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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. Sub-Project Highlights (continued) C. Creating an Enabling Environment: Improving Professional Care For Curable STDs and Increasing Access To Condoms Training Courses for STI Case Management
The impressive findings of the Mwanza study referred to earlier in this paper -- that controlling curable STIs can significantly reduce the incidence of HIV infection -- has clear and pressing implications for AIDS prevention efforts. Consistent with these findings, TAP places high priority on improving health care services for diagnosing and treating bacterial STIs. Three TAP subprojects are key in this regard. The Centre for Educational Development in Health, Arusha (CEDHA), the Primary Health Care Institute, Iringa (PHCI), and the Infectious Disease Centre (IDC) have received TAP assistance to train health care providers in STI case management and to conduct post-training supervision and monitoring at participating health care facilities. CEDHA and PHCI, both professional training institutes established by and operating under the Tanzania Ministry of Health, have focused on training private and NGO sector practitioners in TAP NGO cluster sites outside of Dar es Salaam. CEDHA is responsible for activities in Tanga, Arusha, Kilimanjaro, and Shinyanga, and PHCI is responsible for similar work in Tabora, Morogoro, Dodoma, and Iringa. IDC, which serves as an STI referral clinic in Dar es Salaam and collaborates on STI/HIV related research, trained health workers in the Dar es Salaam NGO cluster area. The combined training and technical experience and capacity of these three organizations makes for a particularly strong TAP partnership, the fruits of which have been overall excellent results in improving access to high quality STI care in TAP project areas. At the time of the TAP project design, nationwide training of public sector providers in STI case management was planned by the NACP with support from the European Union. Most of the participants in TAP's STI training courses have, therefore, represented private and NGO sector health institutions. The courses are based on WHO modules for syndromic case management, which have been adapted to Tanzanian national guidelines for STI care. Emphasizing adult learning techniques, the courses cover: STI/HIV epidemiology in Tanzania; key aspects of STI transmission and control; history taking, examination, diagnosis and treatment using flow charts for syndromic management; the role of laboratory diagnosis; education, counseling, and condom promotion; partner notification; patient forms and reporting; and gender-specific issues. To ascertain the course's impact on clinical practice, follow-up supervision and monitoring is an important aspect of these subprojects. Logistical difficulties and inadequate funding levels have limited the number of post-training monitoring visits, but formal and informal feedback from all regions suggest generally good outcomes from the perspective of practitioners and patients alike. Although not confirmed through systematic study, increased patient utilization of clinic services has been attributed by many practitioners to improved care resulting from training. Together, CEDHA, PHCI, and IDC trained a total of 723 health providers in syndromic STI case management as follows:
Although TAP's STI training component has overall been excellently executed and well received, three principal shortcomings can, nevertheless, be noted. First, the TAP design was overly focused on upgrading private sector care. This focus was in line with TAP's major objective of improving private sector (including NGOs) capacity and engagement in HIV/AIDS work, but it also was formulated specifically in view of NACP plans for training public sector providers in STI case management with EEU funding. That this public sector training has yet to take place is, therefore, important when assessing TAP's overall success in increasing access to high quality STI services. Rather than complementing other programs as intended, TAP's approach has in effect resulted in the exclusion, for the most part, of an important group of health providers. An over-focus on the private sector has furthermore resulted in insufficient attention to training and orienting regional and district medical officers in the syndrome management approach to STI care. As these physicians oversee health policy and practice in their respective regions, their lack of familiarity with the approach is clearly a disadvantage, and in some instances reduced their ability to effectively supervise and offer support for the practice of the syndromic diagnosis and treatment. (The project's ultimate exclusion of informal sector and auxiliary health workers from STI training is similarly an important shortcoming, and is addressed in the "STI Education for Pharmacists" subproject description below.) Second, due to time constraints the counseling component of the STI training courses was insufficient or omitted altogether. Given the importance of proper counseling in ensuring that patients avoid repeat infection and refer their sexual partners for treatment, it is critical that future training curricula sufficiently address this important aspect of STI case management. And finally, logistical difficulties and insufficient funding hampered follow-up supervision and monitoring. While clinician reports were roundly positive regarding the outcomes of the training, monitoring visits indicated insufficient follow-through at some clinics on specific aspects of the new procedures, for example, in completing patient encounter forms. The project managers indicated that immediate and frequent monitoring visits would likely have produced a better outcome in this regard.
Because they are major STI care providers, AIDSTECH initiated a demonstration project with pharmacists in 1991 that aimed to improve their ability to respond effectively to clients presenting with STI symptoms; the project was implemented in partnership with Muhimbili University Medical Center, Department of Pharmaceutics and Pharmaceutical Microbiology. To initially ascertain pharmacists' knowledge about STIs and the nature of advice and sales practices related to these infections, the project conducted "mystery shopper" research in selected pharmacies in Dar es Salaam, where research assistants posed as pharmacy clients complaining of different STI symptoms. Pharmacists working in the city's 57 registered pharmacies were additionally interviewed about STIs generally and drug treatment specifically. Based on findings from this mystery shopper and survey research, one-half of these pharmacists were invited to participate in subsequent educational sessions about STIs and their treatment. Using the non-trained pharmacists as a control group, the study confirmed a significant increase in STI knowledge among pharmacists who participated in the training. In light of these results, AIDSCAP continued to support this activity in 1992, emphasizing in particular further evaluation of the STI training outcomes and development of appropriate educational materials and monitoring tools for pharmacy-based use. This summary focuses on results from the AIDSCAP phase. AIDSCAP conducted another workshop for 27 pharmacists (19 private retailers and 9 public sector) who were not trained during the first phase of the project. Similar to the AIDSTECH training, this three day workshop covered basic information on STIs and AIDS, prevention, use of treatment algorithms, and patient counseling and referral. A second workshop included all pharmacists (40 private and 17 public sector) to reinforce earlier training and to clarify pharmacists' questions. Reference materials were produced for use by trained pharmacists and included such items as a list of common STI symptoms and their complications, treatment algorithms according to national guidelines, and a patient referral card. Pharmacists were also encouraged to distribute educational materials to patients, which described common symptoms, gave prevention advice, and emphasized the need for prompt partner referral. To determine pharmacy patient profiles and gain an understanding of their perceptions and behaviors, the project developed a pharmacy registry system for STI clients. This registry revealed that urethral discharge associated with painful urination was the commonest symptom in both men and women. Significantly more men compared to women were shown to seek STI care at pharmacies, and youth also frequently resorted to pharmacies for advice and treatment for STI symptoms; 20 percent of all registered STI clients were under 15 years old. Approximately 30 percent of all clients complaining of STI symptoms return for additional information and advice, suggesting that pharmacies represent a trusted source of information and health care for the general population. To discern improvement in patient care, the project conducted additional mystery client research. In terms of pharmacy-based diagnosis and proper treatment, these data showed a notable improvement in the quality of care; moreover, pharmacists' refused more frequently to sell patients partial treatments. But the research also revealed that pharmacist assistants, rather than the trained pharmacists, often attended to clients and were, obviously, less inclined or prepared to offer adequate advice and patient referral. Analysis of drugs purchased at different pharmacy sites further confirmed that while most of the drugs available through pharmacies were of satisfactory quality, some had substandard potency according to official guidelines. Overall, STI education for pharmacists proved to be effective for improving treatment in the popular medical sector. In November 1993, however, the project was suspended due to the absence of formal government support for the activity, to persistent problems with treatment algorithms, especially when used with women patients, and to the fact that pharmacy clerks attended to clients as often or more frequently than the trained pharmacists themselves. Careful evaluation of the project and its shortcomings was, therefore, deemed necessary before promoting further pharmacy-based STI diagnosis and treatment. Through the experiences of TAP's other interventions, and in particular the coalition projects, it has, nevertheless, become apparent that some form of intervention with popular sector health providers is urgently needed.
Condom social marketing activities began in 1988 under the USAID funded AIDSCOM project. Sales, however were not as high as expected and as such the Tanzania Social Marketing project was redesigned in 1993 as an integral part of TAP. The Salama brand condom was repackaged and launched on December 1, 1993 as a part of World AIDS Day activities. Since the launching of the re-packaged Salama, over 30 million condoms have been sold. Moreover, PSI and TAP have coordinated an increase of social marketed condoms with a decrease in free condom distribution through the MOH Family Planning Unit and the National AIDS Control Program. The goal of the CSM project was to reduce the sexual transmission of STIs including HIV by making quality condoms attractive, affordable and widely available to the general population while giving special attention to target groups at higher HIV infection risk such as low-income youth, commercial sex workers, truck drivers, mobile traders, migrant and agricultural laborers, soldiers and students. This objective was achieved by increasing access to and use of condoms through an expanded distribution and sales network, through an intensive STI/HIV education program an condom brand promotion strategy for the target groups. An important secondary objective was the transfer of marketing skills, capacity and technology to a wide range of commercial and NGO partners, developing a local infrastructure capable of marketing condoms through the private sector. Over the life of the project, the access to condoms has improved dramatically, both through the number and variety of outlets selling condoms. The project established an extensive and diverse distribution system. By the end of May 1997, project condoms were being distributed by 10 pharmaceutical wholesalers and 38 consumer goods wholesalers and 58 additional wholesalers supplied through the projects national distributor, Kay's Hygiene. For a sustained distribution system, having nearly 32% of the condoms distributed though wholesalers is positive because a substantial and growing quantity of condoms are moving through commercial distribution channels with out external involvement. By the end of the project, PSI was selling to a network of 40 retail sales points across the country's twenty administrative regions. These outlets included 297 pharmacies, 138 duka la dawas (a type of licensed drug store), 52 grocery stores and 471 non-traditional outlets ranging from bars and night spots to hair salons, photo studios and gas stations. In addition a growing number of NGOs are a part of the sales network with community-based AIDS education workers trained as condom sales and distribution agents. During the calendar year 1996, 40% of retail sales were through NGOs. PSI provided training in condom social marketing techniques, promotion and distribution to commercial outlets operators, community based education agents, and NGO officers. The training was done over the course of two days for a total 18 hours. By the end of the project, over 3,000 people had been trained in condom social marketing. As of June 1997, over 30 million condoms had been sold and the average monthly sales increased from 97,744 during the first three months of the project, to an average of 979,968 per month in the last quarter of 1997. Annual sales nearly tripled from 3.8 million condoms sold in 1994 to 10.9 million in 1995. Condom sales and behavior change were promoted and supported by and intensive program of IEC, advertising and promotional events. PSI used a wide variety of media to educate the public about and to promote condom use. Sales teams, in collaboration with local health officials working in each of the four operational zones -- Northern, Southern, Central and the Lake zone -- organized mobile educational and entertaining video shows. Approximately 2 million people attended 457 mobile video presentations on AIDS prevention. PSI also produced and distributed 46,005 information posters target at different audiences. In addition, 252,681 pamphlets and leaflets were distributed to target populations along with condom promotional items such as 6,000 caps, 21,000 T-shirts, and 130,000 bumper stickers. Over two thousand condom promoting and HIV prevention messages were aired on radio, TV or in newspapers. PSI also is active in sponsoring sports, concerts, beauty pageants, and theater groups, and featured condom promotion messages.
Endnotes
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