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This report comprehensively summarizes the FHI/AIDSCAP program in Tanzania (1991-1997). The report includes a background and country context for the program, as well as an overview of the Tanzania AIDS Project, and a discussion of work undertaken to mobilize communities and strengthen capacity; support interventions and create an enabling environment; and conduct research and evaluation. Lessons learned from the program are also listed.
Table of Contents II. Background and Country Context III. The Tanzania AIDS Project: An Overview V. Supporting Interventions and Creating an Enabling Environment VI. Research and Evaluation (See Below) VII. Important Lessons Learned From TAP's Experience VIII. Subproject Highlights A. NGO Cluster Projects VI. Research and Evaluation A. Summary of TAP-Funded Research TAP funded and conducted a number of research studies to date. The methods and general findings from most of these (except for the KABP surveys) are described in more detail in the subproject summaries in Section D; however, the studies are briefly summarized as follows:
Results from these studies were used by TAP for strategic and programming decision-making. KABP survey data from Morogoro, Shinyanga, Tabora, and Tanga Regions, have provided information about the status of key sexual behavior indicators during the life of the project. These surveys are discussed in more detail below along with Health and Demographic Survey (DHS) results, which help to interpret the behavioral impact of STI/AIDS interventions. B. Summary of TAP Behavioral Outcomes AIDSCAP evaluates the overall success and behavioral outcomes of its country programs using three complementary approaches: (1) collection of monthly process indicator data from each subproject, providing cumulative totals of the number of persons trained and educated, condoms distributed and sold, and materials produced; (2) cross-sectional survey research in target populations to determine knowledge, attitudes, beliefs, and practices related to STIs and AIDS; and (3) individual and group interviews with key target audiences in order to gain a more contextual understanding of perceptions and behaviors. Process indicator data are reported in each of the TAP subproject executive summaries later in the report and are summarized together in Attachment D. This section summarizes behavioral data related to individuals' knowledge of HIV/AIDS, perceptions of risk, and sexual behaviors. The behavioral data reviewed in this section come from primary and secondary sources: (1) the USAID-funded Demographic and Health Survey for 1991-1992, which included a small version of the AIDS module, with 9,238 women and 2,114 men between 15 and 49 years of age; (2) the DHS for 1994, which had the full AIDS module, and involved a sample of 4,128 females and 2,066 males; and (3) a series of knowledge, attitudes, behaviors and practices (KABP) surveys conducted by TAP in 1996 in Morogoro, Shinyanga, Tabora and Tanga cluster regions, including 412 girls and 346 boys (between 14 to 20 years old) in secondary schools (self-administered) and 422 women and 368 men (between 20 to 59 years old) in households (interviewer-administered). A DHS was also conducted in 1996-1997, which included the full AIDS module and was expanded from three to six of TAP's cluster regions. In order to highlight changes over time, the data from all surveys are presented together by category, emphasizing knowledge of transmission and prevention, risk perception, partner networking, and condom use. Table 3. Behavioral Data Points for Target Populations Reached Under AIDSCAP/Tanzania (TAP)
Note: Studies not funded through AIDSCAP/TAP include the two rounds of DHS and one round of TKAPS, which were conducted by the Tanzania Bureau of the Censuses in collaboration with Macro International and funded through the USAID Mission in Tanzania. 1. Knowledge of transmission and prevention HIV/AIDS knowledge and awareness has been consistently high, although some misconceptions remain. The 1991/92 DHS reported that over 90% of males and females had heard of AIDS; 83% of females and 90% of males knew that HIV is transmitted sexually. Knowledge of other modes was low: only 7% of females and 16% of males mentioned mother-to-child transmission (unprompted). When asked directly, 59% of women and 77% of men answered yes, but 17% of females and 16% of males did not know. Misconceptions in 1991/92 included the belief that mosquitoes can transmit HIV among 32% of females and 42% of males. Only 62% of females and 68% of males agreed that a healthy person can have HIV, while 21% of females and 17% of males did not know. More than 90% of males had heard of condoms; data were not reported for females. By the 1994 DHS (TKAPS), 34% of females and 54% of males could cite two or more ways to prevent HIV/AIDS, a statistic that was not calculated in 1991/92 or in 1996. Awareness of the existence of AIDS is universal. Knowledge of mother-to-child transmission improved: 77% of females and 82% of males answered yes, although 15% of females and 12% of males still did not know. Virtually no respondents of either sex mentioned avoiding mosquitoes as a way to avoid HIV/AIDS. Knowledge of asymptomatic transmission had improved slightly: 69% of females and 78% of males agreed that a healthy person can have HIV, although 16% of females and 9% of males still did not know. Knowledge of condoms (but not condoms as a way to prevent HIV) was 83% for females and 95% for males. In an unprompted question about ways to avoid HIV, 36% of females and 49% of males mentioned condom use. The 1996 DHS found that prompted knowledge of mother-to-child transmission was 75% for females and 77% for males with 15% of females and 14% of males reporting they did not know. Knowledge that a healthy person can have the AIDS virus remained at 70% for females and 79% for males; 14% of females and 10% of males did not know. In an unprompted question about ways to avoid HIV, 39% of females and 55% of males mentioned condom use, an improvement since 1994. About a quarter of male and female respondents in the 1996 survey say that having only one partner can help prevent the spread of the disease, and 20 percent of women and 17 percent of men report that limiting the number of sexual partners can prevent HIV infection. Urban respondents are more likely to report safe patterns of sexual behavior (condom use, staying with one partner) than their rural counterparts. The 1996 four-region KABP survey did not ask prompted questions about modes of transmission. Percentages of people citing two or more ways to prevent HIV was lowest for girls (87%) but above 90% for boys, men and women. Misconceptions remain, 14% of adults and 16% of youth (very slight gender differences) mentioned avoiding mosquito bites as a way to avoid HIV, although these figures are greatly improved over the 1991/92 DHS. Three percent of youth (no gender differences), 13% of men and 15% of women mentioned that having sex with a healthy looking person could prevent HIV. Again, people were not asked directly about these beliefs, as was done in the DHS surveys. Percentages of respondents who had heard of condoms was over 90% for men and women, 87% for girls and, interestingly, only 75% among boys. Although 36% of youth and adults reported condom outlets within five minutes' walk from their houses, 30% of both youth and adults reported the distance to be more than 20 minutes' walk. 2. Sources of information about AIDS In the 1991/92 DHS, radio and friends or relatives were reported as the principal sources of HIV/AIDS information in Tanzania. Over half of females cited friends or relatives (62%) and radio (56%) as sources of information about HIV/AIDS, whereas 81% of males interviewed cited the radio and 45% cited friends or relatives. In the 1994 TKAPS, 55% of females cited friends or relatives and 61% cited radio as sources of information while 54% of males cited friends or relatives and 82% cited radio. Only two percent of females and one percent of males cited the workplace as a source of HIV/AIDS information. By the 1996 DHS, 25% of females and 12% of males cited the health worker as a source of HIV/AIDS information, while 67% of females and 55% of males cited friends and relatives as their source of information on HIV/AIDS. The radio is still by far the main source of information for the majority of people as reported by 66% of females compared to 88% of males. The 1996 4-region KABP asked separately about friends and family as sources of information about HIV/AIDS. There were insignificant differences between sexes: 49% of youth mentioned family and 45% of youth mentioned friends; 36% of adults mentioned family and 57% of adults mentioned friends. While there were insignificant differences by gender among the youth in terms of radio being a source of information (66% mentioned radio), 79% of adult males mentioned the radio compared to 67% of adult females. In general the in-school youth mentioned more sources of information than the adults, for example, 73% cited newspapers, 63% books, 52% teachers, 52% health workers and 49% religious leaders. Worksites were not listed as a possible source of information for adults in this study, but should be in future studies, especially if worksite-based interventions continue. 3. Risk perception Risk assessment questions were first asked in the 1994 DHS/TKAPS: 31% of females and 22% of males were unable to assess their own risk on a scale of none, small, moderate or great. 49% of females and 61% of males said no risk at all or small risk, while 20% of females and 17% of males said either moderate or great risk. In response to a question about why they consider themselves to be at moderate or great risk, 57% of females stated they are at this level of risk because their spouse or regular partner has another sexual partner besides herself. The most common reasons given by males who considered themselves at moderate to great risk include many sexual partners (24%), sex with prostitutes (22%) and not using condoms (20%). By the 1996 DHS, 32% of females and 25% of males were still unable to assess their own risk. Risk perception changed very little: 44% of females and 59% of males said no risk at all or small risk, while 24% of females and 16% of males said either moderate or great risk. In response to the question about why they consider themselves to be at moderate or great risk, 61% of females stated they are at this level of risk because their spouse or regular partner has another sexual partner besides herself. The most common reasons given by males who considered themselves at moderate to great risk include many sexual partners (20%), sex with prostitutes (21%) and not using condoms (34%). The 1996 4-region KABP survey also included questions on risk assessment. Among this sample, 13% of men, 23% of youth (no gender diagregated data) and 25% of women were unable to assess their level of risk of HIV infection. Those who reported none or little risk included 64% of women, 74% of youth (no gender disaggregated data), and 75% of men. Those who reported moderate or high risk included three percent of youth and 11% of adults (data not disaggregated by gender). Among reasons for small or no risk of HIV, condom use was mentioned by 63% of girls, 73% of women, 76% of men, and 85% of boys. Abstinence was mentioned by 80% of adults (no gender differences), 89% of boys and 93% of girls. A higher proportion of adults (94%) mentioned having regular sexual partners as a reason for low risk, compared to 76% of youth. When looking at those who report moderate to great risk, the sample sizes become small, and results must be interpreted with caution, however, 44% of women and 71% of girls said that they were at moderate to great risk because their partner has other partners. Those who mentioned having multiple partners as a reason included 33% of boys, no girls, 78% of men, and 88% of women. Those who said they did not use condoms (as a reason for their greater risk) included 55% of boys, 29% of girls, 35% of men, and 27% of women. 4. Sexual partners In the 1991/92 DHS, respondents were asked about the number of different sex partners they had had in the four weeks preceding the survey, without specifying type of partner (regular or nonregular), disaggregating by marital status, or whether or not money was exchanged for sex. 6% of females and 29% of males reported more than one partner during the previous four weeks. In the 1994 DHS/TKAPS, 7% of currently married women and 6% of unmarried women reported more than one partner during the previous 12 months. For males, 27% of currently married and 25% of unmarried males reported more than one partner. Interestingly, 68% of unmarried females and 49% of unmarried males reported no sexual partners during the previous 12 months, while 26% of unmarried females and males reported only one sexual partner. Among women and men who ever had sexual intercourse, 5% of females and 9% of males said that they had given or received money, gifts or favors in exchange for sex the last time they had sex with someone other than their spouse or regular partner (during the previous 12 months). In 1994, respondents were also asked if they had in any way changed their behavior since learning about HIV/AIDS and if so, how: 74% of women and 88% of men said yes. Among those who had changed behavior, 59% of females and 53% of males said they were restricting sex to one partner. Additionally, 12% of females and 25% of males said they had reduced number of partners while 26% of males reported that they had stopped having sex with prostitutes. The 1996 DHS found that the vast majority of currently married women (95%) had not had sex with anyone other than their spouse or have not had sex at all in the 12 months preceding the survey, compared to the 1994 figure of 93%; only 4.9% mentioned having more than one partner. In addition, 65% of unmarried women were not sexually active in the 12 months preceding the survey, while only 4.6% reported having more than one partner. 74% of married men reported having only one sexual partner during the previous 12 months, 7% reported abstaining from sex, and 19% reported having sex with more than one woman (in the past 12 months). 40% of unmarried men had been sexually active during the same time period; 21% had one partner and about the same percent had more than one partner. Respondents who have heard of AIDS and ever had sexual intercourse were also asked in 1996 if they had changed their behavior in order to prevent getting infected with the virus that causes AIDS: 82%of women and 91% of men reported that they have changed their sexual behavior since learning about HIV/AIDS. Actions taken to change behavior were similar to percentages reported in 1994. Respondents living in rural areas and those with no education were less likely to have changed behavior in response to perceived risk of HIV than respondents living in urban areas and those who are more educated. The 1996 4-region KABP determined that 42% of youth reported having been sexual active overall, however, within the 15-19 age category, 59% of boys and 25% of girls reported previous sexual activity, and in the 20-24 age category, 75% of boys but only 39% of girls reported having had sex. Of girls reporting sexual activity, 75% said their partners were older than themselves compared with 11% of the boys. Among the youth, 78% of girls but only 47% of boys reported having regular partners (of those youth reporting previous sexual activity). More than 94% of adult males and females had had sex previously, and 76% were either married or had regular partners. Respondents in this survey who were either married or not married, but had regular sex partners were also asked about non-regular partners: 9% of women, 15% of girls, 33% of men and 53% of boys reported having non-regular partners. Of those reporting non-regular partners, 34% of women, 54% of girls, 70% of men, and 78% of boys said they had two or more non-regular partners. The 4-region KABP data is not comparable to the DHS data because of different analysis strategies. DHS compared married (mixing monogamous and polygamous marriages) and nonmarried respondents regardless of partner type, while TAP's survey focused on partner type (regular/nonregular) according to WHO/GPA's definition. The DHS data points suggest the unmarried males and females within the general population are reducing partners to some degree. Trends are not clear for married men and women. Table 4. Percentages reporting more than one sexual partner during previous 12 months
*Question was for the previous four weeks rather than 12 months. 5. Condom use Respondents who reported having had sexual relations were asked in the 1991/92 DHS, if they had used a condom during the previous four weeks, without controlling for type of partner. Only 4% of females and 9% of males responded positively. In the 1994 TKAPS, condom use was assessed in terms of ever use and last time use with a spouse or regular partner and with a non-regular partner. 12% of females and 30% of males reported having ever used a condom. 20% of females and 36% of males used a condom the last time they had sex with a non-regular partner, however only 4% of females and 9% of males used a condom the last time they had sex with their spouse or regular partner. In 1996, the DHS assessed condom use in the same way, finding that 13% of females and 33% of males reported having ever used a condom. 17% of females and 35% of males used a condom the last time they had sex with a non-regular partner, however only 1.7% of females and 4% of males used a condom the last time they had sex with their spouse or regular partner. In 1996, the 4-region KABP determined that, among people with non-regular partners, 54% of youth (no gender differences), 46% of men and 38% of women reported condom use at last sex. Respondents were asked for the brand of condom use used at last sexual encounter with a non-regular partner: 65% of adults and 80% of youth mentioned Salama condoms, PSI's condom social marketing brand. For those reporting sex with non-regular partners, 37% of men and boys, 44% of girls and 34% of women reported an exchange of money or gifts for sex. With regular partners, condom use at last sex was reported by 10% of adults (no gender differences), 53% of boys and 67% of girls. Further, condom use by adults did not differ by rural/urban location, but among youth, condom use in rural areas was higher (63%) than in urban areas (56%). Among adults, reasons for condom use were 63% as protection against STIs and only 23% for family planning. Females among both the adult and youth samples report more condom use for FP, while males report condom use for STIs more often. Table 5. Condom Use Data for General Populations
*Type of partner not specified. The two data points for general population samples (1994 TKAPS and 1996 DHS) suggest slight improvements in ever-use but no change in condom use with nonregular partners and decreases in condom use with regular partners. Condom use among adults in AIDSCAP's intervention sites (4-region KABP) show much higher levels but there is only one data point and the sampling strategies were different between the 4-region KABP and the DHS surveys. At the close of the AIDSCAP program, quantitative evidence of significant amounts of behavior change has yet to emerge, either from the general population data available from the TKAPS or the DHS or from smaller studies of populations targeted by direct interventions. Knowledge of AIDS and of prevention methods is high, but behavior change has lagged behind. However, the DHS and TKAPS results suggest that percentage reporting more than one partner, especially among unmarried people, are decreasing. The higher rates of condom use among samples from AIDSCAP intervention regions, compared to DHS and TKAPS data, suggest that exposure to interventions is having the intended effects, although the samples are certainly not comparable. The clusters of NGOs working under AIDSCAP funding has made impressive progress in understanding the complexities associated with tracking and interpreting behavior change and how it is effected by interventions. The data suggest that change is happening, but we don't as yet have very convincing sets of data points, complemented by well-analyzed qualitative data, to confirm behavioral trends among the key target groups being reached by the various donors' interventions. Donors providing subsequent funding should consider including some system of behavioral surveillance (Mills et al 1997) -- a series of repeated cross-sectional surveys measuring risk behaviors in selected population groups -- as a way of tracking shifts in behavior change among certain key target populations in targeted geographic areas. Behavioral surveillance of these target groups should occur no more frequently than once a year (possibly every other year), depending on information needs of collaborating partners. 6. STI health seeking behavior In the 1994 DHS/TKAPS, respondents were asked about their knowledge of STIs (unprompted) and whether or not they had experienced any STIs during the previous 12 months. While 98% of females and 99% of males mentioned HIV, only 54% of females and 68% of males mentioned syphilis. 61% of females and 80% of males mentioned gonorrhea. 3% of females and 8% of males mentioned genital warts. Only 2% of females and 4% of males self-reported an experience of any STI during the previous 12 months, mostly gonorrhea. The vast majority of respondents (96% of men and 88% of women) who had an STI in the previous year reported that they sought treatment of it. Women were more likely than men to inform their partners of the disease (89% of females vs. 57% of males). However, men were more likely than women to avoid sex. 25% of women said they took no measures to protect their partners because their partners were already infected. In the 1996 DHS, respondents were asked about their knowledge of STIs (unprompted) and whether or not they had experienced any STIs during the previous 12 months. While knowledge of HIV/AIDS is universal (more than 80% for both sexes), 51% of females and 72% of males mentioned syphilis. 57% of females and 78% of males mentioned gonorrhea. 1% of females and 3% of males mentioned genital warts. Only 2% of females and 8% of males self-reported an experience of any STI during the previous 12 months, with males reporting mainly penile discharge and gonorrhea, and females reporting gonorrhea. The vast majority of respondents (84% of both men and women) who had an STI in the previous year reported that they sought treatment for it. Women were more likely than men to inform their partners of the disease (83% of females vs. 58% of males). The 1996 4-region KABP also asked youth and adults which STIs they knew (unprompted). Interestingly, only 22% of 620 youth (no gender differences) mentioned HIV but only 4% of adult men and 7% of adult women mentioned HIV. 35% of youth mentioned syphilis and 43% mentioned gonorrhea. Among adults (again no gender differences), 44% mentioned syphilis and 51% mentioned gonorrhea. Among youth, the most frequently mentioned sources of information about STIs were radio (70%), newspapers (69%), books (64%), teachers (58%), health workers (57%), religious leaders (47%), friends (46%), and family (41%). In contrast, more than 90% of male and female adults mentioned radio and friends, followed by family (89%), health workers (88%), newspapers (81%), meetings (72%), and books (68%). Self-reported STI symptoms (urethral or vaginal discharge) during the past 12 months were mentioned by four percent of adults and two percent of youth. About two percent of adults and three percent of youth reported having had genital ulcers. Endnotes
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