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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 (See Below) VII. Important Lessons Learned From TAP's Experience VIII. Subproject Highlights A. NGO Cluster Projects V. Supporting Interventions and Creating an Enabling Environment A. Support for Training, Media, Materials, and National-Level Advocacy and Collaboration The essential function of TAP's centrally-based activities is to ensure that behavior change interventions are possible and effective. This involves conducting activities that improve the internal functioning of TAP's implementing partners and that positively influence the external social and policy environments within which they must operate. Improving awareness about and access to condoms and high quality STI care are key components of this overall effort, and these are addressed separately below. This section discusses other critical areas of TAP's support functions, including: (1) enhancing the capacity of TAP project partners through training; (2) supporting TAP-funded interventions with electronic and print media; and (3) ensuring national-level support through advocacy and collaboration. Improving the capacity of NGO partners through training was a central TAP concern. Consistent with the overall and long-term objectives of the project, TAP's training agenda for project collaborators embraces the following guiding principles: (1) Institutional capacity implies both sound administrative and financial management and the ability to deliver high quality behavior change interventions that effectively integrate AIDSCAP's core technical strategies -- decreasing the rate of sexual partner change, reducing the risk of infection by increasing correct usage of condoms, and increasing prompt STI treatment seeking from qualified providers. Both technical and management aspects are, therefore, reflected in TAP training. (2) Trainings should contribute to NGOs' and communities' overall resource base. Training individuals was intended to create multiplier effect with trainees disseminating learnings in their home communities. (3) To the extent possible and appropriate, training participants should represent the social makeup and diversity of Tanzanian communities. Participants have thus been drawn from a variety of social, professional and educational backgrounds, and in every case have included government collaborators. (4) Training methods should maximize participant input, exchange of experiences and knowledge, self-learning and discovery, and problem solving and practical skills; participant-centered training techniques are, accordingly, always utilized. Attachment B summarizes the number and kind of training workshops coordinated by TAP, but a brief description of the main training areas follows:
The second major TAP support function entails supplementing and reinforcing community-based behavior change communication efforts through the production of printed materials and mass media programs. Mainly in a technical assistance capacity, TAP resource center staff work closely with partner organizations to conceptualize, field test, and disseminate a variety of educational and promotional materials -- e.g., calendars, cartoons, leaflets, postcards, and posters -- that are geared to the specific needs of different target audiences. TAP produced periodicals, one for adult readers, another for youth, and a third for the NGO clusters themselves, feature contributions from target audience members that deal specifically with topics and events that are immediately relevant and of interest to the readers. Video programs additionally provide NGOs an excellent vehicle for exploring in depth with their target audiences -- interpersonally or in small groups -- complex social and personal issues related to sexual risk, sexual relations, and sexual decision making. Radio and TV broadcasts extend the program's reach by stimulating reflection and discussion in target populations. Interpersonal communication approaches in community interventions complement and build on mass media messages. "AIDS and the Community," for example, a weekly radio program produced collaboratively by TAP and the NACP, provides a forum to discuss various health and social issues related to HIV and AIDS, many of which are raised by members of the listening audience. Especially influential were several TV appearances and a radio series produced in 1994 that gave people living with AIDS the opportunity to speak out about the ways the disease had affected their lives. They conversely gave listeners and viewers the opportunity to hear the personal dramas of ordinary people, like themselves, but whose lives had been drastically and permanently altered by HIV. Such high visibility fora for people to narrate their experiences with HIV and AIDS brought into focus for the general population the personal consequences of the epidemic. For many in the listening and viewing audience, the stories of physical and emotional pain, social stigmatization and isolation, and financial hardship helped transform the abstract concept of disease risk into a reality with tangible and devastating outcomes. This intensive media attention in 1994 furthermore empowered people with HIV/AIDS to speak about and to seek support. From this expressed need emerged a non-profit organization in Dar es Salaam, the Service of Health and Development for People Living with HIV/AIDS (SHDEPHA+), which provides counseling, education and support, including income generating activities, for people infected with HIV. SHDEPHA+ is a member NGO of the Dar es Salaam cluster and it also now receives financial assistance from other major donors. Paralleling similar work in NGO cluster projects, a third major TAP support function involves national-level advocacy. In addition to media, TAP seizes opportunities as they arise to sensitize policy makers and the general public about STI/AIDS and to advocate support for prevention and care programs. World AIDS Day, the International Candle Light Memorial, international trade fairs, etc., represent such opportunities. In close collaboration with the NACP, TAP also works to sensitize and gain the active support of national decision makers. When members of the national parliament recently convened for the 1997 session, for instance, TAP with the NACP conducted a full-day sensitization program with the parliamentarians, presenting basic facts related to STI/AIDS, and addressing issues such as the burden on the nation's health care system, impact on reproductive health, and the effects on the national economy. The parliament's leadership role in setting policy and supporting prevention and care interventions was emphasized throughout the sensitization. B. Improving Professional Care for Curable STIs There is both a biological and a behavioral rationale for including improved access to and use of professional STI care as a priority component in HIV/AIDS prevention programs. In an important study conducted in Mwanza, increased cure rates of bacterial STIs was significantly associated with a reduction in incidence of HIV.1 Because the same risk behavior is at issue, however, targeting patients with sexually transmitted infections other than HIV is doubly important. Upgrading clinical capacity to diagnose and treat curable STIs directly addresses the biological association between STI and HIV infection. From a behavioral perspective, health education and clinic-specific promotion to increase patient use of upgraded facilities provides a way of reaching individuals at high risk for HIV and, influencing them to alter their behaviors. In Tanzania there are significant challenges to improving STI care and to increasing STI care seeking behavior at improved services. First, although an important cause of reproductive morbidity and mortality, STIs in Tanzania have traditionally received insufficient attention in public health initiatives. The legacy of this inattention is poor clinical and laboratory capacity to appropriately diagnose and treat STIs. Syndromic management offers a viable alternative for some, though not all, STI cases. Part of TAP's strategy to increase effective treatment of bacterial STIs is through training clinicians in syndromic case management. A second challenge stems from the perspective of patient behaviors. For a variety of reasons that are incompletely understood, patients with symptoms of STI frequently prefer to self-medicate with readily available antibiotics, or to consult informal and traditional sector care providers who are ill prepared to properly diagnose or prescribe effective treatment. Providing STI education to select informal sector care providers, and emphasizing STI referral in community-based education projects, are TAP's main strategies for improving patient awareness and knowledge about STIs and for increasing patient attendance at upgraded clinics. Four projects have focused on upgrading clinic-based care through clinician training in syndromic case management: the Centre for Educational Development in Health, Arusha (CEDHA), the Primary Health Care Institute, Iringa (PHCI), the Infectious Disease Centre (IDC), and the African Medical Research Foundation (AMREF). The former three trained primarily private and NGO sector clinicians working in TAP's NGO cluster sites. AMREF trained clinicians working in areas of their high risk transmission area project. Between these four projects, TAP trained over 1000 health care providers in syndromic STI case management. With regard to informal sector care, AIDSCAP (prior to the launching of TAP) supported a demonstration project conducted by Muhimbili University aimed at improving STI education among pharmacists and training them in the use of treatment algorithms. Due to a lack of official support for this activity, combined with continued difficulties and uncertainties related to treatment algorithms, this project was suspended in November 1993. Finally, although with varying degrees of success, all of TAP's NGO cluster projects included referral of suspected STI patients to upgraded clinics in their behavior change communication strategies. In the Tanga and Iringa clusters, in particular, referring STI patients has been well integrated into their health education activities of their peer health educators. The syndromic approach used by Mwanza and TAP is currently being planned to expand into clinics in Dar es Salaam. C. Increasing Access to and Use of Condoms Condom social marketing activities in Tanzania began in 1988 as part of the AIDSCOM project. Sales, however did not meet expectations and in 1993, the condom social marketing project was redesigned and established as an integral part of TAP. The condom social marketing program was carried out through Population Services International, one of the AIDSCAP subcontractors. In December 1993, as part of the World AIDS Day activities, the Salama brand condom was repackaged and relaunched. Since then, condom sales have been impressive, topping the 30 million mark by the end of the project. More importantly, the increase in socially marketed condoms has been closely coordinated with the MOH Family Planning Unit and National AIDS Control Program's to replace the steady decrease of free condom distribution. Comparing the DHS data from 1994 and 1996, more men and women can cite the use of condoms as a way to avoid AIDS, and a larger percentage of men and women say they are using condoms more in order to prevent getting HIV/STIs than previously. According to the 1996 data, 93% of men and 85% of women in Dar es Salaam have heard of Salama condoms. Salama condoms were distributed increasingly through wholesalers, NGOs and distributors rather than individual sales people. Condoms sold through NGOs accounted for 40% of sales in 1996. An intensive program of IEC activities, promotional events, advertising and personal contacts were used to encourage condom sales and behavior change. Over 2 million people attended 475 mobile video presentations, and over 3111 community based distribution agents were trained in AIDS awareness and Salama condom sales. Over 46,000 informational posters and 25,000 pamphlets were distributed to target populations and sales promotional items including caps, T-shirts, and bumper stickers were distributed to wholesalers, retailers and customers. Over 2,000 brand promoting or prevention messages were communicated by radio, TV, billboards or newspapers. Endnotes
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