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.

Table of Contents

I.Executive Summary

II.Country Program Description

A.Introduction

B.Country Context

C.Accomplishments and Outcomes
  -Page 1
  -Page 2
  -Page 3
  -Page 4

III.Lessons Learned & Recommendations (See Below)

IV.Subproject Highlights
  -Page A
  -Page B
  -Page C

V.Non-Subproject Highlights

VI.Attachments

 

III. Lessons Learned and Recommendations

The unique features of the AIDSCAP Zimbabwe Country Program were the size of the target population and the potential for community outreach and ownership. By focusing behavior change interventions in work places and targeting interventions to families as well as employees, the program not only reached workers to encourage them to protect themselves, but helped them realize the importance of educating and protecting their families. Changing the sexual behavior of men and fostering protective feelings towards their families may be the most important way of reducing sexual risk for women.

Workers are asking peer educators about talking to their spouses and children; people from communities surrounding worksites are asking peer educators and trainers to talk to them about behavior change. CSWs are saying that they feel sorry for and want to help the married woman who has no control over sexual activities, even if she knows her husband is promiscuous. Anecdotal information indicates that people in targeted areas are networking to help each other.

FHI/AIDSCAP-supported organizations are on a continuum in relation to implementing AIDS prevention and control activities. While "lessons learned" for some of the less experienced agencies, they are banal for other more experienced agencies. Because this continuum of experience is probably representative of most country programs, a range of lessons is presented, realizing that many of the lessons learned could be better identified as "experiences from the field." The lessons/experiences and recommendations that follow are intended for those who want to use worksites as linking pins to the larger community.

A. PROGRAM DESIGN AND STRATEGY

• The success of peer education is dependent upon the level of support received from all levels of management. Sensitization and education of all managers should be completed early in the intervention. In one situation top-management enthusiastically supported interventions, while lower level managers initially refused to give employees time off for peer education training.

• Workplaces are often the only place to target groups of men -- which is crucial -- because men are the sexual decision makers. Changing the sexual behavior of men is critical to decreasing the risk of HIV infection for many women.

• As women move towards establishing more control over their sexual activity, it is important to encourage and provide skills for them to negotiate the use of condoms. (Female condoms, which may actually offer or be perceived by women to offer more female control, have been purchased by the GOZ and should soon be available in the public sector).

• Incorporating issues identified as important by the target population, such as home-based care, well-women care and general health education is important in establishing community ownership of the project. Additionally, if activities can be integrated into existing programs, they will be easier to sustain over the long term.

• While it is known that a gender sensitive approach facilitates training, it is important to remember that a variety of approaches are often required within the same culture. Separating girls and boys initially in school-based AIDS education programs allowed the girls to ask more questions about sexuality without feeling inhibited. Once the girls gained confidence, they wanted the boys to be included in future sessions. On commercial farms, men and women were initially brought together to allow them to channel sensitive gender empowerment issues through a third party -- the peer educator. Then they broke into two groups to hash things over.

• Due to issues of national security, it is difficult to design and monitor effectiveness of projects with the armed forces, even though they are much needed and appreciated. Even when constraints are outlined and understood at the onset, implementation can be frustrating for both parties and requires commitment and understanding of limitations on both sides.

• Peer educators from the "ranks" promote target population ownership of the project.

• Peer educators, school teachers and nurses must be comfortable discussing issues of sexuality and want to discuss them before they can discuss them with others. An excellent curriculum and IEC materials is pointless without participatory sensitization and education programs for the "educators." In some schools, teachers have elected not to give AIDS prevention and control education after attending short workshops and receiving handouts to give to the students because they think it will encourage students to be promiscuous. The curriculum for training teachers, the method, and length of time allowed are all being reviewed.

• Incentives should be used carefully. They can be powerful tools but can also undermine peer activities. Motivational tools that enhance self-esteem, such as badges, T-shirts, and certificates recognizing achievement, seem to be associated with high performance.

• If a baseline survey is not performed early in the project, valuable time may be lost. For example, in some projects it was assumed that knowledge on transmission was low so emphasis was placed on disseminating basic transmission information. When the baseline survey was performed, it was discovered that knowledge levels were high but reported behavior change was low. Program emphasis was changed accordingly.

B. POLICY

• National policy guidelines are needed to establish the rights of the individual, community and workplaces in regard to the control and prevention of HIV/AIDS. Issues related to testing employees as part of the employment process or for subscription to health and life insurance, as well as confidentiality related to notifying partners or health personnel of HIV status, arise and create frustration and confusion.

• A punitive or unclear corporate AIDS policy can obstruct project efforts. For example, some companies charge for STI services but provide other medical services free of charge. Policy level technical assistance would help corporate executives make better informed decisions by introducing them to a variety of options.

C. TECHNICAL

• It is difficult to measure results (impact) from behavioral change interventions. It is easy enough to count the number of condoms distributed, but not so easy to see if people always know how to use them correctly and then use them consistently. Along with asking people to report behavioral changes they have made, it may be necessary to have them demonstrate how to use a condom. Questions must be carefully phrased to address cultural behaviors. Anecdotal reports indicate that people may use condoms for the first sexual act with a non-regular partner but often do not use them for subsequent acts with the same partner on the same day because they feel they know them better and trust them.

• Participatory educational methods are more effective than didactic. Additionally, videos with local people in local languages that actually model behavior change or show how an individual or family is affected by AIDS, bring the message home and promote discussion. Information presented in films featuring foreigners are often discounted as "unimportant and not applying to us."

• Selection for peer education training should not require literacy or educational certificates. It does, however, require that materials used for training, monitoring and evaluation be modified. Some projects found that semiliterate peer educators with good communication skills were highly effective, but adapting training materials to their educational level took much longer than anticipated.

• Negative educational messages not only make people deny AIDS, they increase stigmatization of HIV infected persons. It is important to think of AIDS control, prevention, and care as a continuum where activities support all components because the community does not separate them.

• Social and cultural norms and attitudes are difficult to change and require a long process or a strong association with terminal illness and death. Social norms surrounding highly mobile populations are just one example. Transport workers often phoned ahead to "line up a chick" before they arrived at an outlying location....before it became obvious that many of their coworkers were ill and dying from AIDS-related illnesses. In FGDs with CSWs at truck sites, some CSWs reported that while drivers were their most popular customers, it was becoming increasingly more difficult to secure a partner for the night.

• The media can raise issues, foster debate and raise community awareness. It is important that editors and reporters know the topic and how to report on it, otherwise inaccuracies or incomplete reporting can occur. The benefits of mass media are also its constraints. Once information is "said" to the masses, it cannot be "unsaid."

D. OPERATIONS MANAGEMENT/SUPPORT

• Evaluation should have high priority through completion of a project. PIF reports were not always filled out appropriately or in a timely manner. Perhaps because PIFs were developed centrally, it was difficult for implementing agencies to "own" them and really understand the "global" importance of standardized reporting. Careful planning can ensure that IAs have an understanding of how contributing to global indicators will benefit the future of their projects. Implementing agencies could also be encouraged to contribute to the development of sectoral/project indicators that could be monitored locally as a way to promote "ownership and compliance."

• Some of the larger projects with vertical hierarchical structures moved slowly. Projects that cover large geographical areas can be supervised and respond to project needs better if managerial and financial responsibilities are decentralized.

• Projects with small financial bases were forced to interrupt services when reimbursement was not received promptly. Additionally, project personnel found it cumbersome to move funds between line items. It would help if financial reporting between the AIDSCAP country, regional and headquarters offices were streamlined.

• Cost-sharing and early identification of alternative funding sources promotes sustainability. Financial, materials, and level of effort support was leveraged from many of the subprojects, including NRZ, NECTOI, CFU and Triangle. A method should be established to track and report on cost-sharing.

• On-site monitoring is essential in supervising the financial and technical aspects of a project. Constraints can be identified and technical assistance modified to suit the environment. Implementing agencies also said that on-site visits provided motivation to both management staff and employees.

• Opportunities that affect larger populations within the country and the region must be recognized and promoted. For example, NECTOI identified potential opportunities for sharing strategies, information and IEC materials with counterpart transport organizations in South Africa, Mozambique, Malawi and Zambia. Through regional workshops and study tours, the strategies and interventions developed by NECTOI could be extended.

E. KEY ISSUES/RECOMMENDATIONS

• National policies regarding HIV testing, confidentiality, and life insurance for HIV positive persons must be established as lack of direction is creating confusion and frustration within worksite projects and the broader community. The Intersectoral Committee on AIDS and Employment which is chaired by the Ministry of Public Service, Labor and Social Welfare drafted a National Code of Practice on AIDS and Employment in October 1995. The industrial relations component has been submitted to the Minister in preparation for publication. The Ministry of Health and Social Welfare is being supported by USAID (through the NACP) to develop a national HIV/AID policy document. The first draft was released in December 1996. The process leading to drafting and ratification of these documents has, unfortunately, been very slow.

• Project design whenever possible should include a planned phase-out period when support is gradually decreased so that the project is self-supporting, apart from minimal technical assistance, for at least the last three to six months of implementation. Leveraging financial, material and level of effort support as well as capacity building fosters greater local ownership and creates the basis for project sustainability. AIDSCAP successfully leveraged support from many organizations. This phase-out period where only technical assistance is provided is the next logical step in the capacity building process.

• Support should now be given to mass media to keep AIDS on the agenda and promote behavior change at all levels through provocative reporting on policy issues, using soap operas, serials and human interest stories to model positive behavior as a way to change social norms, and accurate reporting on the level of the epidemic and efforts to control it. Mass media interventions are powerful tools and can be instrumental in keeping HIV/AIDS issues on the political, economic and social agenda. Mass media activities not only create awareness but facilitate social mobilization and behavior change. Recently the media have successfully targeted both the stage of the epidemic in Zimbabwe and the stage of behavior change of many of the intended audiences, creating dialogue about HIV/AIDS among policy makers and within the general public.

• Donors and IAs should support comprehensive programs that include emphasis on both prevention of HIV/AIDS and care of persons with AIDS. HIV/AIDS control, prevention and care are different aspects of one global problem and communities do not separate them. Now with many communities in Zimbabwe inundated with problems associated with caring for people who already have AIDS, prevention issues cannot be addressed without addressing the immediate care issues.

• Sentinel surveillance, blood donor infection rates, AIDS case counting, research reports on targeted populations, and the DHS all play important roles and should be supported. Epidemiological surveillance of the epidemic is critical for monitoring the epidemic as well as the effects of interventions over the long term.

• With the level of the HIV/AIDS epidemic in Zimbabwe and the strong association between STIs and HIV infection, it is crucial to continue including recognition of the signs and symptoms of STIs and promotion of early STI treatment seeking behavior in any behavioral change intervention. Research on low-cost, low-technology screening methods for diagnosing asymptomatic women (40-60 percent of STI infected women) must continue. Synergy among the World Bank/ODA STI projects and implementing agencies supporting behavioral change interventions is essential.

• The AIDSCAP Country Office is applying for registration as a local NGO and should continue to strengthen the strong role they play in providing direct technical assistance and promoting networking and sharing of skills among GOZ, NGO and private organizations. A synergistic multifaceted approach is key in combating the HIV/AIDS epidemic. The AIDSCAP Country Office is in a pivotal position in that it not only supports its implementing agencies but is frequently asked to join planning/policy making groups on a national level.

• Women who are at risk of HIV infection because of partners who practice risky sexual behaviors should and can be targeted in family planning and antenatal clinics. In Zimbabwe, as in most African countries, gender and economic issues play a major role in transmission and cannot be ignored. Women face multidimensional problems and need a matching approach to ensure that all the problems are addressed.

• Men should and can be reached through the workplace; a change in the sexual behavior of men is critical to decreasing the risk of HIV infection for many women. Workplace interventions can serve as a linking point to the larger community, especially in "occupational" communities such as farming, mining and military bases.

• Implementing agencies must be educated on social learning and behavior modification theories and how to apply them to their specific social and cultural situations. Emphasis should be placed on where the targeted group is, what the next steps are and how group progress will be measured, rather than a few individuals who change one aspect of their behavior. Social and cultural norms have to change before significant behavioral change can occur. Behavioral change activities must target underlying beliefs and motives as well as the behaviors themselves. Basic behavior change and social learning theories suggest that people will adopt new behaviors if they assess their risk, feel the new behavior will "work", feel the new behavior is achievable and will be beneficial and finally, that the new behavior fits the norm. The stages of behavior change, sample messages and indicators have been presented and discussed at workshops with IAs. Social norms related to discussions of sexual issues and practices are examples of those already being stretched by IAs. Single women (CSWs) and married women are meeting together in peer education groups and talking about how to improve communication between men and women. Groups of men and women are attending peer education sessions together and discussing sensitive sexual issues.

 

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