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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 (See Below) VIII. Subproject Highlights A. NGO Cluster Projects NGO Cluster Projects The cluster projects had similar objectives, which included building capacity of local NGOs to design and conduct STI/AIDS interventions; implementing comprehensive behavior change communication programs focusing on partner reduction, condom promotion, and prompt STI treatment seeking; providing care, counseling and support for people affected by AIDS; and sensitizing decision makers and community leaders about STI/AIDS and advocating their support of and active engagement in cluster activities. With varying degrees of creativity and overall success, each of the coalition projects conducted activities toward achieving these objectives. In this section, each project is described briefly, highlighting unique strengths, challenges, and accomplishments. For a complete list of participating NGOs in TAP's coalition projects, refer to Attachment A.
Arusha is one of TAP's largest and programmatically dynamic NGO coalitions. The cluster began with only five members, but following initial community sensitization, and with full encouragement from various political and community leaders, it quickly expanded to include 26 NGOs. With such an extensive range and number of participating organizations, the Arusha cluster accommodates a variety of community-specific characteristics and needs, and effectively represents the region's diverse cultural makeup. A uniquely diverse peer education program is one significant outcome of the cluster's broadly-based NGO membership. To date, over 210 peer health educators have been trained, including workers (from coffee estates, tourist hotels, and other major employers in the region), family planning counselors, traditional birth attendants, traditional circumcisers (for men), commercial sex workers recruited from bars and other business establishments, and young people from different youth organizations. Because of their ability to broach, with authority, sensitive issues related to sexuality and sexual risk, traditional birth attendants and circumcisers have proven to be especially valuable community resources for communicating STI/AIDS prevention messages. Additionally, by emphasizing safe traditional delivery and circumcision procedures, interventions with traditional birth attendants and circumcisers provide an opportunity for having an HIV/AIDS prevention impact beyond sexual risk reduction. Close to 110,000 people in Arusha Region have learned about STI/AIDS risk and how to avoid it through these community and peer educators. Almost as many more individuals have been reached through 109 cluster-supported community performances and through approximately 520 video shows followed by discussion sessions. The cluster similarly exploits the natural diversity that exists in Arusha communities in other aspects of the project. Salama brand condoms, for example, are sold by community and peer educators and through a variety of independent vendors and outlets, including shoe shiners, hair dressers, youth organizations, and so on. Through these various access points, the project sold or distributed free almost 250,000 condoms to target audiences. To increase popular awareness about and understanding of AIDS-related issues, in addition to World AIDS Days and International Candle Light Memorials for AIDS, the Arusha coalition also sponsored educational events in conjunction with World Population Day, Peasants Day, and International Women's Day celebrations. In its first two years of operation the cluster initiated extensive counseling, care and support activities as well. Project trained counselors and home-based care providers have thus far conducted over 400 home visits to families affected by AIDS, counseled 477 other individuals living with AIDS and provided pre- and post-test counseling to approximately 600 people seeking HIV testing. Also, the project helped 217 orphaned children by providing basic material support and vocational training. In order to sustain these relatively costly care and support activities, the project successfully implemented several income generating activities, setting an excellent example and aggressive pace recognized by other clusters who are now following the Arusha region's lead. The Arusha cluster's programmatic dynamism won substantial attention. Donor agencies, national officials, and dignitaries, including the US president's wife and daughter, have visited and commended the project for its efforts to creatively counter AIDS in Arusha Region. Despite its overall programmatic success, however, some management and organizational problems have emerged. Through a process of participatory evaluation and supervision with TAP staff and with peers from other cluster projects, the Arusha leadership identified the cluster's main weaknesses and developed a plan of action for redressing these. Clarification of roles, responsibilities, and authority levels for the coordinating NGO, the member NGOs, the steering committee, and the project management team is one of the Arusha team's immediate concerns. While the specific actions to be taken have been determined by the cluster, TAP continues to provide supportive and facilitative supervision and technical assistance throughout the process. It is important to stress that despite some residual organizational difficulties, the Arusha cluster worked well during this initial phase. Instituting a coalition among many disparate organizations is a complex process, and structural and management problems, especially initially, should be expected. Because there is no learning substitute for direct experience, the problems encountered by the cluster become opportunities. No amount of training could replace what the Arusha team (and other clusters) learned through the setbacks and successes of their first years of operation. Nor are there any pre-established formulas that can be introduced from the outside to resolve their internal issues. Aided instead by TAP technical assistance and by the opportunity to exchange experiences with their peers from other regions, the cluster's members and leaders have worked through many of the startup difficulties themselves. In Arusha, the organizational weaknesses engendered many important lessons for the young coalition, which in the long run will make the project, which is already programmatically sound, even stronger and more effective.
Mainly a function of the composition of its membership, the Dar es Salaam network's greatest strength is its counseling, care and support activities. Half of the coalition's members have expertise and significant experience in pre- and post-test counseling for HIV and counseling and care for AIDS patients; two participating NGOs -- WAMATA and SHDEPHA+ -- are geared specifically to provide medical, legal, social and material support to people living with HIV/AIDS. With complementary skills and strengths among the counseling and care service organizations, combined with referrals from the cluster's prevention interventions and centrally located resource center, the Dar es Salaam cluster effectively established a system for providing HIV/AIDS services to many of the city's residents. Altogether, cluster counselors and home care providers have helped almost 3,000 people in Dar es Salaam, either through pre- and post-test HIV and AIDS patient counseling or home care visits. Especially needy patients and families receive material support from cluster-sponsored activities or benefit from income generating activities and training, including 57 AIDS orphans. The individual member NGOs of the Dar es Salaam cluster project all have excellent track records working in the city and, as a group, they have collaborated with moderate success on network conducted activities, especially for increasing patient and family access to HIV/AIDS counseling, care and support services. Unlike in the other regions, however, TAP's NGO cluster concept in Dar es Salaam failed to take satisfactory hold. Due to persistent organizational and management problems, as noted earlier in this paper, the Dar es Salaam cluster is being decentralized in an accelerated process to form new clusters in each of the city's three districts. The regional network is being dismantled in the process and the participating NGOs absorbed into the district coalitions. TAP is working closely with the old and the new steering committees in order to achieve a smooth transition, to encourage and facilitate linkages between district clusters, and to ensure adequate transfer of the lessons learned from the experiences of this first phase to the newly formed coalitions.
As elsewhere in Tanzania, in response to the increase in AIDS cases in Dodoma Region in the mid- to late-1980s, several organizations began working independently to prevent further spread of the disease and to mitigate its impact on local communities. Eleven of these groups combined efforts in 1994 under the TAP NGO cluster initiative and developed a collaborative program that improved programmatic coverage and reduced redundancy. In line with an overall regional strategy and plan, individual member NGOs in the cluster develop and conduct different, but mutually reinforcing and complementary, activities. The cluster made a concerted effort as well to implement activities that complement other AIDS prevention and care interventions implemented by organizations who for various reasons cannot participate in the Dodoma cluster. In particular, the cluster worked closely with the region's religious community, and has even been instrumental in the development of a separate regional coalition of religious organizations. As a result of the cluster's efforts to create and maintain strong linkages with the religious community in Dodoma, the project enjoys an unusually supportive and collegial relationship with this sector. Effective utilization of diverse community resources has been one of the Dodoma project's notable strengths. Through peer and community educators, including an important and dynamic contingent of traditional birth attendants, the cluster reached over 135,000 people with STI/AIDS education. Recognized by TAP, other cluster projects, and regional and district authorities alike, the project's community drama component, which has several village-level groups, is especially strong. Winning the enthusiastic support of the regional cultural officer and increasingly district cultural officers has substantially aided the project in its educational efforts through community theater. To date, close to 17,000 people have been reached through these culturally sensitive and locally relevant communication strategies. Video shows coupled with small groups discussions and a high visitation rate at the cluster's resource center are other important avenues for informing and educating the Dodoma population about AIDS and other STIs; taken together, around 214,000 more people have been reached through these means. One of only two of TAP's cluster projects that support regional radio programming, the Dodoma cluster also produced and aired 65 radio programs to date. Because they are conceived and produced locally, these programs emphasize issues and needs that are specific and appropriate to the region. And finally, the cluster developed an impressive counseling, care, and support component. Through a variety of services available from member NGOs, a total of 215,086 AIDS patients have benefited from counseling, another 210 from home care visits, and 126 AIDS orphans have received counseling, material support, or both.
The Iringa coalition developed during this start-up phase into TAP's model NGO cluster project. The cluster was formed initially with 18 NGOs, but since expanded to include 41 organizations working in all of the region's six districts. While facilitating the formation of district level networks, two of which are already functioning, the regional cluster increasingly concentrated its own activities in Makete, Iringa Rural, and Iringa Municipality due to the severity of the AIDS epidemic in these districts. The project's greatest overall strength is the participating NGOs' high motivation to make the cluster work. As noted elsewhere in this document, the Iringa project's start-up was not entirely smooth, but was beset by organizational troubles that the NGOs, as a unified group, had to work through. As a starting point, the cluster had to establish criteria for membership. This was especially important for eliminating the debilitating influence of NGOs that were the source of frequent conflict; in articulating these criteria, the cluster forcefully demonstrated its commitment to founding a coalition where collaboration and collegiality are expected as the operating norms. The steering committee was also reconfigured to a manageable size. Instead of representing all of the NGOs, the committee now includes only 11 elected members, thereby limiting the potential for disputes and facilitating rapid decision making. While the steering committee attends to basic and pressing management issues in monthly meetings, cluster management meetings, with representation of all member NGOs, are conducted less frequently (five to date) and address larger policy, planning, and coalition leadership issues. In hiring a project management team, the coalition was also careful to select a project manager with formal training and extensive experience in community development, and in so doing ensured competent initiation of community-based activities. In the process of confronting and working through issues and problems as a team, the Iringa cluster conceptualized an organizational and operating structure that privileges streamlined management while at the same time emphasizes full representation and participation of member NGOs, and allows for close collaboration with government bodies and TAP. While all of the clusters, except for Dar es Salaam, have progressed solidly in the direction of establishing stable organizations, the Iringa cluster excelled in this process, making the coalition well on its way to being institutionally sustainable. A solid organizational structure is, instrumental to sound programming. In Iringa such programming began with securing the active support from government leaders and other community influentials. To this end, the project conducted a series of seminars to sensitize 366 regional and district and 137 ward and village leaders to key issues and concerns related to HIV and other STIs. While newcomers to the region receive a personalized sensitization session and orientation to the project, quarterly debriefings with various government officials serve to keep leaders appraised of the project's activities and of important STI/AIDS related issues generally. Through these regular contacts, joint planning for collaborative interventions and events is possible, thus maintaining the full engagement of government institutions in the project. Sensitization and collaboration have, in this way, become intrinsic to implementation of the coalition's activities. Leaders who appreciate completely the gravity of AIDS for Tanzanian society, the significance of other STIs on the health of women and infants, and the role they, as leaders, can play in helping to reduce further infection, tend to extend their full support for project activities. In Iringa this support is demonstrated in various ways. In terms of material commitment, leaders have manifested their support by providing facilities to the project for information and counseling centers, contributing financially to cluster-organized training and advocacy events, and, from the regional commissioner's office, making a vehicle permanently available to the cluster in order to facilitate implementation of region-wide activities. Coalition initiatives are supported in other non-material ways as well. While, for instance, ward and village leaders regularly excuse peer educators and theater group members from other community duties so that they may attend to their STI/AIDS educational activities, the regional commissioner personally assisted the cluster in mobilizing district and ward resources for supporting the region's growing number of AIDS orphans. Perhaps most significantly, however, is that STI/AIDS in Iringa has been fixed as a permanent agenda item on village and ward development committee meetings. This internalization of STI/AIDS prevention and care in local decision and policy making processes facilitated concrete and community-specific actions. The overall outcome is that, in Iringa, there now exists a stable forum for maintaining STI/AIDS in the public eye and for manifesting community consensus on how to reduce high risk situations in local populations. With official and community support the cluster is positioned to concentrate on preventing AIDS and other STIs, and on helping those already infected or affected. Aided by its composition of religious organizations, various cultural groups, youth clubs, trade unions, women's initiatives, etc., the Iringa cluster achieved an extensive community reach. To date, 107 community-based educators have provided one-on-one and small group STI/AIDS education to approximately 60,000 people; drawing on local experiences and situations, community drama troops from each ward have performed a total of 114 times in front of a combined audience of 150,000; while three condom wholesalers in the region have allowed the project to maintain a reasonably stable condom supply, 175 independent vendors and over 340 other retail outlets established in the region facilitated the sale of over 800,000 condoms so far; 51 clinics in Iringa now offer upgraded STI care from 101 health providers who have received specialized training in STI case management; and the project's extensive home care and counseling network conducted more than 600 counseling sessions with individuals, 358 home visits, and vocational training for 29 orphans in the region. With particular concern for better helping needy families and orphaned children, the cluster increased its income generating activities to supplement and extend these ongoing activities. The Iringa coalition also set the standard for conducting AIDS awareness and advocacy. Effectively mobilizing the participation and material support of government and other collaborators, the project organized high profile events in association with World AIDS Days, the International Trade Fair, International Women's Day, and International Home Economics Day. Deserving special mention are events organized in two districts -- Iringa Municipality and Makete -- for the International AIDS Candle Light Memorial and Mobilization. Intersectorial organizing committees in each district mobilized extensive participation of regional, district, and village leaders and generated significant community interest that ultimately attracted approximately 8,000 people in Iringa Municipality and 4,500 in Makete. Parades, poetry readings, and special performances kept the spectators engaged in the event's day-long activities. It was the personal stories of individuals suffering the consequences of the AIDS epidemic, however, that most gripped the participating audience. Explaining her struggle to hide her HIV status out of fear of being ostracized by fellow community members, one woman living with AIDS made a frank appeal for increased compassion and support for HIV-infected persons. Another boy, in recounting his family's trajectory into destitution following his father's death from AIDS, conveyed in vivid detail the incongruence between traditional inheritance patterns and contemporary social reality. And a 13 year old girl's description of how she assumed the role of mother to her younger siblings upon the death of both parents' from AIDS, poignantly highlighted the disintegration of the traditional safety net of kinship systems under the strain of economic despair, which is aggravated by high adult mortality from AIDS. In the moments that these and others shared their painful experiences with the participating audience representing the broader community of Iringa -- including the highest ranking regional authorities to the most highly esteemed religious and traditional leaders to average citizens -- the community was brought together in the recognition of the need to unite in an effort to stop the disease's spread and to cope with the health and social aftermath of an already advanced epidemic.
The Kilimanjaro coalition represents a dynamic and diverse organization of 37 NGOs that have a wide range of interests and experience working in the region. After some initial changes in its management, the cluster has become organizationally quite sound, conducting monthly steering committee meetings that involve regional and district leaders, achieving impressive cost recovery from income generating activities, and completing decentralization to Hai and Moshi districts. Consistent with TAP's other coalition projects, the Kilimanjaro cluster includes components in institutional capacity building; behavior change interventions; counseling, care and support; and policy initiatives. Its unique strengths, however, are in the areas of community and peer education, especially with youth, an aggressive STI education strategy, and concerted attention to issues that particularly affect women's risks for STI/AIDS. While this summary reviews the project activities generally, it highlights these unique aspects and related accomplishments. The Kilimanjaro project implements one of TAP's strongest interventions targeting both in-school and out-of-school youth. Peer education (including condom distribution) is a main component of the school-based and non-school based activities. Selected from various school and community groups, peer educators receive basic training in STI/AIDS transmission and prevention, in STI symptoms recognition and the importance of prompt treatment from qualified health care providers, and in communication skills and condom social marketing. But their training also focuses on issues that are especially or uniquely relevant to the experimental and vulnerable lives of young people. Drawing specifically on the actual experiences of youth in the region, topics on human sexuality and sexual debut, alcohol consumption and sex, coercive sexual relations, and sex in exchange for material support, for example, are treated in a frank but tactful manner. Equipped with concrete knowledge about STI/AIDS and enhanced communication skills, peer educators are thus positioned to influence their peers, effectively responding to special needs and concerns and in a language and communicative style shared by youth. The region's relatively well developed school system, with a total of 700 primary and 100 secondary schools, has been particularly facilitative to reaching youth and institutionalizing sexual risk reduction education. A school curriculum in sexual health education supplements and reinforces the peer-to-peer approach. KIWAKIKU, a Kilimanjaro coalition member, developed and, following some official resistance, pilot tested a teachers manual for sexual health education. The manual is now distributed to schools throughout the region with full support from regional and district education officers and teacher training in using the curriculum is also underway. In addition to basic STI/AIDS information, teacher training is specifically designed to prepare teachers for the delicate task of broaching sensitive and potentially embarrassing subjects related to human sexuality. The results of this activity to date are promising as they indicate that with appropriate training and support from educational authorities, teachers do overcome personal and cultural barriers to addressing openly matters related to sexual behavior and sexual risk in youth. Educational drama, other performances and forms of creative expression, video shows, and printed materials are either integrated into or complement interpersonal and classroom approaches. Peer-to-peer education is also key in the behavior change communication and condom promotion strategy targeting adults. Close to 360 community-based agents from the family planning association (UMATI) have been trained to integrate STI/AIDS education into their family planning sessions with women and men; 22 other UMATI agents have specifically been trained as STI/AIDS counselors. Facilitated by their established presence in Tanzanian communities, these community-based educators have, to date, provided STI/AIDS education to over 60,000 sexually active adults in Kilimanjaro Region. Other member NGOs have additionally trained 97 other adult peer health educators. Aiming for sustained sexual behavior change, these peer educators conduct intensive educational follow-up with at risk individuals in their community. As with youth interventions, drama, video, community seminars, and various special events serve to reinforce one-on-one education with adults. One grassroots women's initiative in Sonu Hai District, which involves interpersonal and other community-based behavior change communication activities, extended its educational objectives to include assertive activism, seeking specifically to change sexual norms that increase women's risk, influence local policy so as to reduce women's sexual vulnerability and risk, and empower women to gain control over their sexual decision making and to effectively negotiate safe sex with the partners. The group also intervened in specific cases and situations in which women and children are in especially vulnerable situations. An example of such an intervention in one community involved a fund raising effort to construct a safe dwelling for a widowed woman and her mentally impaired teenage daughter. Due to the dilapidated condition of their home, prior to the group's intervention the woman and her daughter were subject to repeated break-ins and sometimes rape by local vagrants. This grassroots initiative serves as an important example of communities assuming control over STI/AIDS programs and policies. In the instance of the Suno Hai women's group, the women themselves define the intervention agenda according to local need and, to the extent possible, seek out local resources to support the intervention. STI education has been integrated into all of the cluster's behavior change communication efforts. In order to reinforce peer and community educators' appreciation of the need for prompt and appropriate STI care, an STI specialist participates in all peer and community trainings, providing basic STI education and emphasizing the role of educators in referring suspected patients to the upgraded STI services that are available in the region. Combined with discussion, the educational video "Silent Epidemic" -- which clearly describes STI symptomatology, complications, and association with HIV transmission -- has proven especially useful in peer and community educator training and has been equally effective in community educational sessions. As a result of these concerted education and referral efforts, over 3,000 people have gone to upgraded STI clinics for treatment since the start of the project. The Kilimanjaro cluster finally has a well developed community- and hospital-based counseling, care and support component. Thirty seven project counselors have provided psychosocial support to more than 300 individuals, and 61 home-based care providers have helped 320 AIDS patients to better manage some opportunistic infections and to better cope with AIDS-related illnesses. The formation of a "body positive" group of HIV-infected persons is one important outcome of the coalition's attention to providing HIV/AIDS patients compassionate and high quality counseling and support. This association (Kikundi cha Matumaini), whose goal is to instill hope and provide assistance to its members, thus far has 29 HIV-infected members (including a chairperson and secretary), meets several times weekly, and initiated various income generating activities. Two NGOs in the cluster focus on supporting orphans. The Kilimanjaro Project Against AIDS (MKUKI) conducts 4 to 6 week training programs for teenagers in carpentry, tailoring, cooking and agriculture. While the cluster provides funds for needed equipment and materials (e.g., sewing machines, cloth, timber, etc.), the local community provides the facilities and farming plots. To defray some of the operating costs, products from the training (e.g., simple furniture, table clothes, mats, produce and so on) are sold to the local community; also, other interested non-orphaned children can also take an MKUKI training course for a modest fee. In all, 47 orphaned young people have completed this training, most of whom are now either self-employed or working in groups. Another member NGO placed 50 orphans in internships with different crafts people, such as shoe makers and tailors.
The Morogoro coalition project is composed of 13 NGOs. It works in six of the region's districts and has decentralized activities in three of these -- Kilosa, Kilombero, and Morogoro Rural -- where district cluster management teams facilitate networking between NGOs in the districts and with the regional cluster. In order to improve NGO membership involvement in the implementation and management of the project, the cluster established a somewhat unique implementation structure that involves two main committees: a steering committee, which decides on policy issues and general directions and is composed of one member from each of the cluster's member NGOs, and an implementation committee, a smaller group of elected or appointed individuals (by the steering committee) that supervises the day to day management of the project. As intended, the creation of these two distinct management bodies greatly enhanced the project's implementation and overall daily functioning. The coalition's behavior change communication activities have been especially successful. NGOs with religious affiliations have supported educational interventions with church congregations, in the general community through house-to-house visits, and peer education with in-school youth. Other member NGOs focus on workers, women's groups, and community leaders. Many of the peer educators and other community-based health promoters have also been trained in condom social marketing. From the combined efforts of the coalition members, this regional project so far reached over 40,000 individuals with peer and other community-based education, sold or distributed free of charge more than 200,000 condoms, and sensitized 131 government, 45 business, and 299 various other community leaders about the health risks and social impact of STI/AIDS. Community- and school-based drama, video, special advocacy and promotional events further support small group and interpersonal communication efforts. With the enthusiastic support of radio personalities and production staff, the cluster also developed a dynamic radio program in the region, thereby making topics on AIDS and other STIs prominent themes in every day discourse. Nurturing intersectorial collaboration has been another of the Morogoro cluster's strengths. Select regional and district authorities are invited members of the coalition's steering committee, which facilitates joint planning of awareness and advocacy events and helps maintain and strengthen political support for all cluster activities. It works closely as well with other ministries. The Ministry of Agriculture, for example, collaborated with the project on developing crop and gardening cultivation skills with orphans; the Ministry of Social Welfare also assists care and support projects by helping the project to identify the most needy orphans who support or vocational training; the Ministry of Education provides training facilities and some materials for the cluster's teacher and youth peer health educator training; and the Ministry of Community Development worked with and supported specific community mobilization efforts initiated by the cluster. Combined with the project's business and religious community interventions, this multisector support and collaboration firmly grounded the Morogoro coalition project in the regions key political and social structures.
*200,000 Condoms were sold and distributed free. The process information available did not distinguish between free and sold. Condoms sold through TAP projects are accounted through the PSI CSM project.
An influx of migrant miners in to Shinyanga coupled with the region's commercially central location that links it to several other regions in Tanzania and neighboring countries made Shinyanga Region particularly vulnerable to rapid spread of HIV. With the TAP coalition initiative, in late 1995 12 NGOs in the region formed the Shinyanga AIDS Project, which comprises jointly planned activities in institutional capacity building, behavior change communication, condom distribution and promotion, strengthening STI services, and providing care and support to persons affected by HIV and AIDS. With the ultimate objective of expanding interventions through future coalition formation among 18 other organizations working in Shinyanga, the regional coalition has chosen to focus on consolidating interventions in select districts, while at the same time facilitating collaboration with other NGOs. Management difficulties at the start of the coalition were important constraints to the project's implementation. With supportive and facilitative technical assistance from TAP and inter-cluster meetings, the Shinyanga team worked through most of the main organizational problems, which primarily involved replacing problem members of the management team and clarifying roles and responsibilities. Despite these initial challenges, the project's overall outcomes to date have been satisfactory and impressive improvements are evident in management and implementation. Most of the interventions focus on youth, sex workers and their clients, and sexually active adults and adolescents more generally. The project trained over 130 peer health educators, helped form community theater groups and established an STI/AIDS resource center. Through these efforts, it reached more than 66,000 individuals through peer and community-based education and provided STI/AIDS education to another 51,000 people who visited the resource center. In a concerted move to improve condom distribution and sales, the cluster is presently collaborating with the social marketing project to strengthen the region's condom distribution network and to train independent condom vendors. Thus far, it trained 41 community-based condom promoters and established 62 condom sales outlets, through which approximately 43,000 condoms have been distributed. Twenty four project trained counselors provided psycho-social support and advice to 978 HIV/AIDS patients, of which 770 were home care visits. The project has also been especially attentive to sensitization efforts. To gain the support of local leaders, it conducted 32 sensitization sessions with regional and district officials and another 7 sessions with 318 various other community leaders.
As in regions throughout Tanzania, the AIDS epidemic in Tabora Region progressed rapidly. It was the second region in the country to report AIDS cases in 1984. By 1995, over 3,200 cases had been detected and seroprevalence rates in blood donors was found to be 12.9 percent for women and 6.2 percent for men. Annually, over 15,000 STI cases are reported from public and private health facilities in the region. In order to achieve a far reaching and diversified program, the Tabora coalition is working explicitly to construct an NGO membership of mixed skills, experience, and interests. The cluster is presently composed of twelve organizations, about one-half of which serve the general population, including three major hospitals. The other six have specialized services focusing on various target groups such as parents, youth, women engaged in small business, and commercial sex workers. To increase the project's access to adults generally and workers specifically, two trade unions are also presently joining the coalition. The Tabora project had a strong peer health educator emphasis. It trained 223 peer educators who, in turn, have provided STI/AIDS education to close to 13,000 persons in Tabora Region. Several tens of thousands more people have participated in community performances and video showings followed by discussion. In its behavior change interventions, however, the project has been especially successful at integrating condom promotion into its community-based activities. MARTEA, the NGO assigned primary responsibility for overseeing this component, applied an aggressive multisector approach that involved training hundreds of community-based educators and independent vendors as condom sales promoters and retail agents. MARTEA also established eight wholesale and 126 retail outlets for condoms in its own organization acting as a regional distributor; additionally, 19 of the health facilities that participated in STI case management training have been incorporated into the cluster's condom social marketing network. The Tabora condom distribution mechanism worked well for the coalition, making it one of the most successful of TAP's NGO cluster in overall condom distribution, at close to 500,000 to date. As condom demand increased, however, the project repeatedly had a problem of maintaining a regular condom supply, indicating both the cluster's success in this activity and the need the project to strengthen ties with the social marketing project.
Tanga reported cases of AIDS for the first time in 1987. By 1995 HIV prevalence in Tanga was reported at 7.1 percent overall, 10.4 percent among male blood donors, and an astounding 20.8 percent among female blood donors. As elsewhere throughout the country, local organizations in the region integrated AIDS education into their community services in response to the rapidly expanding epidemic. With technical and financial assistance from TAP, six NGOs in Tanga formed the Tanga NGO cluster in 1995 with the aim of ensuring better collaboration between concerned NGOs and thus a strengthened response to the epidemic. Although the cluster's activities are consistent with other TAP coalition projects, the scope and manner in which the Tanga project utilized community and cultural resources in its prevention and care programming sets it apart. A diverse and extensive peer education program, dynamic community drama, and innovative dissemination of educational messages through traditional forms of communication and locally produced items, exemplify the cluster's focus on community-based and culturally-sensitive activities. Moreover, the cluster is paired and overlaps with a sister TAWG project, also supported by TAP, that centers on developing skills of traditional healers and on establishing collaborative links between biomedical and traditional practitioners for providing STI/AIDS services. While this summary outlines education and prevention activities of the Tanga cluster, the complementary and overlapping aspects of TAWG's counseling and care project with healers are described under that project's executive summary. Because the two projects are so complementary and overlapping, however, to appreciate fully their innovation and outcomes in Tanga Region, it is necessary to consider them as components of a fully integrated regional program strategy. In addition to 80 traditional health practitioners trained in prevention and care by TAWG's sister project, the Tanga NGO cluster trained 230 other peer and community educators in STI/AIDS prevention and referral: 60 women and men at work sites, 20 out-of-school and another 20 church-based youth, 40 women from the community at large and another 40 identified through churches, and 50 church leaders. In their interpersonal encounters with peers and others in the community, these health educators reached approximately 7,715 individuals with in depth messages about HIV and other STIs. Drama groups of healers, youth, and active church members reinforce one-on-one efforts with entertaining and locally pertinent performances. Emphasizing traditional communication channels, such as vituko, a traditional form of theater among coastal populations through which sensitive and otherwise taboo topics can be addressed openly without inhibition. These channels help to empowered women to deliver convincing HIV prevention messages publicly to the community and particularly to men. To expose more people to the these educational events, the project recorded several performances on video and aired others on local TV channels. Collaborating with local clergy represents an equally important opportunity for conveying STI/AIDS messages through another important social channel. Acting in the role of community educators, church leaders introduced STI/AIDS related themes into their sermons and STI/AIDS education in other community services that they provide. Distribution of health education materials and condom promotion supplement community and peer education efforts. With regard to the former, while conventional print materials (e.g., leaflets, posters) are important sources of basic STI/AIDS information and behavior change messages for targeted populations, the cluster utilized a variety of alternative, locally produced and available means for disseminating printed messages, mainly on common household and personal items such as fans, baskets, plates, mats, and so on. In addition to promoting self-sufficiency from decreased costs and the potential for cost-recovery from the sale of crafts and utilitarian objects, prevention messages delivered in this manner evoke a sense of the mundane, and of taken-for-granted normal behavior. As a health promotion tool, delivering basic messages through these common and ordinary objects that make up are part of people's everyday environments powerfully reinforce educational approaches that focus in depth on risk-related issues and safe behavioral options. With regard to condom promotion, the cluster succeeded, with assistance from the social marketing project, in establishing a viable private sector condom distribution mechanism that complements public sector efforts. It established numerous condom retail outlets and developed capacity at TAWG to function as a condom wholesaler for the region. As a result of these efforts, the coalition sold 320,00 Salama brand condoms during the project period and distributed for free 173,000 NACP condoms. The Tanga NGO cluster coupled with its TAWG sister project implemented a uniquely innovative and community-appropriate strategy for providing STI/AIDS prevention and care services to the population of Tanga. The project's unwavering emphasis on bringing existing community and cultural resources to the fore in their prevention and care efforts, is indicative of the Tanga team's commitment to facilitating local control and ownership of the interventions. Although the cluster continues to work on its organizational structure and management mechanisms, specifically on diffusing control and authority that has to date been overly concentrated in the lead NGO, its intervention approach serves as an excellent model for achieving full community participation in and ownership of the program and hence advancing towards long-term sustainability.
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