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

Executive Summary

I. Country Program Description

A. Introduction

B. Country Context

C. Accomplishments and Outcomes

• Page 1
• Page 2
• Page 3
• Page 4

D. Implementation and Management Issues

E. Non-Subproject Highlights

II. Lessons Learned and Recommendations

III. Subproject Highlights

• Page A
• Page B
• Page C
• Page D (See Below)

IV. Attachments 

Glossary of Acronyms

III. Subproject Highlights (continued)

Research/Studies

Epidemiological Surveillance of HIV and Syphilis in Senegal
(FCO 57465)

AIDSCAP partner:	L'Hôpital Le Dantec
Geographic focus:	Ziguinchor, Kaolack, Dakar, Thies, Mbour
Target population:	Pregnant women, tuberculosis patients, male STI patients, hospital patients and female sex workers
Project dates:	February 1, 1994 to July 31, 1997

Background and Scope of the Intervention

HIV sentinel surveillance data has been collected in Senegal since 1989 by the Bacteriology and Virology Laboratory of l'Hôpital Le Dantec, in collaboration with the Programme National de Lutte contre le SIDA (PNLS). It was supported by WHO/GPA until 1993 in Dakar, Kaolack, St. Louis and Ziguinchor. After GPA funds were discontinued, AIDSCAP picked up support for sentinel surveillance in 1994 in Dakar, Kaolack, Ziguinchor, Thies and Mbour. The groups that were monitored include pregnant women, tuberculosis patients, male STI patients, hospital patients and female sex workers.

The principal objectives of the surveillance system were 1) to measure the annual prevalence of HIV-1, HIV-2 and syphilis among selected sentinel groups, 2) to examine HIV-1, HIV-2 and syphilis trends in the different regions, 3) to evaluate preventive measures put in place for these groups, 4) to disseminate the information obtained in order to reinforce control measures, 5) to reinforce AIDS case notification and 6) to reinforce cooperation between the different government services implicated in AIDS prevention.

Accomplishments

AIDSCAP was not the sole supporter of the surveillance system. Its funds were used primarily for the purchase of reagents and equipment and payment of some staff. Project staff consisted of one professor of bacteriology, one biologist, one technician and one statistician. The latter three underwent training at various levels while working with the project. An epidemiological bulletin of surveillance results was produced annually. In addition, during a technical assistance visit early in 1995 by an FHI modeling expert, the research team in Senegal prepared national and region-specific projections of the AIDS epidemic.

Constraints and Recommendations

In any surveillance system, continuity of data collection is one of the most essential elements necessary for success. The surveillance system in Senegal has undergone many disruptions, not only because of the switch from one donor to another, but because of delays of disbursements of funds which made it impossible to purchase reagents in a timely fashion. For this reason, there were no data available for most of 1994.

In the future, it would be highly desirable to revisit some of the methodological issues which might make this surveillance system perform better. Some of these issues are:

• the number and type of sentinel groups being monitored
• the timeframe for data collection
• quality assurance

Specific results of the surveillance can be found in the Project Outcomes Section of this report.

Religious and Opinion Leaders Study
(FCO 53483)

AIDSCAP partner:	African Consultants International (ACI)
Geographic focus:	Ziguinchor, Kaolack, Dakar, Thies
Target population:	Religious and political leaders
Project dates:	April 18, 1994 to June 20, 1994

Background and Scope of the Intervention

African Consultants International (ACI) conducted a study to assess political and religious leaders' concerns, including knowledge about HIV/AIDS issues, and to identify and develop an approach to inform and sensitize Senegal's Muslim and Christian religious leaders and political leaders about the seriousness and potential impact of the HIV/AIDS epidemic. The study was conducted through interviews with various religious and political leaders with an objective of stimulating the interest of the interviewees in HIV/AIDS issues. The study was undertaken in the first quarter of 1994, in close consultation with the Programme National de Lutte Contre le SIDA (PNLS) and included questions about sexual education, condom promotion, prostitution, and the vulnerable status of women.

Although Christians -- overwhelmingly Catholic -- comprise only 5 percent of the Senegalese population, as organized groups they are important for their role in education and institutional coherency. Muslim adherents are divided into four major brotherhoods which provide spiritual leadership, social cohesion and some administrative guidance.

Interviews about HIV/AIDS and the religious groups' responses to the epidemic were held in the four main AIDSCAP regions with the following groups: Catholic bishops or their regional representatives; members of major families within the brotherhoods; advisors and spokespersons for the brotherhood leaders ("califes"); community guides ("imans"); Muslim educators; and Muslim association leaders.

Among the findings of the Religious Leaders study, the following are most significant:

• There is a wide range of knowledge among religious leaders about the epidemic, with younger leaders generally demonstrating a higher degree of understanding. Leaders who had little or no knowledge about HIV/AIDS reacted with expressions of divine retribution.
• Religious leaders were not aware of the Programme National de Lutte Contre le SIDA (PNLS) in Senegal, but some were aware of the general work of a couple of service and information associations.
• Few religious leaders had taken any action in their communities in response to the AIDS epidemic. Two factors seem to explain the low level of religious response: a feeling that AIDS results from a breach of religious rules; and ignorance of the potential impact of HIV/AIDS.
• In general, religious leaders are against the use of condoms. Official positions, however, may vary with circumstances and in a few cases may be ignored in favor of prevention.
• To enhance the response of religious authorities, it was suggested that assistants and spokespersons for leaders be engaged in initial dialogue. In turn, these policy "influencers" would help guide policy responses.
• Both Christian and Muslim leaders shared the opinion voiced by one interviewee: "The best solution is to educate people towards a return to Islamic [sic] rules and engage the individual and collective responsibility of the person ... when said individual, despite being informed, keeps on being unfaithful."
• Among the political leaders interviewed were state-level administrative and political decision-makers, leaders of political parties, community leaders, influential civil servants and technical specialists, educators, and union leaders.
• These leaders knew about the HIV/AIDS epidemic, but tended to underestimate (according to the consultants who conducted the study) its importance. Many political leaders doubted the accuracy of estimates offered during the interviews and felt that Senegal would suffer only a mild epidemic. Although awareness was high, knowledge about basic aspects of the disease was often weak. For example, one third did not understand the link between STIs and HIV.
• Most of the political leaders interviewed were supportive of youth sexual education, condom use and STI prevention. However, there was a sense of disagreement with some religious leaders who spoke of AIDS as a divine curse and placed discussion of the epidemic strictly in the context of individual behavior. Also, there was a sense that public health and medical professionals excluded political leadership as partners in controlling the epidemic. There was criticism that prevention activities were based heavily in Dakar and other main cities, had little sustainability, were not coordinated, and were not targeted to grassroots communities.
• Although more political leaders were active in some form of HIV/AIDS prevention, they remained a minority and usually cited conference and information forums as the activities in which they had participated. IEC activities were the most commonly made suggestion for needed action. Political parties had not made HIV/AIDS a major issue within their programs.

AIDSCAP Partner	Process Indicators
African Consultants International (ACI)	Individuals trained	N/A
	Individuals educated	86
	Materials distributed	N/A
	Condoms distributed free	N/A

Targeted Intervention Research on STDs in Senegal
(FCO 54465)

AIDSCAP partner:	University Cheikh Anta Diop
Geographic focus:	Dakar, Thies, Kaolack, Fatick, Ziguinchor
Target population:	Community leaders, STI patients in clinic setting, pharmacist, CSWs and clients
Project dates:	May 1, 1994 to October 31, 1994

Background and Scope of the Intervention

The University of Cheikh Anta Diop in Dakar, Senegal conducted an ethnographic research (Targeted Intervention Research) of STIs in Senegal to document STI treatment-seeking behavior and health services utilization patterns related to STIs in the primary field sites of AIDSCAP activities -- Dakar, Thies, Kaolack, Fatick and Ziguinchor. The objectives of the research were:

1. To collect and synthesize qualitative information to be used in STI and communication project design for the AIDSCAP STI program in Senegal. The information falls into the following broad topic areas:
   • STI symptom recognition and understanding of western biomedical terms for priority STIs (HIV, gonorrhea, syphilis and chancroid);
   • Range of knowledge, attitudes, beliefs and behaviors relevant to STI control;
   • Qualitative information on patterns of health service utilization, including use of health facilities and other informal sources of STI care;
   • Perceptions of STIs, of STI risk, and of clinic-based care for STIs.
2. To collect the above mentioned information among several broadly-defined groups under the guidance of a Technical Advisory Group (TAG). These groups include community members, STI patients in a clinic setting, health care providers including pharmacists and traditional healers, and commercial sex workers and their clients.

Methodology

Nine semi-structured interview guides were elaborated for the research covering the following topics:

1. General illnesses that are considered the most common within the community;
2. Illnesses considered to affect regions of the body between the navel and knees;
3. Illnesses considered by the populations to be transmitted sexually;
4. Symptoms associated with STIs;
5. Guides 5, 6 and 7 address persons who have had an STI or know someone who has had a STI;
6. Guide 8 addresses health care workers; and
7. Guide 9 is comprised of three parts:
   • a list of questions to patients seeking care for an STI
   • a list of questions to health agents regarding the care of the above mentioned patients
   • a list of questions to the same patients after consultation

For guides 1 through 4, 253 people (127 women and 126 men) were interviewed. Interviews were conducted in a variety of different locations -- 151 in-home interviews and the rest ranging from bars and restaurants, to markets, stores, banks, workshops, garages, etc. A large variety of social-economic categories were represented as well as a mix in professions. All ages were represented, however, ages 25 to 44 represented the majority of persons interviewed. In addition, the majority of persons interviewed reported having had no formal education (58.5 percent), reflecting the reality of the general population of Senegal. For the remaining guides 5 through 9, 38 people were interviewed (19 women and 19 men). The demographic and ethnic profile of this second group of interviewees was similar to that of the first.

A glossary was compiled grouping illnesses with the symptoms commonly associated with them. A second glossary correlates biomedical terms with a list of local names that are used. The glossaries attempt to fit such terminology into the ethnic, cultural and geographic context by taking into account such factors as the languages, age groups and level of education of the people who use them. In sum, the information collected in the first phase of the TIR served to uncover and explain the perceptions and principal manifestations of STIs in the community.

Findings

• For guide 1, the most common illness cited was malaria, followed by fever, diarrhea, stomach ache and tuberculoses. Some STIs were cited, however, HIV/AIDS was only mentioned 13 times. This would indicate that the community does not consider AIDS to be a common illness.
• Numerous misconceptions concerning STIs were identified. For example, 68 percent of the respondents considered STIs to be very serious and 30 percent considered them to be not at all serious. 56 percent of the respondents stated that STIs could not exist without some sort of symptoms. Answers to guide 3 indicated that no clear distinction was made between the cause of an illness and the method of transmission. In addition, misconceptions regarding methods of prevention, for example, religious dispositions and basic hygiene, were also noted.
• In general, the concept of a sexually transmitted disease is very complex and difficult to define with precision. Different expressions exist in local languages which could encompass all STIs, however, general terms are not specific to the symptoms. In addition, local languages use different terms to describe the same symptoms or for identifying the actual illness. This often causes confusion on the part of health care workers and patients.
• When questioned about illnesses which are transmitted sexually, 38 percent of the respondents mentioned AIDS. In the section of Guide 5 which deals with AIDS, only 1 of the 38 interviewed stated to never have heard of AIDS. The description of symptoms perceived to be AIDS-related coincided with the usual symptoms associated with AIDS (weight loss, diarrhea, skin infection, etc.) However, 17 percent responded that AIDS could not exist without symptoms.
• When questioned about how one could tell if a person was infected with HIV/AIDS, only one of the 38 respondents answered that it was impossible to know, and one responded that only lab tests could identify the existence of the virus. Thirty-five percent stated physical appearance as indicators to the existence of HIV/AIDS. AIDS, as with other illnesses, is considered to have biological as well as social and supernatural causes. Although 60 percent of the respondents indicated that there is no treatment for AIDS, 24 percent of the persons having indicated AIDS as a sexually transmitted disease stated that treatment by a modern doctor is possible. Three percent of those persons indicated treatment is possible by traditional medicine.
• Certain categories of people had greater access to modern doctors for treatment as opposed to traditional doctors. CSWs, persons without formal education, women and people of 50 years or older had less access to modern doctors than did people with secondary education, men and younger people. In addition, traditional doctors are seen as more discreet and more available.
• In addition to traditional and modern doctors, patients have access to unofficial services by midwives, retired nurses or other health care workers working outside of established health care facilities or during off-hours. These services are known to be less expensive, more confidential and less time-consuming than official clinics or hospitals. Private clinics exist in certain regions and are frequently attended, however tend to be poorly equipped. Public health clinics are considered the last choice for treatment as they are viewed as very public and seen to be frequented only by CSWs.
• STI Centers, with the exception of those in Dakar, are found to be poorly equipped with only slightly functional laboratories and poorly trained personnel. As a result there is a lack of credibility for these centers in the communities. In addition, these centers are often viewed as lacking confidentiality and privacy as patients are forced to wait in waiting rooms with persons of the opposite sex, different age groups and of the same village. The cost for medications was identified as another constraint to treatment for STIs.
• Communication problems exist between doctors and patients, particularly in terms of vocabulary used. Thirty percent of patients stated they did not know what illness they were suffering from after consultation with a doctor, although only 2 percent of cases were reported by doctors not to have been diagnosed. Seventy-two percent of the patients following consultation stated to not have received condoms or been given recommendations concerning condom use. Doctors surveyed stated that in only approximately 30 percent of consultations did they recommend condoms. Abstinence during treatment and the necessity to treat the patient's partner were more often emphasized during consultations. However, only 24 percent of persons having had at least one STI affirmed to having treated their partners. One constraint to partner notification identified in the study was a lack of communication between sex partners, as well as suspicion of infidelity.
• Although condom use seems to be becoming more accepted among younger males, accessibility and price are still constraints to use. Social taboos regarding condoms, however, do still exist, particularly for women. No woman in the survey stated to have received condoms or recommendations in this regard.

Lessons Learned and Recommendations

• Personnel of health structures need training in communication skills and understanding the perceptions and vocabulary of STI patients in the community. In addition, health care workers should be better informed of confidentiality issues and respect for the privacy of patients.
• Training is needed for communities, by way of youth associations, women, opinion leaders and traditional healers, as to the biomedical elements of STIs and in the identification of the rights of patients in terms of medical confidentiality.
• Proposals should be elaborated for the reorganization and improvement of local health services in order to integrate issues of confidentiality and improve access to women.
• Interpersonal communication skills of doctors and health practitioners should be improved in order to integrate into consultations information about the risks of HIV infection and methods of prevention..

AIDSCAP Partner	Process Indicators
University Cheikh Anta Diop	Individuals trained	N/A
	Individuals educated	N/A
	Materials distributed	N/A
	Condoms distributed free	N/A

Needs Assessment of Registered and Clandestine Commercial Sex Workers
(FCO 53588)

AIDSCAP partner:	Environnement et Développement du Tiers-Monde (ENDA-Santé)
Geographic focus:	Ziguinchor, Kaolack, Dakar, Thies
Target population:	CSWs
Project dates:	April 1, 1995 to October 30, 1996

Background and Scope of the Intervention

Environnement et Développement du Tiers-Monde (ENDA-Santé) an international nongovernmental organization, conducted a review of the intervention activities carried out by the Programme National de Lutte Contre le SIDA (PNLS) and other NGOs with registered commercial sex workers (CSWs). Although the PNLS has worked with CSWs, its interventions have only reached registered CSWs (estimated at 2,000 in Dakar, 1,000 in Thies, 1,200 in Kaolack and 2,000 in Ziguinchor). During its review of intervention activities, ENDA-Santé identified clandestine commercial sex work as a growing problem in Senegal. As mentioned in the report, "The multiple forms of prostitution (clandestine, registered, occasional, married/divorced, under guise of petty trade) explains the complexity of the phenomenon." This assessment study measured the knowledge of STI/HIV/AIDS and risk perception in seven pilot sites within the four AIDSCAP geographic regions: Dakar, Pikine, Mbour, Joal, Kaolack, Ziguinchor and Cap Skirring.

The objective of the study was to assess the needs of CSWs and propose recommendations which would facilitate AIDSCAP interventions and serve as an important tool for the design of large-scale interventions in this field.

Principal Accomplishments

Due to the sensitivity of the subject, which can be attributed to the conservative nature of the Senegalese society, the first steps of this study consisted of observing the CSWs' environment in Dakar and conducting visits to the targeted geographic regions. Initial contacts were made with the social services section of civilian police, the civilian police chiefs and heads of STI clinics frequented by registered CSWs. These contacts were crucial to the study's success because of the intricate linkages between the CSWs and these institutions. The contact visits were followed by a two-day workshop during which the ENDA team finalized the actual methodology for data collection.

Using a training team from ENDA, two consultants specializing in socioeconomics, local resource persons, social workers and four facilitator/interviewers, this study was able to directly involve 120 CSWs, both registered and clandestine, of varying ages. These diverse resource persons worked with CSWs in 15 groups consisting of 8 persons each. Nine focus group discussions were conducted with registered CSWs and 6 with clandestine CSWs focusing on problems encountered by the CSWs in exercising their profession, reasons for being in the profession and risks involved in relation to STIs/HIV/AIDS.

A workshop to validate the study was conducted at the end of the study regrouping CSWs and the relevant institutions.

Methodology

A sociological approach to commercial sex work was used to elaborate appropriate methods for collecting data. Three methods were adopted:

• Interview questionnaires
• Informal participatory discussions led by CSWs
• Qualitative study (focus group discussions)

Findings

Through this study, a better understanding of sexual practices and the risks of the target group was gained. The principal findings are as follows:

• The economic status of the women involved in the study was a major contributing factor to their engagement in commercial sex work. In all of the study sites, commercial sex work began at age 14 and continued up to age 60. Due to their vulnerable status, they were not able to negotiate condom use.
• The clients of the CSWs were from a higher social strata and in a sense were considered as their protectors: law and order forces, high level civil servants, officials in the private sector, etc. Law and order forces had become nonpaying clients and at the same time required the CSWs to pay bribes during unnecessary raids.
• Several problems were encountered by the CSWs during their mandatory consultation visits to the STI clinics: 1) Consultation fees were minimal but if the CSW was not able to pay, she was sent away without being examined. There is also an age limit (21 years old) for official registration and therefore possession of a card was only possible upon attainment of the legal age; 2) Mismanagement of blood donated by CSWs for STI/HIV/AIDS testing was also a point of concern for the CSWs; and 3) Condoms were sometimes not available.

Important Constraints

Four principal constraints were encountered during the study:

1. Political tension prevailing in the region of Ziguinchor in the end of 1995 and the beginning of 1996 created an attitude of mistrust among CSWs and the authorities which became an obstacle for this study;
2. CSWs disappeared from a slum area in the Kaolack region following arson. The ENDA-Santé team had to undertake several site visits to identify new strategies in this area;
3. In general, the identification of clandestine CSWs proved more difficult than anticipated. As a result ENDA-Santé was obliged to include registered CSWs in the study in order to facilitate the inclusion of those categorized as clandestine (i.e. the registered CSWs helped in the identification of clandestine CSWs and in influencing them to participate in the study);
4. The intricate linkages of CSWs with authority figures required lengthy and delicate sensitization of these authorities as to the importance and relevance of the study in relation to the prevention of the spread of STIs/HIV/AIDS.

Lessons Learned and Recommendations

• There is an urgent need to make funds available that would enable CSWs to undertake a whole range of income generating activities: selling tea, peanut butter and smoked fish, running a canteen, tailoring, hair dressing etc. These conversion programs could also be combined with literacy classes for a better understanding of their rights as women.
• It was recommended that there be regular discussions between law and order officers, organizations working with CSWs and institutions providing STI services to CSWs, to better coordinate the treatment of CSWs.
• The institutions providing STI services were called upon to be open to providing more information concerning risks relating to STIs, as opposed to only being concerned with whether the CSWs could afford to pay for the services. These STI clinics were also requested to ensure the continued availability of condoms and to provide information as to their correct use.

AIDSCAP Partner	Process Indicators
Environnement et Développement du Tiers-Monde (ENDA-Santé)	Individuals trained	N/A
	Individuals educated	N/A
	Materials distributed	N/A
	Condoms distributed free	N/A

Needs Assessment of Market Women's Associations in Dakar and Kaolack
(FCO 33587).

AIDSCAP partner:	Christian Reformed World Relief Committee (CRWRC)
Geographic focus:	Dakar, Kaolack
Target population:	Market women's associations
Project dates:	January 16, 1995 to November 30, 1995

Background and Scope of the Intervention

Market women are often an overlooked, but at-risk group for HIV infection. As part of the AIDSCAP Women's Initiative, the Christian Reformed World Relief Committee (CRWRC) conducted a needs assessment study of the Market Women's Associations in Dakar and Kaolack. The project objectives were to identify market women's associations in Dakar and Kaolack and determine their organization, function, composition, objectives, membership rules and regulations, location and leadership; to determine market women's knowledge, attitudes, behavior and practices regarding AIDS/STIs; and to determine if training materials designed for one selected group of market women are applicable to other groups representing different ethnic background and socioeconomic status.

Findings

• The assessment identified different categories of market women and factors which affect their level of HIV/STI risk. Several strategies for targeting both the general population of market woman as well as specific categories of women were identified and explored. Information gathered through focus groups indicated that most market women were aware of HIV/AIDS and understood that the disease is incurable and deadly, however did not perceive themselves as personally at risk and did not feel their protection from HIV infection was totally within their control.
• Market women are generally at risk for HIV due to their own non-monogamous sexual behavior, low levels of condom use, and certain sexual practices. However, even greater is their risk from their partners' non-monogamous sexual behavior and women's inability to negotiate and communicate with their partners.
• The greatest constraint to HIV/STI education programming is the women's lack of time. As selling in markets requires large amounts of time to sell as well as to purchase the goods to be sold, the market women work long hours in addition to their heavy family responsibilities. They are also often heads of households, as their husbands migrate in search of work. Almost 25 percent of the Wolof retail sellers participating in focus groups had husbands who live and work elsewhere.
• Among all retail market women, about 70 percent belong to some type of association. There are about 22 different types of associations, both inside and outside of the market place, and varying in size, purpose and activities. The amount of solidarity among women in the associations varies greatly from members not even knowing who the other members are, to groups that are very close knit. Some groups have meetings or organized social events and others not. If meetings are held, they are usually done outside of the market. For these reasons many of these groups are not initially structured in ways which are helpful for HIV/STI education programs.
• Every association identified in the assessment had some sort of leadership, either just one person or sometimes several. Generally leaders do not change and they tend to have a great deal of power. Most of the market women are illiterate. Information is generally passed by word of mouth, or in some circumstances, a crier is hired to spread a message. These criers often tend to be designated criers in an association and animate the groups' meetings.

Lessons Learned and Recommendations

IEC interventions need to increase the women's personal risk perception. In addition, market women need to be empowered with the ability to communicate and negotiate with their partners and to make and carry out decisions to protect themselves. Lastly, the market women need information about the risks associated with certain sexual practices.

Two main strategies were identified for targeting market women for IEC about AIDS and STIs. The first is a general approach, attempting to target as many women as possible within the market systems. This approach would need to take into consideration the time constraints on women and would best be coupled with a program that meets an identified need of theirs. One strategy option is an integrated economic/AIDS education program which has economic incentives for women to participate, as well as providing economic assistance to allow them to be away from their work. In addition, through economic empowerment, these women might become free from some of the economic situations that force them into sexual liaisons not of their choice and beyond their control. Such programs should be set up to meet the needs of women in the full range of economic strata that exist in the marketplaces and be coupled with education relating to economic issues.

Another general approach strategy option is to conduct IEC activities at their place of work, thereby not taking away from their work time. Interventions such as theater troupes during slow periods of the day, criers to spread information, providing certain women with condoms to sell in the market and provide informal information about their use, and training as peer educators women who sell safal could be effective ways to communicate AIDS/STI information. In addition, radio or TV programs could be used to reinforce messages, as well as the possibility of audio systems to broadcast messages into the marketplace.

The second approach would be a more specific approach targeting specific groups of women with education programs tailored to their cultural, social and work-related realities. Outlined below are proposed strategies for the five most at-risk groups identified in the study.

1. Women who work in wholesale markets:
   • Interactive theaters in the marketplaces between busy times.
   • Locate opinion leaders among these women and work with them to help spread messages about HIV/STIs.
   • Make condoms available and educate the men in wholesale markets.
2. Women who travel as part of their work, either to weekly markets in villages or to other areas or countries to import goods:
   • Use the Laobe market women who go to weekly village markets selling items to increase women's sexual appeal to their partners to sell condoms and inform clients of HIV prevention options. These women also might travel with other market women and could use travel time as an opportunity to do interactive education.
   • Locate and educate opinion leaders in this group.
   • Locate the places where these women stay while traveling and target them for intervention sites, selling condoms or giving information.
   • Identify travel routes and target interventions in places where women must wait for long periods, or during travel on trains, in bush taxis, at border posts, etc. These could be one-time reinforcement messages.
3. Women who come into cities from villages to sell in markets. (As these women come from villages and are most often the poorest women working in the marketplace, they generally sleep in the marketplace. They pose an additional threat to their villages as they could bring HIV infection back to the village. In addition, they often travel with their daughters who are also at risk through men at the marketplace and due to their economic situation):
   • Set up centers near where these women stay with economic empowerment programs as well as AIDS education programs.
   • As these women are often members in associations based in their villages which are well established, long lasting associations with very strong solidarity, leaders could be trained as peer educators and used to help spread information among this group, as well as among other members based in the villages.
4. Women without enough capital to start trading:
   • Set up AIDS education programs that include economic empowerment programs involving credit and education on how to manage their money and build up capital.
5. Clandestine sex workers who frequent marketplaces in search of men:
   • Provide economic opportunities for these women to help them find other solutions to their basic needs.
   • Sensitize clandestine sex workers in markets to the risk of AIDS and provide protection information and condoms.

Other Recommendations

• Empower women to communicate and negotiate with their partners about other partners, condom use, testing and delaying sexual contact until other issues are cleared.
• Empower women to educate their daughters, sons and husbands about communication, mutual respect and risks of HIV. Use the social importance of people's connectedness and cultural roles and responsibilities towards each other to help people deal with sensitive issues.
• Expand programming and research outside of Dakar and Kaolack and serve other ethnic groups besides Wolof people.
• Encourage research and education with men, especially in their attitudes towards women.
• Institutionalize testing and counseling services in a economical and embarrassment free manner.
• Educate and sensitize men to women's risks and men's responsibilities to women within the culture.
• Popularize and create acceptance for testing and counseling for men who travel and then return to their wives.

AIDSCAP Partner	Process Indicators
Christian Reformed World Relief Committee (CRWRC)	Individuals trained	N/A
	Individuals educated	N/A
	Materials distributed	N/A
	Condoms distributed free	N/A

Needs Assessment and Feasibility Study: Mobilizing Traditional Medical Practitioners in South Africa and Senegal to Effectively Prevent and Treat HIV/AIDS

AIDSCAP partner:	Center for Natural and Traditional Medicines
Geographic focus:	Senegal and South Africa
Target population:	Traditional Medical Practitioners
Project dates:	February 15, 1995 to August 14, 1995

Background and Scope of the Intervention

Since its detection in the early 1980s, the HIV/AIDS pandemic in Africa has been spreading rapidly, infecting millions of people every year. Traditional medical practitioners (TMPs) who form the largest, most accessible health care system in the world today have been actively providing care to at least 70 percent of the people living with AIDS in Africa, as well as developing various techniques and strategies to prevent the spread of the disease. However, they have been excluded from mainstream efforts to prevent, control, research or develop cures for this disease.

The Center for Natural and Traditional Medicines (CNTM) conducted a Needs Assessment and Feasibility Study in Senegal and South Africa to determine the feasibility of mobilizing TMPs as forces for preventing HIV/AIDS and caring for AIDS patients. Specific objectives for the study included:

• Investigate the informal network of traditional medical practitioners in South African and in Senegal, where traditional medicines are illegal;
• Determine how effectively TMPs can transmit AIDS education and prevention messages to populations at risk; and
• Assess the benefit of formalizing and legalizing the TMPs role in primary health care to help prevent the spread of HIV/AIDS.

The methodology of the study consisted of two phases: 1) background research; and 2) the needs assessment and feasibility study. During the background research, CNTM reviewed existing literature on TMPs, selected collaborating organizations, and made preliminary site visits in order to build trust with the traditional practitioners. During the needs assessment and feasibility study phase, CNTM conducted focus groups and in-depth interviews with TMPs, covering all aspects of the current political and practical reality for traditional practitioners.

Findings

• The study resulted in some general findings which are relevant to most TMPs , and also findings specific to Senegal and South Africa. As culturally appropriate therapies and medical practices have a critical role to play in the prevention and control of HIV/AIDS, there is a need to coordinate programs of primary health care based on natural and traditional medicines globally in order to maximize the effectiveness of such programs.
• The ability of TMPs to add to their skills and medical knowledge is hindered by low levels of literacy. Education was identified as one of the greatest needs in order to improve TMPs skills in areas of advocacy, research and practice of traditional medicines, in addition to increasing interest among young people to advance the field of African Traditional Medicines.
• Government efforts to impede TMPs from gathering medicine plants in the wild need to be addressed as well as issues of deforestation. Many traditional plants are becoming increasingly rare and difficult to find and/or access. Economic conditions also affect the ability of TMPs to provide treatment as patients are often unable to pay for their services. TMPs cannot allocate all of their time practicing medicine if they are required to work in other areas in order to provide food for their families. Economic generation has to be considered in the planning of sustainable AIDS programs.
• TMPs provide services to a large portion of the Senegalese population, despite the fact that the practice of traditional medicine is illegal in Senegal. This is a major impediment to the freedom of practice and the freedom to choose one's source of treatment. TMPs in Senegal would like to see the ban removed immediately so that they can practice legally, and participate in the national strategy and programs in AIDS prevention and treatment.

Lessons Learned and Recommendations

• Due to the history of colonialism, the exclusion of traditional medicine from the national health care system, discrimination against traditional practitioners, and bad experiences with outside researchers, it is critical to establish trust and set up a truly collaborative process with the TMPs at the start of any new programs.
• It is highly recommended that organizations include TMPs as equal, collaborating partners in developing any project's goals, objectives and activities and that the cultural appropriateness of an intervention is thoroughly examined. This will increase the project's chances of success and decrease the chances the project will be rejected by the TMPs or the community.
• The illegal status of TMPs in Senegal must be addressed if any programming targeting TMPs is to be established in that country.
• Organizations should assist by means of advocacy and/or technical assistance in the creation of support networks and/or associations linking TMPs to improve communication, information sharing and unity among TMPs locally and globally.
• Conservation issues should be included in TMP projects in order to preserve medicinal plants, as well as advocacy programs to enforce outside organizations' cooperation with these efforts.
• Establish traditional medicine centers.

AIDSCAP Partner	Process Indicators
Center for Natural and Traditional Medicines	Individuals trained	N/A
	Individuals educated	N/A
	Materials distributed	N/A
	Condoms distributed free	N/A

Behavioral Surveillance Survey and STD Evaluation
(FCO 57470)

AIDSCAP partner:	Institut Supérieur Africain pour le Développement en Afrique (ISADE)
Geographic focus:	Dakar, Kaolack, Ziguinchor, Thies
Target population:	Male and female secondary school students, male and female university students, male workers, registered CSWs
Project dates:	June 1, 1996 to June 30, 1997

Background and Scope of the Intervention

When AIDSCAP first began work in Senegal in 1994, there were very few quantitative data available to help design appropriate prevention programs. Only one 1989 survey from Dakar and some demographic and health survey (DHS) data from 1992 existed and neither included much information useful for HIV prevention strategies. Data on indicators related to knowledge about STI and AIDS, sexual partner networking and condom use were needed to plan interventions and serve as a baseline for future evaluations. However, with the multitude of interventions in Senegal, serving multiple and overlapping target groups, it was not practical or efficient to think about gathering baseline data for each one of them. In 1995, inspired by the success of the Behavioral Surveillance Surveys (BSS) in Thailand and other Asian countries, AIDSCAP decided to apply the methodology in Senegal, becoming its first introduction into Africa.

Principal Accomplishments

• A widespread search among different research firms in Dakar led to the selection in September, 1995 of ISADE, a Senegalese firm specializing in the areas of management and marketing, to conduct the first round of BSS in Senegal. After the selection of ISADE, AIDSCAP started an intense capacity building exercise to orient ISADE to the new methodology, which was being introduced for the first time in the African context and therefore required considerable adaptation.
• Several technical assistance visits by AIDSCAP staff and African consultants took place between September 1995 and November 1996 before the first round of data collection was completed. Activities during the summer and fall of 1996 included construction of sampling frames for six different target groups, formative research for questionnaire development, selection and training of interviewers and pretesting of the survey instrument. Data collection took place in January and February 1997, followed by data analysis and report writing.
• The preliminary results from the first round of behavioral surveillance were presented during the Senegal Lessons Learned Workshop in May 1997 and generated much lively discussion and debate among the AIDSCAP implementing agencies and the Programme National de Lutte contre le SIDA (PNLS). The success of the first round of the BSS led Dr. Ibra Ndoye, head of the PNLS, to call the methodology "an extremely useful tool which provides important information about the epidemic in Senegal" and to promote its expansion into all regions of Senegal (AIDSCAP had worked in only four out of ten regions). Since then he has actively encouraged other partners and donors to participate in this effort. UNDP and UNICEF have already solicited proposals to conduct BSS for their program evaluation from ISADE and its new spin-off partner organization, Hygea, which focuses exclusively on health issues.

Constraints

ISADE did not have a lot of experience in the area of health-related data collection and analysis. AIDSCAP country program staff also were not specialized in this domain. Despite concerted efforts on the part of ISADE, the fact that it was not possible to have a full-time evaluation specialist present to monitor and supervise their activities led to delays in implementation, as well as a lack of quality assurance during the survey operation and subsequent data processing, analysis and report writing.

Lessons Learned and Recommendations

One of the major lessons learned so far is the importance of selecting an implementing agency to conduct BSS that has a vested interest in the results. This would not only lead to better quality of collected data, but also insure that evaluation activities would be institutionalized in a more sustainable fashion in the selected host countries.

Specific data from the BSS survey can be found in the Project Outcomes section of this report.

Rapid Response Funds.

AIDSCAP partner:	Various
Geographic focus:	Ziguinchor, Kaolack, Dakar, Thies
Target population:	Youth, members of religious associations, general population, CSWs, women, PLWAs, transport workers, apprentices
Project dates:	November 1994 to April 1997

Background and Scope of the Interventions

As part of the AIDSCAP strategy to encourage the development and implementation of community level interventions, as well as reinforce the capacity of local NGO's and associations to implement programs in HIV/AIDS prevention, several projects were supported under Rapid Response Funds. A total of 34 associations and local NGOs received assistance for the implementation of AIDS prevention activities, for a total of US $ 98,086.23. Individual activities received an average of US $5,000 and were short-term, lasting between 3 and 12 months.

The activities financed under the Rapid Response Funds were implemented in the four AIDSCAP regions of Dakar, Thies, Ziguinchor and Kaolack in both urban and rural settings. Interventions were organized to target specific populations:

• Youth -- male and female
• Members of religious associations
• General population in rural settings
• Casual sex workers (CSWs)
• Women
• Persons living with HIV/AIDS (PLWAs)
• Transportation workers and apprentices

Interventions consisted of BCC activities: 992 discussions and conferences, 317 theater presentations, and 258 home visits -- all with the objective of preventing the spread of HIV/AIDS by educating the target populations and encouraging the adoption of safer sexual behaviors. A total of 6,572 youth (5,110 male and 1,462 female) and 55,528 adults (34,835 men and 20,693 women) were educated during these activities and 31,348 condoms distributed free and 2,718 sold.

Among the persons reached during the Rapid Response activities, 620 peer educators were trained to continue IEC activities within their communities, sensitize the general population about AIDS issues and assist in mobilizing their communities in the fight against AIDS. Religious and community leaders were included in IEC activities to incite their support and active participation, and in some cases were trained as peer educators. Interventions also sought to achieve a closer collaboration between the religious and community leaders and the local public health structures. In some communities where activities were implemented, certain groups, particularly women's associations, were motivated to organize their own sensitization campaigns with resources from within their association and without financial support from outside sources.

These rapid response funds gave small local associations and organizations experience in implementing public health projects and in the management of project funds. In addition, AIDSCAP support helped increase the visibility and credibility of these associations in their communities.

Important Constraints

• The greatest constraint faced by the implementing partners of these activities was the slow disbursement of funds. As these associations were small and without extensive funding, they were unable to proceed with project activities until funds were disbursed.
• There was also an insufficient quantity of IEC materials and, in particular, insufficient materials in local languages.

Lessons Learned and Recommendations

The associations found it difficult to reach groups through IEC who have overwhelming economic concerns. As these groups spend most of their time trying to provide for themselves and their families, there is not much time for other activities. BCC interventions should combine income-generating activities with IEC to increase participation in such interventions.

The execution of projects within their communities improved the visibility and credibility of the associations participating in the project. In addition, these small interventions led to new ideas for future activities, particularly among women's groups who, after having executed a project with AIDSCAP support, felt greater capacity and confidence to lead interventions and seek funds from other sources for future projects.

Other lessons and recommendations include:

• Visual supports should be provided in sufficient quantities and easily accessible. The distribution system for IEC support materials should be reviewed as materials were not always available to the targeted populations. Involve local associations and NGOs in the development and production of IEC materials.
• Increase the translation of IEC materials into local languages.
• Purchase generators to allow for evening IEC activities and events in rural areas.
• Avoid delays in the disbursement of funds when possible to avoid disruptions in project implementation.
• Include income-generating projects with IEC activities, particularly for CSW projects, where economic improvements could aid in the adoption of safer sexual behaviors.
• Increase the establishment of kiosks for the dissemination of health information. Kiosks provide easy access of such information to the general public.
• Improve counseling capacity through the development of a training curriculum for public health workers.

AIDSCAP Partner	Process Indicators
Rapid Response Funds	Individuals trained	2,141
	Individuals educated	62,100
	Materials distributed	17,006
	Condoms distributed free	31,348
	Condoms sold	2,718

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