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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) D. Research and Surveillance STI Prevalence and Screening Strategies for Women Attending Family Planning Clinics in Dar es Salaam Muhimbili University Medical Centre The primary contact with the professional health sector for many women is through maternal child health and family planning clinics. There is increasing interest, therefore, in integrating STI care into MCH/FP services. Toward this end, AIDSCAP collaborated with Muhimbili University Medical Centre on a study designed to ascertain the prevalence of selected sexually transmitted infections among women attending family planning clinics, and to validate STI screening strategies for use in such clinics. AMREF conducted laboratory analysis on clinical samples drawn from study participants. Women from three family planning clinics in Dar es Salaam were randomly selected to participate in the study. A total of 908 women were interviewed, and 897 underwent clinical examination, during which samples were taken for candida, trichomonas, gonorrhea, syphilis, chlamydia, and HIV testing. Seventeen percent of the women tested positive for HIV. Among the subjects with cervicitis infection, 70 percent were asymptomatic, making clinical screening for cervicitis problematic. The study also confirmed the difficulty of clinically distinguishing between trichomoniasis and candida infection. Because of asymptomatic infection for cervicitis and ambiguous clinical signs for trichomoniasis and candida, overall, the Tanzanian flowcharts for symptomatic patients did not perform well in the family planning population. These research results clearly indicate that for women, there is no "magic bullet" for STI control, and that alternative strategies to syndromic management need to be conceptualized and tried. Focused Ethnographic Study Among Sex Workers in Morogoro Health for All Volunteers Trust Although the significance of commercial sex work to STI/HIV epidemiology is well documented, relatively little is reported in the scientific literature about the social dynamics underlying the trade or the health perceptions and behaviors of the women who are engaged in it. To gain a better understanding of the factors drawing women into the commercial sex trade, and to examine sex workers' STI treatment seeking and sexual behaviors, AIDSCAP provided technical and financial assistance for a focused ethnographic study that combined depth interviewing, survey and clinical research methods1. The study focused on brothel-based sex workers living on Shamba Street in Morogoro. Although still incomplete, preliminary data analysis provided critical insight into the changing dimensions of sex work in Morogoro and into the broader social context that engenders and shapes commercial sex trade. To the extent that the results can inform targeted STI/AIDS prevention and control, the study also has important pragmatic value for public health. Drawn to Morogoro in search of economic emancipation and frequently to escape family and marital conflict, the women on Shamba Street, coming from villages from throughout the Kagera Region, are united in a unique social nucleus of their own. Often introduced to commercial sex work via friends, acquaintances or family members, the majority of informants explained that their venture into sex work was intended to be only a temporary step towards a more reliable and "respectable" livelihood in Morogoro. Once they enter the trade, however, it becomes difficult for them to abandon it, mostly due to the lack of viable economic options outside of selling sex. Informants were universally aware of the health hazards associated with prostitution. Some reported to have suffered from repeated STI infections and many were already infected with HIV. But as many of the women expressed, given the options of immediate survival through sex work or the risk of infection with HIV or other STIs, the choice is obvious. Ever mounting AIDS-related deaths have, nevertheless, had a significant impact on commercial sex trade in Morogoro. Most of the informants, for example, indicated that they began using condoms regularly with clients, though not their steady partners, to protect themselves from infection. Furthermore, increasing awareness of and personal experiences with AIDS resulted in a marked decline in the trade as a whole. Many of the informants reported that they were trying other income generating activities, such as illicit sales of local brew, petty trade, and taking jobs as bar maids as a way of offsetting their lost income from decreasing rates of commercial sex transactions. The data overall are clearly suggestive of an important programmatic opportunity for helping these women complete their transition from sex work to alternative livelihoods. The study also highlights specific aspects of treatment seeking behavior for STIs. Many of the informants reported persistent infections, indicating high rates of inappropriate treatment. In order to avoid harsh and discriminatory treatment from public health workers, most of the women preferred to either self-medicate or to seek care at private health care facilities. Resort to traditional healers for STI care was overall insignificant. Perceptions of Public and Private Business Organizations About AIDS Intervention Programs at Workplaces in Tanzania Tanzania AIDS Project To ascertain management and employee conceptions of STI/AIDS and its impact on the workplace, and to assess the business community's response to these infections in terms of their clinical and health education services, the TAP project support unit conducted a survey in 40 randomly selected private and public sector business organizations in the city of Dar es Salaam. Data were collected through a self-administered questionnaire directed to the attention of personnel administrators and through focus group discussions with female and male employees in five (of the 40) randomly selected business sites. Ultimately, the results were used to guide TAP's strategic and programming decisions related to its workplace-based initiatives. In all, 55 percent of the organizations reported having an in-house health facility and some reported having sponsored informal HIV/AIDS education for their workers (i.e., educational seminars, film shows, etc.). Twenty three percent of the organizations offered STI diagnosis and treatment services to their employees; through these services, 9,304 STI cases had been attended to in the year previous to the study (representing 13 percent of the total combined workforce of businesses participating in the survey). AIDS was perceived all around as having a substantial impact on the workforce. Approximately 18 percent (n=7) of the companies reported having on average 119 HIV infected people in their workplaces, and 53 percent (n=21) indicated, on average, a loss 23 employees due to AIDS. Eighty percent of the participating organizations expressed an interest in initiating HIV/AIDS intervention programs for their workers, and employees were equally supportive of the idea. AIDSCAP/GPA HIV Multicenter Counseling and Testing Efficacy Study Center for AIDS Prevention (CAPS) Numerous HIV/AIDS counseling and testing services are presently available in Tanzania. Little systematic research, however, has been conducted to determine the efficacy of these programs. As part of a multi-country study, with research sites in Tanzania, Kenya, Trinidad, and China, a study of counseling and testing services in Tanzania was carried out specifically with the intent to identify the range of social and psychological outcomes experienced by persons receiving counseling and testing, to develop questions for measuring the psychological and social impact of HIV testing and counseling, and to assess popular knowledge, perceptions, and behaviors related to HIV/AIDS infection and sexual risk. This multi-site study is a preliminary phase to test research instruments for a planned randomized control trial to determine the comparative efficacy of HIV/AIDS counseling and testing versus standard health education on reported sexual risk behavior among persons seeking such services in Dar Es Salaam. The Muhimbili University College of Health Sciences was commissioned to conduct this study in Tanzania. The objectives of the study were as follows:
The site for this study was located at the Muhimbili University College of Health Science hospital. It was a randomized study in which subjects were assigned to either HIV counseling and testing (C&T) or HIV standard health information (HI). Subjects in C&T received pre-test counseling, had blood taken for HIV antibody testing, were provided with condoms, and asked to return two weeks for HIV serostatus notification and post-test counseling. Those assigned to HI were shown an informational videotape containing culturally appropriate information on the prevention of HIV and other STDs, and provided with a stock of condoms. All subjects were invited to come back to the center at 6 and 12 months. At 6 months they were administered a follow-up questionnaire and they underwent physical examination and laboratory testing for sexually transmitted diseases (and received treatment if positive for any STD). People in the HI arm were offered HIV counseling and testing at this point. At 12 months a final questionnaire was administered to all returning study participants. Outcome data from this study are not available yet as the research team is still in the process of data entry, cleaning and analysis. However, the following preliminary observations are interesting to share:
Table 6. Risk Reduction Strategies
Note: Percentages in columns do not add up to 100 because participants were allowed multiple responses. The study encountered several constraints. Participants movement between Dar Es Salaam and rural areas coupled with the difficulty locating physical addresses in Dar Es Salaam presented a challenge to locate participants for the six and twelve month follow-up visits. Also, poor telephone lines in Tanzania affected communication between AIDSCAP head quarters and the site and significantly slowed down the process of computer data entry, cleaning, and transfer. While the recommendations from the study will not be available until the data has been fully analyzed, two preliminary recommendations can be made from the initial observations:
Survey of STI Prevalence in Truck Stops Along the Dar es Salaam-Songea Highway in Tanzania African Medical Research Foundation (AMREF) To evaluate the progress and impact of its STI control activities targeting populations living in high risk transmission areas, AMREF conducted a survey in six (out of a total of 22) randomly selected truck stops located along the Kibiti-Dar es Salaam-Songea highway. The study was designed specifically to determine the prevalence of selected STIs by subjects' age, occupation and duration of residence in project area. Although additional research is necessary to confirm the trend, AMREF's data suggests an overall reduction in STI prevalence (see Table 2 under section II.A for a summary of prevalence of selected STIs in 1993, 1994 and 1996). Upon the appearance of STI symptoms, patient utilization of improved STI services was very high, and particularly as a result of referral by peer health educators. While the study indicated a need to improve reporting, most health care providers trained in syndromic management were correctly applying these procedures. The study also validated the efficacy of treatment algorithms used in STI case management and evaluated drug sensitivity patterns in N. gonorrhea strains. Study of a New Model of Prevention: Targeting People with HIV Through Care and Support Tanga AIDS Working Group (TAWG) The goal of this eight month study, which is still in progress, is to identify differences in risk reduction among people with HIV enrolled in TAWG's program of enhanced care and support, compared to those receiving post-test counseling only. The specific aims are to: (1) identify the behaviors of people with HIV that spread the disease; (2) examine the attitudes and behaviors of people with HIV toward their own condition; (3) determine strategies that support preventive behaviors; (4) ascertain partner-related factors that influence preventive decision-making in couples; and (5) assess the health and well-being of people with HIV receiving enhanced care and support, compared to those receiving routine post-test counseling. Approximately 200 research subjects who have already received post-test counseling and who meet inclusion criteria were enlisted to participate in the study. Subjects were then assigned by random selection either to a control group, comprised of individuals who continue to receive standard counseling and health care services, or an intervention group, those individuals who receive services of an experimental protocol of enhanced care and support from regular home-based and individualized care and counseling sessions. Trained counselors collect data on the subjects' self-reported risk behavior; experience with and acceptability of condom use and other preventive behaviors; experience in discussing HIV risk with their partners and in providing advice to others on safe sexual practices; their relationship history; their attitudes and beliefs regarding HIV and AIDS and perceptions about their own conditions; and treatment behavior related to sexually transmitted infections; and perceptions about how their families and the community accepts people with HIV. The study is now in its final phase and data analysis is ongoing. Endnotes
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