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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 VII. Important Lessons Learned From TAP's Experience VIII. Subproject Highlights A. NGO Cluster Projects VIII. Subproject Highlights (continued) B. Other Community- and Workplace-Based Initiatives Community and Workplace Intervention in High Risk Transmission Areas
Background and Scope of Intervention AMREF has extensive experience in STI/AIDS prevention in Tanzania. With AIDSTECH assistance, it began implementing behavior change interventions with truck drivers, driver assistants, and sex workers in 1989. Under TAP, AMREF expanded and diversified its AIDS prevention activities, replacing in 1993 focused truckers projects with a more broadly community-based "high risk transmission area" intervention. While AMREF's focus remained on highly traveled routes and truck stop towns along the Kibiti-Dar es Salaam-Songea highway (traversing four regions and 1400 km of highway), the targeting strategy has been substantially expanded. In addition to truck drivers, driver assistants, and sex workers, AMREF's high risk transmission area initiative targets petty merchants, travelers, workers and miners, women generally, and other various at risk populations. Workplace-based activities and efforts to increase access to and use of improved STI care have specifically been included as part of this expanded project focus. AIDSCAP through TAP has supported a number of individual AMREF projects. Because these projects build on and complement each other, rather than detailing them separately, they will here be discussed together, highlighting activities in community-based activities in high risk transmission areas generally, workplace-based activities, and upgrading clinical capacity in STI care. By the end of this project period, AMREF was working in 22 high risk transmission areas including truck stop towns and select urban neighborhoods. In order to facilitate full community involvement in and ownership of the project, an AIDS Advisory Committee has been formed in all but one of these 22 sites; the committees assist in project oversight and implementation of activities. Peer education represents the crux of the behavior change intervention. Trained in basic issues related to STI/AIDS and in interpersonal and group education techniques, peer educators from a variety of target groups conduct one-on-one and small group educational sessions, show educational videos and conduct follow-up discussions, distribute or sell condoms, and explain supplementary educational materials in various popular locations, such as bars and guest houses. Condom social marketing mechanisms have been established in 17 of the 22 high risk transmission area sites, including the creation of 135 condom sales outlets. In each site as well, upgraded STI services have been established (discussed below) and, to better meet the needs of women and engage them in planning and conducting activities, Women's Health Groups have been formed. These women's groups convene regularly to plan and conduct activities and events for generating income. Also, 45 women, two from each Women's Health Group, have been trained as counselors and provide services to their peers as well as the community at large. Workplace-based activities were launched initially in 1989 to 1992 as part of the targeted interventions with truck drivers and their sexual partners. AMREF began to focus on developing workplace programs in 1993 and by July of the same year, AIDS prevention activities were being implemented in six companies, mainly trucking companies and plantations. From the start, AMREF's worksite interventions have included STI/AIDS education and condom promotion for employees -- involving one-on-one peer education, small group sessions, and video and drama shows -- combined with sensitization of company management. To extend its impact, AMREF began identifying new worksites in 1995 and initiated sensitization of top management and key department heads, intended specifically to familiarize them with and the state of the AIDS epidemic, basic STI/AIDS issues, and AMREF's experience to date. At this phase, the project's approach emphasized institutionalization of the program and long-term sustainability, reflected in the formation of Company AIDS Committees at each worksite and aggressive promotion of a company cost-sharing scheme. By the project's end, 18 major companies were participating in the AMREF workplace intervention and sharing 50 percent of the associated costs. Company AIDS Committees had been formed and 94 peer educators had been trained and were planning and conducting behavior change activities at their respective worksites. Condom social marketing or another condom distribution mechanism had been established in all of the worksites, involving either the company purchasing condoms from CSM agents and distributing them free to workers as another medical supply, peer educator condom sales (93 peer educators had received additional training in condom social marketing), or sales from company compound vendors who were encouraged by management to include CSM condoms into their product lines. AMREF staff visited the worksites quarterly to ensure continued management support, assist peer educators as needed, and monitor implementation of activities. Based on their combined experience in conducting worksite AIDS prevention interventions, AMREF, OTTU and TACOSODE collaboratively developed and field tested a "Model Worksite Intervention" guide. This manual is currently being used by TAP's cluster interventions to guide their efforts to increase activities in business sector. Upgrading STI case management is another critical component of the high risk transmission area interventions. By training 294 clinicians in syndromic diagnosis and treatment, AMREF improved the quality of STI services at 21 truck stops along the Kibiti-Dar es Salaam-Songea highway. These upgraded clinics are visited at least once every two months, when an AMREF STI coordinator observes clinical practices, checks case registers, and records drug supplies. To maintain comprehensive documentation of utilization patterns and disease trends and to facilitate reporting requirements, patient records are entered into an AMREF database after each supervisory visit. A training manual and a clinical procedures guide for provider further reinforces competent application of enhanced clinical skills, while monitoring of N. gonorrhea sensitivity to ciprofloxacin and co-trimoxazole ensures continued treatment efficacy. Evaluation research conducted by AMREF suggests that their efforts have produced impressive results. In patient surveys, for example, women demonstrate an increase in knowledge about STIs and in prompt treatment seeking at upgraded facilities. Seventy two percent of women who sought care for STI symptoms in the previous 12 months indicated resort to AMREF trained providers, many citing peer educators as key in motivating them to seek care. Moreover, although more research is required to verify the trend, surveillance of select STI prevalence in project sites in 1993, 1994, and 1996, strongly suggest an overall reduction in prevalence of T. vaginalis and syphilis. Accomplishments Overall, the major activities accomplished in AMREF's high risk transmission area projects can be summarized as follows:
STI/AIDS Peer Education for NGO Employees
Background With AIDSTECH and AIDSCOM assistance in 1990, the Tanzania Council for Social Development (TACOSODE), an umbrella organization of 70 NGOs, initiated peer health education on AIDS for their employees. Although AIDSCAP continued to support this project, it was ultimately phased out during the TAP project. It now is funded by another donor and some of TACOSODE's regional branches are members of TAP's regional NGO coalitions. Accomplishments During the reporting period, 50 educators from 22 of TACOSODE's member organizations were trained in six, two-day training sessions and an additional one five-day training in counseling skills. The peer education activities accomplished can be summarized as follows:
STI/AIDS Peer Education in the Workplace
Similar to the TACOSODE project, OTTU was initiated under AIDSTECH and phased-out during TAP. These activities are currently supported by another donor while some of its regional branches have been integrated into TAP's cluster projects. OTTU's overall aim was to influence the entire workplace community, including management, union branch leadership, and workers, to improve conditions and support for HIV infected employees and to increase preventive behaviors among workers. The project's educational activities, however, also had a multiplier effect, benefiting workers' families, friends, and others in the community. Peer education was OTTU's main focus. During the project period indicated above, peer educators conducted over 3,000 small group educational sessions with over 65,665 workers. In 452 one-on-one sessions, over 8,000 workers were educated about STIs and AIDS. In addition to prevention objectives, peer educators, who had also received training in counseling, provided psycho-social support to co-workers infected with HIV. An important aspect of the support activities was developing workplace policy on HIV/AIDS, specifically related to testing services, confidentiality, and working conditions for HIV infected employees. With regard to this latter objective, a three-day meeting for the leaders of OTTU was conducted.
Support to People Living With AIDS, Their Families, and Orphans
Prior to being integrated fully into the Dar es Salaam NGO cluster structure, PASADA, a well established community organization in Dar es Salaam that provides a variety of services to poor residents, received TAP assistance to implement a comprehensive program with an emphasis on providing care and support to people affected by HIV/AIDS. In addition to strengthening PASADA's capacity to deliver HIV/AIDS prevention and care services, the project's specific aims were to increase clinical and home-based care and counseling for HIV/AIDS patients and to develop community-based STI/AIDS prevention education. The project was conducted through PASADA's community and health centers and its parish network. With TAP assistance, PASADA significantly increased its HIV/AIDS service capacity at the Chang'ombe day clinic. Supplementing provision of HIV testing, which is always accompanied by pre- and post-test counseling, the clinic increased its HIV/AIDS treatment and counseling patient load from 40 to 500 monthly. Patients who were too ill to come to the clinic, identified through initial community assessments, received home-based care. Home-based care teams provided basic care and treatment every month to home bound patients, effecting a total of 621 home visits during the project period. Psycho-social and in some especially needy cases modest material support was also given to affected families. An important function of the home visits in situations where death seemed imminent, was to help prepare both the patient and the family for patients nearing death. PASADA's Kariakoo Center cared for 90 AIDS orphans and further extended various kinds of support to families with orphaned children, which included training in income generating activities, providing small amounts of financial assistance in times of acute need, assisting families with food, transportation, clothing, school fees, etc. The project identified vocational training opportunities for other AIDS orphans among skilled crafts people in the community. In some instances, the project assisted older children to find employment after their training. While PASADA's support and care to orphans is impressive, a major constraint for this intervention area is the high cost of meeting the many needs of children without parents. Educational activities targeting youth were especially important in the PASADA intervention. The project, for example, facilitated formation of a chapter of "Youth Alive Club International," an HIV/AIDS prevention organization initially established in Uganda. With a membership of 100 young people, the club provided a structure of training youth educators, who also provided support and friendship to other youth infected with HIV or orphaned due to AIDS-related deaths of their parents. A "junior branch" for youth 9-14 years old was also formed to extend educational activities to younger children at perhaps more impressionable ages. To assist parents and church leaders address issues of sexuality with youth, the project developed a sexual education manual. Through the parish network, PASADA also implemented 26 community education seminars and outreach services aimed specifically at reaching high risk communities. Parish counselors, who participated in a two-week counseling training workshop, serve as permanent community resources, for people seeking information about HIV/AIDS or some other kind of related support. Finally, to inform the larger community about HIV/AIDS risks and about PASADA's services, the project integrated messages into its FM radio program.
Care for Persons and Families Affected by HIV/AIDS
A growing concern about AIDS among biomedical and traditional health practitioners alike led to the formation of the Tanga AIDS Working Group (TAWG) in 1992. The group gained official recognition in 1994 when it also began receiving TAP assistance to implement a program of community-, hospital-, and home-based HIV/AIDS services, which emphasized integrating biomedical and traditional health care resources available in the region. Rather than treating the phenomenon as a programmatic constraint, by forging a collaborative and mutually supportive partnership between biomedical and traditional healers the project succeeded in using to its advantage the pluralistic nature of health care services in Tanga Region. In the process, and to the benefit of the patient population, both health care sectors have been strengthened to deliver effective HIV/AIDS prevention, care and support. The main objectives of the TAWG project is to reduce hospital patient loads and to improve care and support for HIV/AIDS patients through home-based counseling and care services. As it acknowledges and appreciates the role and influence that traditional health providers have in their communities, the biomedical and traditional healer partnership has been the linchpin of this endeavor. Establishing and continually improving collaboration and referral between the two health sectors involved a process of increasing mutual understanding of each others' medical concepts and practices and, in turn, implementing an intervention strategy that draws upon these in complementary fashion so as to maximize the quality of patient care. As an innovative starting point, herbal remedies used by traditional healers for treating AIDS-related symptoms were clinically tested for efficacy. The study demonstrated that the traditional remedies, alone and in combination with biomedical treatments, had a positive affect on alleviating AIDS-related diarrhea, oral thrust dermatitis, dementia, and vomiting. These various treatments have been used in the project's home-based care activities, thus offering patients a wide range of treatment options to suit their particular health needs, treatment preferences, and reactions to drugs. To further enhance their HIV/AIDS-related care giving, 80 traditional healers have also been trained in basic clinical aspects of STIs and AIDS and in health education and counseling skills. While village health workers work alongside and oversee the healers' activities, regular meetings between district level biomedical practitioners and the healers facilitates ongoing exchange. Through their collaboration and continual exchange, a system of mutual referral has been established, for example, healers referring suspected STI cases to upgraded professional clinics and professional clinicians referring some AIDS patients for home-based care by a local healer. The collaboration worked so well that it extended to other important health problems in the community; better recognizing difficult cases and symptoms of especially dangerous diseases that demand immediate professional attention, such as cerebral malaria and convulsions in childhood, trained traditional healers practice early referral to professional facilities. Brought together through the TAWG project, the healers have since formed their own association. Through these collaborative efforts of Tanga Region's traditional and biomedical health communities, TAWG has been able to provide intensive home-based treatment and counseling to 237 people living with AIDS in over 4,300 home visits. In addition to easing patients' physical suffering, home-care teams also address the social dimensions of patient suffering. Helping other patients to understand their ailing health status and cope with the stigma associated with HIV-infection, long-term AIDS survivors have played a key role in the project's counseling and support component of the project. The disadvantaged position of orphans and widows has become strikingly apparently through TAWG teams' encounters with AIDS-affected families. Following traditional custom, a man's extended family assumes control over his property and affairs upon his death. Unfortunately, orphans and widows in contemporary society are often entirely neglected in the process, leading many such families down a path of total destitution. To try and remedy this situation, TAWG initiated collaboration with the Tanzania Women and Law Society, which provides advice to clients and legalizes matters related to patient wills before death occurs. Community-based counseling and education supplement home-care activities. TAWG maintains a permanent counseling staff at its offices. As the community has become familiar with the project, people have increasing come in on their own accord, for example, with specific questions, for advice about a sick relative, and for HIV testing. TAWG counselors have advised and as appropriate referred 1,615 adults who have used these services. Additionally, more than 5,400 adults have been referred to TAWG's counseling services, usually by health providers (biomedical and traditional) who have not been trained in counseling and are uncomfortable raising the possibility of HIV-infection with their patients. Educational activities aimed at the general community reinforce the project's extensive counseling network, TAWG supports. In hospitals, for example, 1,241 HIV/AIDS educational sessions have been conducted reaching a total of 19,294 patients, while traditional healer drama groups provide information and education to village communities at large.
Endnotes
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