the Programme National de Lutte Contre le SIDA (PNLS). In addition to USAID, the World Health Organization (WHO), the Canadian International Development Agency (CIDA), the European Union (EU) and the French Cooperation were pledging support for the PNLS. WHO was primarily assisting with administrative support, sentinel surveillance, testing, and technical assistance in the development of a medium term plan (MTP), however indicated it would not be able to continue financing surveillance, and was therefore seeking a replacement donor. The French Cooperation pledged to strengthen the screening of blood products nationwide and CIDA pledged a two year program focusing on BCC activities and training in the regions of Diourbel, Kolda and Tambacounda. The EU was strengthening selected STI clinics outside Dakar. Responding to the Government of Senegal's (GOS) wish to decentralize the AIDS control program, the AIDSCAP project was directed towards four of the ten Senegalese regions with more than 60 percent of the population: Dakar, Thies, Kaolack and Ziguinchor. The following major components of the national STI/AIDS control program were subsequently supported by AIDSCAP:
While these components were considered crucial, other components such as policy dialogue, support to the PNLS in strategic planning, grant support to national and international NGOs as part of capacity building, behavioral and operations research, and evaluation (including support for sentinel surveillance) were considered as complementary and important components of the PNLS program requiring support. The three major components targeted high-risk populations, such as commercial sex workers (CSWs), other women at risk with multiple partners, men at risk, such as male partners of CSWs, men in the workplace, long distance drivers, and the military. Youth were targeted, both those in and out of school due to their nature of high-risk behaviors. While the focus was on urban and to a limited extent rural populations, it was found that more attention needed to be paid to the serious problem of internal/external migration for both men and women, and the particular risks for those who stayed at home and were therefore exposed to returning infected spouses. Women appeared to be particularly disenfranchised, and the notion that only commercial sex workers were "high risk" was reevaluated in light of new assessments. The recession and the devaluation of the CFA franc further weakened the rather fragile economic fabric facing women. In addition to CSWs, women at risk were migratory domestic workers looking for work, single divorced mothers with children, co-spouses in polygamous marriages, and uninformed spouses exposed to the virus by returning husbands. Implementation Process Implementation of the AIDSCAP/Senegal project began in July 1993 with the arrival of the Resident Advisor in Dakar. Initial project activities focused on the renovation of office space, recruitment of office personnel, and other administrative activities related to project functioning according to Senegalese regulations. Rapid contacts were made with bilateral, multilateral and international organizations and agencies working in AIDS. This was followed by initial field visits to the project regions (with the exception of Ziguinchor) to present the project and discuss issues with regional personnel. In terms of subproject activities, initial work concentrated on the development of workplans for all components of the project. A subagreement for epidemiological surveillance, inherited from the Global Program on AIDS (GPA), was finalized and identification of STI pilot areas and definition of a strategy were completed. Important strides were made in the NGO grant component, with the development of a grants brochure outlining criteria necessary for grant proposals. Once the criteria was specified, a two-day workshop was conducted to present the initiative to the NGO community. Following this workshop, work focused on involving two NGO consortiums in the planning and management of this component: Conseil National des ONG Africains pour le Développement (CONGAD) and the International Council of AIDS Service Organization (ICASO). Formulation of BCC activities began with the arrival of the expatriate IEC officer and recruitment of the IEC national expert. As the primary emphasis of the project was behavior change communication, initial work of the experts concentrated on determining what was currently occurring in the field. Work then shifted to the development of the specific plans of action for each target group. Establishing Interventions By the end of the first year of the AIDSCAP project considerable advances had occurred in all program areas. Despite major constraints beyond the control of the Senegal program, such as the blockage of funds for a period of eight months, creative ways were explored to continue activities. The STI component completed a baseline survey in all intervention regions for pilot STI sites. This was immediately followed by the signing of two subagreements outlining the objectives and outcomes of the STI interventions in the selected sites with the PNLS and the Association Des Postes de Santé Catholiques au Sénégal (APSPCS). Relating to the STI interventions, a Targeted Intervention Research (TIR) focusing on treatment seeking practices of patients with STIs also began. Initial analysis of data on general health beliefs showed new information that was considered valuable in explaining why the population was not as concerned as expected about STIs. Behavior change communication (BCC) focused primarily on training. Training sessions were conducted for health personnel, social workers, school teachers, youth organizers, and women's organizations. AIDSCAP, in collaboration with the PNLS, conducted training in the form of training of trainers (TOT) workshops and sessions on peer education techniques. Subprojects were developed through Letters of Agreement (LOA) and subagreements, in collaboration with the AIDSCAP regional office and headquarters, targeting men in the workplace, university students, women, commercial sex workers, women of low literacy levels, out of school youth, and the general population (through mass media). The development of educational materials for targeted high-risk groups was also undertaken. AIDSCAP/Senegal focused on the logistics aspects of the condom promotion and distribution component, taking into consideration the quantities agreed upon with the USAID Mission and the PNLS. The PNLS condom storage space in the national warehouse was renovated with security fencing and locks, electrical repairs and pallets to stock condom cases. A new quarterly distribution system was established to deliver condoms to the 10 regions of Senegal for specific institutions as determined by the PNLS. One of the main emphasis of the AIDSCAP project was to encourage NGOs to include AIDS prevention behavior change communication activities in their work. In Senegal, as in other countries, it was recognized that the government could not accomplish this task alone. During the period that AIDSCAP/Senegal was developing its implementation strategy, there was only one NGO (ICASO-Senegal) regrouping approximately a dozen other NGOs, whose work concentrated on HIV/AIDS. One larger NGO, CONGAD, a collective of more than 85 Senegalese and foreign NGOs, had the major role of coordinating the work of all NGOs in Senegal. CONGAD worked to create an exchange of information to avoid unnecessary duplication between NGOs, to strengthen NGO/government relations and to offer services to its members such as the provision of technical assistance, the production of two network periodicals and the running of a business center. Against this backdrop, AIDSCAP/Senegal initiated an intervention with African Consultants International (ACI) to network closely with both groups in order to widely publicize the new AIDS training possibilities for NGOs. This intervention with ACI focused its attention in two main areas of support: 1) training NGOs in AIDS prevention activities; and 2) encouraging policy dialogue. With regard to training, it was determined that if NGOs were to play a role in AIDS prevention and control they must have in-house expertise on AIDS. A series of TOT workshops were held for NGOs interested in conducting AIDS prevention work. These seminars targeted primarily non-health, development NGOs, although NGOs working in health were not excluded. It was anticipated that at the end of their training, participants would understand the causes, modes of transmission, prevention measures and socioeconomic implications of AIDS. NGOs would also be informed of the types of funding available for HIV/AIDS projects. In response to the AIDSCAP Women's Initiative, ACI made an effort to ensure that fifty percent of the trainers or participants at each workshop would be representing NGOs which had a primary focus on women's issues, and/or were run by women. It was hoped that by specifically targeting NGOs concerned with women's issues, AIDSCAP Senegal would receive proposals that were gender oriented and culturally sensitive, and which would explore new avenues to reach a broader target audience (i.e. monogamous women at risk, women in the workplace, female adolescents, separated/divorced women and other unmarried women). In order to encourage a favorable environment for conducting AIDS activities, a study involving individual interventions and focus group discussions with religious, political and community leaders was also included in the subproject with ACI. The results of this study became a starting point of discussions with the regional opinion leaders, religious leaders (both Muslim and Christian), and members of parliament, through seminars, symposia and conferences. By the end of the project, AIDSCAP/Senegal had successfully put into place 25 major interventions through subagreements and Letters of Agreement and 34 short-term activities with local associations through the rapid response fund mechanism. Constraints
Management By the beginning of 1994, AIDSCAP/Senegal had been allocated office space consisting of six rooms, within the locality of Centre d'Hygiène de Médina. The office space was provided by the GOS as part of their contribution to the AIDSCAP project, in conformity with the provision contained in the bilateral agreement signed between USAID/Senegal and the GOS.
Constraints
Capacity Building (Management) Capacity building was one of the major goals of the AIDSCAP program. The AIDSCAP/Senegal office determined that capacity building was not only applicable to local implementing agencies, but also for the AIDSCAP team itself. Thus, a one day training course in AIDS education and prevention was conducted for all members of the AIDSCAP staff by African Consultants International (ACI), prior to the startup of implementation of the program. The goals of this training were: to help team members protect themselves and their families from infection of HIV/AIDS; to increase the commitment of each team member to the goals of the AIDSCAP project; and to give all team members the basic skills necessary to participate in the process of gathering and disseminating information related to the epidemic, the prevention of the spread of HIV and the care and support of those infected. In terms of technical skills, the national IEC Officer attended a training course in program management in Santa Cruz, California. The same IEC Officer together with the Assistant IEC Officer attended a one-week BCC workshop held in Kenya, regrouping all IEC Officers of AIDSCAP's countries in the Africa region. The two accountants also benefited from in-house training on FHI's accounting procedures, and the assistant accountant attended a one week workshop in Kenya for all AIDSCAP's accountants in the Africa region. AIDSCAP/Senegal also organized in-house computer training for the National IEC Officer, the two secretaries and the two accountants. As keeping abreast of current information on HIV/AIDS was also considered a priority, the National IEC Officer attended the African International Conference on HIV/AIDS in Kampala, Uganda in 1995 and the Resident Advisor attended the International HIV/AIDS Conference in Vancouver in 1997. Following a restructuring of the internal division for the prevention of AIDS of the Ministry of Education, a plan of action was elaborated with the following objectives:
AIDSCAP supported the training of professors of natural science and home economics, the establishment of AIDS prevention centers in 25 schools, and the organization of BCC activities and training of supervisors of literacy programs. In addition, 2,500 educational brochures were produced for literacy classes in 6 local languages, a training module was developed for students, 15 educational facilities were supported in organizing AIDS prevention activities and technical assistance was given for the restructuring of the internal AIDS division of the Ministry of Education. Support was also given to the PNLS for the organization of special events -- World AIDS Day, Women and AIDS Week, and Youth AIDS Week. Each region and district elaborated a one-week program of activities and community mobilization. Ninety small associations of youth, women and men received financial, material or technical support to organize BCC activities. One hundred and twenty activities, such as conferences, radio shows, theater presentations, discussions and debates, were held reaching 13,106 people. Other BCC activities were held with the following populations:
A conference on Women for the Prevention of AIDS was organized with 20 representatives from NGOs with the objectives of informing the NGOs of the AIDSCAP initiative for women, identifying the different priority target groups for AIDSCAP, and elaborating a list of priority interventions for each target group. As a result of this conference, the following target groups were identified: adolescents aged 13-20 in the informal sector; young girls aged 8-12; managers of bars and small restaurants ("gargottes"); women's associations. Two information campaigns were carried out with the development of 40 billboards, 300 posters for buses, and 1000 stickers. In addition, local radio stations covered 13 hours of special events and round table discussions, and 2 television commercial were developed -- one which ran during the World Cup and another 20 second spot which ran two times per week for one month. Finally, two workshops were held for 36 NGOs to discuss the diversity of interventions and reexamine the relations between partners, identify factors which influence the functioning and results of projects, share evaluation results, and develop priority strategies and actions for the sustainability of AIDS prevention programs. These two workshops resulted in the following recommendations:
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