Making Prevention Work
Global Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997

This publication documents the experience of the world's largest international HIV/AIDS prevention project, which was implemented by FHI and its partners in 45 countries. It describes lessons learned during AIDSCAP, with examples and project profiles, in 10 technical and programmatic areas: behavior change communication, improving prevention and treatment of sexually transmitted diseases, prevention marketing, policy development, behavioral research, evaluation, gender and HIV/AIDS, management, AIDS care and support, and cross-border interventions.

Table of Contents

Making Prevention Work (See Below)

1. Behavior Change Communication: From Individual to Societal Change

2. Improving STD Prevention and Treatment

3. Prevention Marketing: Condoms and Beyond

4. Policy Development and HIV/AIDS Prevention: Creating a Supportive Environment for Behavior Change

5. Behavioral Research: Using Results to Design Behavior Change Interventions

6. Evaluating HIV/AIDS Prevention Programs: Developing New Tools for Meaningful Measurement

7. Women, Men and HIV/AIDS: Building Gender-Sensitive Programs

8. Managing HIV/AIDS Programs and Building Capacity to Sustain Prevention Efforts

9. Prevention and Care: Mutually Reinforcing Approaches

10. Crossing Borders: Reaching Mobile Populations at Risk

Partners and Acronyms

Making Prevention Work

By far the most ambitious international HIV/AIDS prevention effort ever undertaken, the AIDS Control and Prevention (AIDSCAP) Project worked with more than 500 nongovernmental organizations (NGOs), government agencies, community groups and universities to strengthen the response to the epidemic in more than 40 countries. The project, which was funded by the U.S. Agency for International Development (USAID) and implemented by Family Health International (FHI) from August 1991 to December 1997, managed 584 projects and activities in Africa, Asia, Latin America and the Caribbean.

In six years, AIDSCAP trained more than 180,000 people in a variety of HIV/AIDS prevention skills and supported the production and dissemination of some 5.8 million videos, dramas, television and radio programs and advertisements, and printed materials. These efforts reached almost 19 million people. By June 30, 1997, the total number of condoms distributed and sold by the project had exceeded 254 million.

Evaluations of programs in 19 countries suggest that these efforts had an impact on knowledge of HIV, attitudes toward those affected by the virus, perceptions of individual risk, and sexual behavior among the target groups. In Cameroon, for example, the proportion of male students who reported having sex with more than one partner dropped from 53 to 36 percent in three years. In Nepal, 62 percent of sex workers in the AIDSCAP intervention area reported using condoms with their most recent client in 1996 -- up from 35 percent in 1994 -- while reported condom use actually decreased among sex workers in areas that had not benefited from AIDSCAP interventions. And in Jamaica, where the majority of the population now reports some kind of behavior change to avoid HIV infection, the percentage of 12- to 14-year-old boys reporting sexual experience fell from 59 to 41 percent.

AIDSCAP interventions were built on three strategies for reducing HIV transmission: communication to encourage people to avoid behaviors that put people at risk of infection, improving treatment and prevention of other sexually transmitted diseases (STDs), and increasing access to and correct use of condoms. These central technical strategies were supported by policy development, behavioral research, evaluation, gender initiatives and capacity building.

Communication to encourage behavior change was at the heart of all AIDSCAP interventions. Through technical assistance, training and distribution of a series of handbooks, the project promoted a shift from the old information, education and communication (IEC) model to a more systematic approach that gives people the knowledge, skills, encouragement and support they need for HIV risk reduction. Behavior change communication (BCC) efforts used the results of epidemiological and social science research to design creative interventions that called on the talents of artists, writers, actors, producers, counselors and community members.

AIDSCAP was one of the first organizations to adopt STD prevention and treatment as a primary HIV/AIDS prevention strategy. The project's most important accomplishment in STD programs was increasing the use of syndromic case management, an approach that has improved access to effective STD services for tens of thousands of people. AIDSCAP conducted studies to validate and adapt syndromic management algorithms, worked with local officials and providers to develop national case management guidelines, and trained providers, program managers and pharmacists in the syndromic approach in 18 countries. The project also developed a methodology for conducting rapid ethnographic studies designed to improve communication between health care providers and their clients and tested several innovative approaches to expanding access to STD treatment.

Although millions of free condoms were distributed as part of AIDSCAP interventions, social marketing was the project's main strategy for increasing condom use. Using commercial distribution systems and marketing techniques, AIDSCAP and its partners sold more than 222 million condoms in eight countries. The project also revised the traditional social marketing model, developing innovative distribution strategies and opening thousands of nontraditional sales outlets to provide reliable, affordable condom supplies to those at greatest risk of HIV infection.

These efforts to change behavior and provide the services individuals need to act on behavior change messages were bolstered by policy development initiatives to create a more supportive environment for HIV risk reduction. Recognizing that policy development must be initiated and sustained locally, AIDSCAP provided technical assistance, training and information to strengthen the capacity of individuals and organizations to inform and influence policy. Strategic use of analytic tools, including policy assessments, socioeconomic impact models and cost analyses, helped influence the HIV/AIDS policies of governments, businesses and religious organizations in Kenya, Tanzania, Senegal, Indonesia, the Dominican Republic, El Salvador, Honduras and Nicaragua.

Behavioral research activities provided the scientific foundation needed to design effective interventions and built the capacity of more than 150 social scientists and 100 institutions to conduct such research for HIV/AIDS prevention. The scale of the research conducted by AIDSCAP and its host-country partners ranged from small, program-related studies of behavior among specific populations to a large efficacy trial of voluntary HIV counseling and testing in three countries. Research studies and pilot interventions produced recommendations and models for addressing emerging issues such as the role of structural and environmental interventions in HIV risk reduction, prevention options for women in stable relationships, and the linkages between HIV prevention and care.

AIDSCAP advanced the practice of HIV/AIDS evaluation by refining existing methods and testing innovative approaches. Detailed evaluation plans were designed for each of the 19 country programs at the outset, and implementation of these plans yielded important lessons for evaluators worldwide as well as evidence of changes in knowledge, attitudes and risk behaviors. New tools developed by the project will help evaluators overcome some of the limitations they face in assessing progress in HIV/AIDS prevention. One example is the behavioral surveillance survey methodology AIDSCAP pioneered in Bangkok, which enables evaluators to monitor trends in risk behavior among different target groups and has already been adapted in eight countries.

Through the AIDSCAP Women's Initiative, the project played an important role in raising awareness among policymakers and program managers about women's vulnerability to HIV infection and the need for more gender-sensitive prevention efforts. AIDSCAP used gender analysis and training to help project staff and implementing partners strengthen their interventions to meet the needs of both men and women. It also worked with international and local women's organizations to empower women to protect themselves from HIV infection. AIDSCAP-sponsored research offered valuable insights into the barriers to sexual communication, the role of peer support in sustaining use of the female condom, and ways to encourage dialogue between men and women.

Management systems linking AIDSCAP headquarters, regional and country offices, and host-country implementing partners created the infrastructure needed for successful implementation of technical strategies. In addition to creating systems for planning, monitoring, financial management and reporting for the world's largest international HIV/AIDS programs, AIDSCAP built the capacity of more than 400 organizations to design, implement and evaluate their own prevention projects. Special initiatives were created to involve more local community-based organizations and U.S. private voluntary organizations in HIV/AIDS prevention, create indigenous NGOs to help sustain interventions, and develop models for integrating prevention into AIDS care and management programs.

Since AIDSCAP's mandate was to build capacity in prevention, its experience in HIV/AIDS care and management was limited to pilot projects in a few countries. In one country -- Tanzania -- AIDSCAP had the opportunity to integrate prevention and care into community-based programs in nine regions. These experiences suggest that programs are more effective when they address both prevention and care, but few studies have examined this linkage. An AIDSCAP study conducted in Tanzania -- one of the first to assess whether providing support for people with HIV/AIDS can encourage them to adopt prevention measures -- will offer important guidance for policymakers and program managers struggling to meet the burgeoning need for care and prevention in many countries.

AIDSCAP was also one of the first organizations to address the heightened risk of HIV infection among mobile populations. Early interventions with truck drivers and their partners along major highways in Africa were expanded to reach other mobile populations, including sailors, migrant workers, military troops and refugees. AIDSCAP's success in carrying out some of the world's first "cross-border" prevention projects in Asian border towns and port cities has inspired other donors to join USAID in supporting and expanding such efforts. And the first large-scale, early HIV/AIDS intervention in a refugee camp -- an AIDSCAP-sponsored demonstration project in Rwandan refugee camps in Tanzania -- has served as a model for reaching vulnerable refugee populations in other parts of the world.

As the AIDSCAP Project drew to a close, technical and project management staff around the world were challenged to distill what they had learned and to disseminate those lessons widely. This report presents the key lessons that applied over countries and cultures and makes specific recommendations for strengthening HIV/AIDS efforts in behavior change communication, STD services, social marketing, policy development, behavioral research, evaluation, gender initiatives, management, care and support, and programs to reach mobile populations. Each chapter ends with a list of the challenges to be met by the next generation of HIV/AIDS programs.

The replication of AIDSCAP's cross-border model, the behavioral surveillance surveys and many of its other approaches, methods and tools in countries throughout the world illustrates that one of the project's most important legacies is its experience. Learning from that experience, and using it to build more effective and sustainable HIV/AIDS programs, is the next challenge.