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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 (See Below) II.Country Program Description C.Accomplishments and Outcomes III.Lessons Learned & Recommendations IV.Subproject Highlights VI.Attachments
A peer educator explains what he does....... "I deliberately provoke discussions at the bus stop -- or like last night, in the bar. Just to get the feeling of how other members of society are taking the program or if they are aware of what is happening. And then we share ideas. Half the time you will find out that they know about the disease, but they will still ask some questions and it is my duty to answer them as accurately as I can. "As a peer educator, I have discussions with my peers at work on a daily basis. Some will come to you -- even with a pimple -- and ask if this is AIDS-related, or something like that. So we try to find out how much that person knows. And if we find we cannot answer a question, we refer to another person. I myself go out to educate during the weekends and each time I find a group of people I ask if they would like to know more about STDs and HIV. I always wear my NRZ T-shirt so they know I am a peer educator. I also try to carry some pamphlets and condoms. It is wherever you are. You always have to start a discussion on AIDS -- on the bus, on the train -- wherever you are. "We discovered later that we can't just discuss this AIDS with peers at work. It is something that concerns the whole of Zimbabwe -- so we discuss -- even at home." Peer Educator (National Railway of Zimbabwe), I. Executive SummaryHIV/AIDS is a serious problem in Zimbabwe with one million people estimated to be HIV positive (22 percent of all adults). By September 1996, over 61,000 AIDS cases had been reported, which is only a fraction of the 200,000 AIDS cases estimated to exist. Young women age 15-19 years are reported to have AIDS at five times the rate of young men the same age. Through the AIDS Control and Prevention (AIDSCAP) Project , Family Health International (FHI) was contracted by the United States Agency for International Development (USAID) in 1994 to support implementation of the first stage of the USAID/Zimbabwe AIDS Prevention and Control (ZAPAC) Project in conjunction with the United Nations International Children's Education Fund (UNICEF) and the Government of Zimbabwe (GOZ) National AIDS Coordination Programme (NACP). The AIDSCAP component focused on behavioral change communication interventions in the workplace. The specific target groups identified for intervention were commercial farm workers, transport workers, uniform service personnel and their families as primary target groups and commercial sex workers as the secondary group. As in many other African countries, the more mobile populations grouped in or around major commercial centers and transport routes have higher HIV infection rates and are therefore epidemiologically important to reach. The AIDSCAP Zimbabwe Country Program was designed to support behavior change in major occupational groups spread over vast geographical areas which not only ensured access to large populations but promoted networking efforts where the target groups overlapped. This design also resulted in complex coordination, management and monitoring on all levels; thus making one of the greatest advantages also one of the greatest challenges to implementing an effective program in three years. The challenge was met with the country program reaching approximately 23 percent of Zimbabwe's population of 10.5 million people with communication activities (128% of the targeted 1.8 million) and distributing over 19 million condoms over the life of the project. Additionally, as it is estimated that 50 percent of the total population is over 13 years of age and therefore at risk of HIV infection through sexual transmission, the project reached approximately 44 percent of the sexually active population in Zimbabwe. The total target population for the entire project was 2.5 million people. It is important to note, however, that the primary target population was the workforce, which represented 434,700 people. The key intervention strategy used to reduce high risk behavior was behavior change communication through peer educators. These peer educators used one-on-one discussion, drama and role plays, video shows and films to reach the target audience. Behavior change interventions were targeted directly to two levels of individuals: workplace managers and general employees (and their families); and indirectly to national and community leaders, whose support created an enabling environment. Mass media interventions, which influenced the social environment and supported behavior change within the target groups, had the added benefit of "spilling over" to the rest of the country. In addition, peer education activities benefited the entire communities as community members attended shows which were mostly performed outdoors. The specific objectives of the project in the respective communities were:
Overall, the project was very successful. A total of 26,112 people were trained, including peer educators located in rural and urban communities countrywide, including army and air force camps and with the potential of reaching 30 percent of the population of Zimbabwe. The target population to be educated was 1.8 million, however approximately 2,507,712 people were educated in all the work sites, along transport routes, on commercial farms, military bases and in surrounding communities. The initial target for the production and distribution of materials (videos, key chains, bumper stickers, vehicle license holders) was 58,502, however a total of 635,581 materials were produced and distributed over the life of the project. Additionally, 19,450,770 condoms were distributed in the target populations in rural and urban areas, at worksites, bars and hotels along transportation routes, and in surrounding communities, exceeding the target of 7,000,000 (279 percent of the target). The importance of having community leaders in targeted areas support activities was strongly emphasized throughout implementation. For example, the National Employment Council for the Transport Operating Industries (NECTOI) reported that communities along transport routes became involved and actually helped the project select sites. Triangle reported that they did not involve community leaders early enough and had to backtrack, conducting four workshops for religious leaders to secure their support and stop efforts to close down the project. Top management in workplace interventions were generally very supportive and often were responsible for the organizations contributing financial, material or level of effort support to the projects. The most neglected cadre of managers was reported to be middle-managers, who directly supervised peer educators. Often projects started by sensitizing top management and training peer educators to get things moving, assuming they would sensitize middle managers later. When this did not work, organizations like the Zimbabwe National Army (ZNA) changed direction and immediately held classes for mid-level management. While this resulted in more support for and recognition of peer educators, it did not result in managers seeing themselves as a group that should be targeted for behavior change activities by peer educators. Both Triangle and the National Railways of Zimbabwe (NRZ) reported this reluctance of mid-level managers to attend activities where they were also targeted. By focusing behavior change interventions in workplaces and targeting them 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 toward their families may be the most important way of reducing risk of infection for women. Subsequent to peer education activities, workers asked peer educators about talking to their spouses and children and people from communities surrounding worksites asked peer educators to talk to them. Commercial sex workers (CSWs) expressed that they feel sorry for and want to help the married woman who has no control over her sexual activities, even though she knows her husband is promiscuous. Anecdotal information indicates that these people are talking to each other. To establish and sustain an environment conducive to behavior change among targeted populations a wide variety of media activities were implemented. AIDSCAP supported a critical analysis of Zimbabwe media in relation to HIV/AIDS reporting, a workshop for media gatekeepers and policy makers, radio/TV programs, 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 postgraduate students enrolled in the diploma program for Mass Communications and Media Development. Due to the urgency and seriousness of the epidemic, IA's began implementation of interventions immediately after approval of the project. Baseline knowledge, attitudes, beliefs and practices (KABP) surveys were undertaken after implementation had already begun. As a result, baseline data reflect the effect of the interventions which were already underway. Differences between the baseline and second data points would therefore not be as great as if the first surveys had been done before the startup of interventions. Analysis of the 1996/1997 survey data in project sites show that knowledge of HIV/AIDS was very high. More than 85 percent of the adult population, 86 percent of CSWs and 73 percent of youth correctly reported at least two methods of preventing HIV infection. However, risk perception was somewhat low; approximately 40 percent of adults, 32 percent of youth and 76 percent of CSWs perceived themselves at risk of HIV infection. Multiple sexual partners was fairly low among the adult population with approximately 1.2 reported partners in the last three months, compared to 3 partners among youth. Incidence of STI infection among adult females was 11.7 percent, 28.2 percent among adult males, 53 percent among CSWs, and 5 percent among youth. Approximately 90 percent of the target population reported they could access condoms whenever they needed them, and 47 percent of the total study sample of the adult population reported condom use with their most recent non-regular sexual partner. Seventy-nine percent of CSWs reported condom use with their most recent sexual partner. In comparison, condom use among adult females of reproductive age was estimated at only 2 percent in the 1994 Demographic and Health Survey. The AIDSCAP Country Office approach to capacity building was to encourage a high level of participation from its implementing agencies (IAs) to ensure ownership and promote sustainability, understanding that sustainability, in many cases, may mean a combination of leveraging resources from donors as well as internally. Two key components of its capacity building program were leveraging financial, material, and level of effort support from IAs and promoting collaboration. The following are the results of AIDSCAP's leveraging effort:
KEY ISSUES AND LESSONS LEARNED
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