|
Programs |
||
|
|
||
|
This report comprehensively summarizes the FHI/AIDSCAP program in Zimbabwe (1992-1997). The report includes a country context description, accomplishments, constraints, and outcomes of the program, and a series of lessons learned and recommendations.
II.Country Program Description A.Introduction (See Below) B.Country Context (See Below) C.Accomplishments and Outcomes III.Lessons Learned & Recommendations IV.Subproject Highlights VI.Attachments
II. Country Program Description A. INTRODUCTION USAID Zimbabwe supports the Government of Zimbabwe (GOZ) National AIDS Coordination Program (NACP), UNICEF, and Family Health International's (FHI) AIDS Control and Prevention Project (AIDSCAP) to implement activities that decrease HIV-related high risk behavior within defined target groups and strengthen the delivery of services that help to reduce the spread of HIV in these defined target groups. The five year (1992-1997) USAID/Zimbabwe AIDS Prevention and Control Project (ZAPAC) was designed in collaboration with the NACP and is consistent with the Second Medium Term Plan (MTP II) 1994-98. Family Health International's AIDSCAP project was contracted by USAID to support implementation of the first stage of the ZAPAC project. The AIDSCAP component focused on behavioral change communication interventions in the work place using peer education as the main approach. Specific preselected target groups were the commercial farm workers, transport workers, uniform services personnel and their families as primary target groups and commercial sex workers as the secondary target group. These four target groups are not only large population groups but are epidemiologically important. Geographic areas with large commercial farms, main trucking routes, uniformed services personnel and training centers were selected as primary intervention sites. Commercial sex workers clustered around these worksites were targeted as well as employees and their families. As in many other African countries, the more mobile populations grouped in and around major commercial/trading/ training centers and transportation routes have higher HIV infection rates than other less transient populations. To support and enhance peer education efforts, a wide variety of media activities were also implemented. AIDSCAP supported a critical analysis of Zimbabwean media in relation to HIV/AIDS reporting, a workshop for media gatekeepers and policy makers, radio and TV shows, a mass media program evaluation, and two columns in nationally distributed newspapers. The University of Zimbabwe was supported to develop an AIDS training module for students enrolled in the post graduate Mass Communication and Media Studies diploma program. Projects were implemented through local organizations to both ensure effectiveness of programs and to strengthen the capacity of selected NGOs, industrial associations, nonprofit groups and private companies to develop and carry out HIV/AIDS prevention activities. AIDSCAP worked with their grantees and the GOZ and NGO/private sector suppliers of condoms and health services related to STIs to coordinate efforts and foster strong working relationships HIV/AIDS, a serious problem in Zimbabwe, is transmitted principally through sexual intercourse with an infected person. Transmission through infected blood products, needles, syringes and from an infected mother to her child during pregnancy, delivery and breast feeding accounts for less than 10 percent of the epidemic. AIDS was first identified in Zimbabwe in 1983 and by September 1992, 16,882 cases of AIDS had been reported out of a population of approximately 10.5 million. By March 1993, the number had increased to 21,500 and by September 1996, to 61,037. This , however, is only a fraction of the 200,000 AIDS cases that are estimated to exist. Seroprevalence data (1992) from antenatal clinic attendees and STI clients in several rural and urban sites indicated that about 330,000 urban inhabitants and 460,000 rural inhabitants, a total of 790,000 Zimbabwean adults of sexually active age, were HIV positive. Sentinel surveillance data (1992) indicated a range from 10 percent among one study of rural antenatal clinic attendees to 60 percent of clients in an urban STI clinic. A 1995 study of 2,876 clinic attendees from six Harare antenatal clinics found that 892 (32 percent) of the women were HIV positive. The mean age of that cohort was 21.3 years. The overall analysis of data indicates that HIV prevalence is high in small towns along major transport routes (over 30 percent); in the five major urban areas of Harare, Bulawayo, Chitungwiza, Gweru, Mutare and in rural areas near transport arteries, mines and military bases (approximately 25 percent). Other rural areas are likely to have prevalence levels closer to 15 percent. One million people are estimated to be HIV positive (22 percent of all adults). Young women age 15-19 are reported to have AIDS at five times the rate of men the same age. The immediate and long-term effects of the epidemic noted by the National AIDS Coordination Programme (NACP) include increased mortality, especially among young adults; reduced productivity at work; increased morbidity and demand for health and social services, including hospital beds; an increased number of orphans and the disruption of the family unit. General findings from studies carried out in Zimbabwe suggest that women, due to cultural practices and the current political economy, are placed in a subservient position in relation to men. Consequently women are made more vulnerable to HIV infection. Fear of blame, abuse and/or economic dependence often makes women powerless to control sexual activities. Paradoxically they then find themselves, often without the knowledge and resources, responsible for caring for people with AIDS. One cultural practice, the use of vaginal substances for enhancement of sexual experience, was found to be prevalent and acceptable among both 'high and low status' men and women. Although a 1995 study did not find any correlation between the practice of drying the vagina and the spread of HIV/AIDS, it did conclude that more research was needed. There is significant private sector and NGO involvement in AIDS prevention, with over 60 percent of companies reporting that they have sponsored some AIDS prevention activities for their employees. Since many of these efforts have been limited to the provision of printed materials and AIDS awareness lectures, there is need for targeted behavioral change interventions. NGOs involved in AIDS education number over 40, but many require strengthening in coordination. The NACP, which was established in 1988, is housed within the Ministry of Health and Child Welfare (MOH). From 1988 to 1992, the NACP (MTP I) had a budget of US$ 4.5 million. Many donors including the World Health Organization (WHO), the United Nations Population Fund (UNFPA), UNICEF, the Swedish International Development Agency (SIDA), USAID, and Danida supported the NACP and/or specific projects during these early years. As in other African countries, the initial emphasis was on direct implementation of IEC activities designed to create public awareness and the support of a national blood transfusion system to ensure the provision of safe blood products. While efforts on these fronts did not stop the epidemic, they did increase knowledge levels, creating a basis for the implementation of behavior change interventions; and strengthen the national laboratory system so it could develop blood donor selection criteria and provide safe blood for transfusion. Knowledge levels of AIDS are very high, perhaps due to these early campaigns as well as later targeted interventions. The most representative early survey of knowledge is that of the 1988 Demographic and Health Survey (DHS) which interviewed a nationally representative sample of 4,201 women aged 15-49 years. Eighty-six percent of the women had heard of AIDS and 75 percent could spontaneously name one correct mode of transmission. (Men were not interviewed in the 1988 survey.) The 1994 DHS interviewed a representative sample of both women and men; ninety-nine percent of women and 100 percent of men were aware of AIDS. The National Blood Transfusion Service (NBTS) has progressively instituted selective screening procedures which have made an impressive improvement in the percentage of donors testing HIV positive. HIV seropositivity among blood donors peaked at 5.18 percent in 1989, but due to selective donor recruitment (65 percent were school children), this percent declined to 1.28 percent by the third quarter in 1996. Unfortunately, with the closure of the World Health Organization Global Program on AIDS (WHO/GPA) and the creation of the Joint United Nations Program on HIV/AIDS (UNAIDS), a change in approach dictated that financial support for surveillance would no longer be available to NACPs. Without funding, the NACP has found that it has not been able to adequately support sentinel surveillance sites. This inadequate support has resulted in sporadic reports with no consistency in methodology, which makes it difficult to compare data and monitor the epidemic. In 1992, the primary role of the NACP (MTP II) changed from implementation of AIDS control and prevention activities to cross-sectoral coordination of AIDS control, prevention, care and support programs. The name of the program was appropriately changed from the National AIDS Control Programme to the National AIDS Coordination Programme. Main responsibilities now include providing leadership in information, education, and communication (IEC), counseling, home-based care, surveillance and laboratory and blood safety as well as coordinating donor support and the activities of implementing agencies. Two other ministries play key roles in AIDS control and prevention. The Ministry of Education and Culture (MEC) is working with UNICEF to establish a national program in AIDS awareness and prevention for school-age youth. The Ministry of Social Welfare (MSW) has identified issues related to gender inequality, discrimination of HIV infected persons, increasing pediatric AIDS cases and AIDS orphans. The Women's League of The Ruling Party played a role in raising AIDS awareness in the political arena. Members campaigning in the provinces linked AIDS to political, economic and social conditions in the country and asked for action. Donor support to the NACP continues. WHO, the United Nations Development Program (UNDP), the Norwegian Agency for Development (NORAD), SIDA and the Canadian International Development Agency (CIDA) are providing direct support to the NACP as well as through various agencies for community-based activities. The Netherlands provides some support to the NACP for research activities and substantial support to the Tuberculosis (TB) program. Danida continues to support the laboratory component of the NACP. The European Community (EC) funds the STI coordinator position at the NACP and has provided support for the Blood Transfusion Service to open two new sites. The World Bank, British Overseas Development Agency (ODA), and USAID have worked with the NACP to develop major complimentary programs which support MTP II. The five year World Bank Sexually Transmitted Infections Prevention and Care Project (STIPCP) which started in 1993 provides critical programmatic and commodity support to the GOZ program for STI prevention and care. There are five components: condoms, STI diagnosis and treatment, HIV diagnosis and screening, treatment of HIV-related infections and health system support. The ODA five year Sexual Health Project (1994-99) is integral to the implementation of the World Bank Project as it entirely supports the condom component as well as a considerable portion of the STI diagnosis and treatment component. The wider project objective is to promote sexual health by reducing the incidence of STIs which will be achieved by improving STI treatment and prevention services and by encouraging increased use of condoms. The MOH/NACP, supported by these projects has developed cost effective STI treatment and prevention policies and protocols and has disseminated them throughout the health system. They are working to improve the quality of provincial and district STI and prevention services, with particular emphasis on services for women. They are also working to develop GOZ capacity for procuring condoms, ensuring adequate supplies and efficient distribution and improving access to condoms throughout the country. The World Bank/ODA finances 50 percent of all drugs procured by the GOZ. While this has improved the overall supply of drugs, many clinics (especially in remote areas) continue to experience erratic supplies and stockouts due to lack of financing for transportation from provincial/medical stores to district depots and clinics. A recent situation analysis of reproductive health services in Zimbabwe conducted by the Zimbabwe National Family Planning Council (ZNFPC) found that between 62 and 91 percent of first line STI drugs were available at facilities visited. USAID and ODA have recently financed Population Services International (PSI) to revitalize Zimbabwe's existing socially-marketed condom, Protector. USAID is financing operations and ODA is financing the cost of condoms through the year 2000, assuming that there will then be adequate donor interest as well as a sizable revolving fund to subsidize the cost of the condoms. AIDSTECH to AIDSCAP Family Health International has been working on AIDS control and prevention in Zimbabwe since 1988 through the USAID supported AIDSTECH project. Support was given to the Commercial Farmers Union (CFU) for their peer education program and to the University of Zimbabwe for working with the Bulawayo City Council to target people practicing high risk sexual behaviors. The CFU project was expanded to cover a larger geographical area during the AIDSCAP project and is discussed in the accomplishments and outcomes section of this report. The Bulawayo intervention extended beyond the AIDSTECH project and was completed in December 1993 before the Zimbabwe AIDSCAP delivery order was signed. The Bulawayo intervention model integrated community mobilization, AIDS education, condom promotion and STI control. Peer education was the foundation for community outreach; and nearly three quarters of peer educators were female and worked or had worked as CSWs. The rest were cultural performers, persons living with AIDS (PLWAs) and community leaders. After two years, there was a significant change in reported condom use when a random sample of 705 CSWs were interviewed. Reported condom use with the last client rose from 18 percent at project onset to 66 percent at project end. Condom use was strongly associated with program exposure. This project has been expanded to other groups and sites in Zimbabwe and has the support of several donors. ZAPAC The five year (1992-1997) USAID/Zimbabwe AIDS Prevention and Control Project was designed to decrease HIV-related high risk behavior within defined target groups and strengthen services that help to reduce the spread of HIV in these defined target groups. The MOH was funded to support NACP policy development and dissemination activities. A grant was given to UNICEF to work with the Ministry of Higher Education (MHE) to support activities in AIDS education in tertiary institutions. Family Health International/AIDSCAP was contracted to work with indigenous NGOs to carry out AIDS prevention (behavior change communication) activities with specific high risk groups and occupational populations. AIDSCAP had a three pronged global technical strategy:
USAID/Zimbabwe requested that AIDSCAP focus only on behavior change interventions in Zimbabwe as the other two components of this strategy were being supported by the World Bank STIPCP Project and the ODA Sexual Health Project in Zimbabwe. These projects aim to: (1) ensure that there are adequate supplies of condoms countrywide; and (2) designated provincial and district level health facilities have the capacity to diagnose and treat STIs that facilitate HIV transmission in those populations most at risk. The behavioral change interventions that AIDSCAP supported were complemented by and dependent on the availability of condoms and STI services. Perhaps due to higher than projected demands, difficulty establishing rural distribution, and the assumption that a condom social marketing program would lighten the demand for free condoms, condoms were not always accessible to AIDSCAP-targeted populations. Experience has shown that in any society where HIV levels are as high as they are in Zimbabwe targeting high transmitters such as CSWs and transport workers alone is not sufficient. It is important to combine targeted interventions with community outreach. The AIDSCAP component of the ZAPAC project focused on behavior change interventions in the workplace. By primarily targeting transport workers, farm workers, uniform services and their families, the project had the potential of accessing approximately 30 percent of the Zimbabwean population (target 17 percent) and actually reached at least 23 percent of the population through peer education efforts in less than three years. Additionally, mass and small media coverage through educational TV shows and columns in newspapers with national coverage made it possible to reach and possibly influence behaviors of those outside the targeted populations. Timeline |
|||
 |
|||
