15856.pdf

Media

extracted text
' ^1
■

•c

[
’ :

lakn

'••^m ':

H

• i
■ i-’MW

S3

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

1DJCAP

N

B:I
L--’^ O

r v - Liy

’

.

' vW>
Er

£>IS3^S~
l

«r®H|Era

1 if -j
owgroil

SSfclRw BSnSwjjam

tTfaSSWmwEmT
wtHiPj^SE”

g

*

r

-Jil

Sj? £
4”

.|

,l"

ISIH

Irail

£

asd^vis isv-i aiva am

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

October 1997

Project 936-5972.31-4692046 • Contract HRN-C-00-94-00001-17
The AIDSCAP Project, implemented by Family Health International, is funded by the United States
Agency for International Development.

Table of Contents
Acronyms

3

Making Prevention Work

5

Behavior Change Communication:
From Individual to Societal Change

8

2.

Improving STD Prevention and Treatment

19

3.

Prevention Marketing:
Condoms and Beyond

30

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

40

Behavioral Research:
Using Results to Design Behavior Change Interventions

52

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

62

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

75

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

88

Prevention and Care:
Mutually Reinforcing Approaches

98

Crossing Borders:
Reaching Mobile Populations at Risk

105

1.

4.

5.

6.

7.

8.

9.

10.

1

Acronyms

AIDSCAP

AMREF

AIDS Control and Prevention

African Medical Research and Education Foundation

ARLS

Association Rurale de Lutte Contre le SIDA (Sengalese NGO)

AWI

AIDSCAP Womens Initiative

BAP

Bhoruka AIDS Prevention (Indian project)

BCC

Behavior change communication

BMA

Bangkok Metropolitan Administration

BSS

Behavioral surveillance surveys

CAPS

Center for AIDS Prevention Studies (University of California at
San Francisco)

CDS

Centre Pour le Developpement et le Sante (Haitian NGO)

COIN

Centro de Orientacion e Investigacion Integral (Dominican
NGO)

CRS

Contraceptive Retail Sales (Nepali company)

CSM

Condom social marketing

C&T

Counseling and testing

FGD

Focus group discussion

FPAN

Family Planning Association of Nepal

GLAS

Groupe de Lutte Anti-Sida (Haitian NGO)

GPA

Global Programme on AIDS

GUD

Genital ulcer disease

GWP

General Welfare Pratisthan (Nepali NGO)

3

IEC

Information, education and communication

ISSS

Institute Salvadoreno de Seguro Social (Salvadoran Social Secu­
rity Institute)

KABP
KANCO

KAPC

Kenya AIDS NGOs Consortium
Kenya Association of Professional Counselors

LAC

Latin America and the Caribbean

MCH

Maternal-child health

MOH

Ministry of Health

NGO

Nongovernmental organization

PHC

Primary health care

PI

Prevention indicator

PSAP

Private Sector AIDS Policy

PSI

Population Services International

SSM

Servicio de Sanidad Militar (Guatemalan military health service)

STD

Sexually transmitted disease

TAP

Tanzania AIDS Project

TCI

Transport Corporation of India

TIR

Targeted intervention research

UNAIDS

4

Knowledge, attitudes, beliefs and practices

joint United Nations Programme on HIV/AIDS

USAID

U.S. Agency for International Development

WHO

World Health Organization

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 nongovern­
mental organizations (NGOs), government
agencies, community groups and universities to
strengthen the response to the epidemic in 45
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 De­
cember 1997, managed 584 projects and activi­
ties in Africa, Asia, Latin America and the Carib­
bean.
In six years, AIDSCAP trained more than
180,000 people in a variety of HIV/AIDS preven­
tion skills and supported the production and dis­
semination 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 num­
ber 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 ex­
ample, the proportion of male students who re­
ported 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 per­
cent 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: commu­
nication to encourage people to avoid behaviors
that put people at risk of infection, improving
treatment and prevention of other sexually trans­
mitted diseases (STDs), and increasing access to
and correct use of condoms. These central techni­
cal strategies were supported by policy develop­
ment, behavioral research, evaluation, gender ini­
tiatives and capacity building.
Communication to encourage behavior change
was at the heart of all AIDSCAP interventions.
Through technical assistance, training and distri­
bution of a series of handbooks, the project pro­
moted a shift from the old information, education
and communication (IEC) model to a more sys­
tematic approach that gives people the knowledge,
skills, encouragement and support they need for
HIV risk reduction. Behavior change communica­
tion (BCC) efforts used the results of epidemio­
logical and social science research to design cre­
ative 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 provid­
ers, 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 ap­
proaches to expanding access to STD treatment.

5

Although millions of free condoms were distrib­
uted as part of AIDSCAP interventions, social mar­
keting was the project’s main strategy for increas­
ing 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 re­
vised the traditional
social marketing
model, developing
innovative distribu­
tion 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 initia­
tives to create a more
supportive environ­
ment for HIV risk
reduction. Recogniz­
ing that policy devel­
opment must be initi­
ated and sustained
locally, AIDSCAP
provided technical
assistance, training
and information to strengthen the capacity of indi­
viduals 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, Indone­
sia, the Dominican Republic, El Salvador, Hondu­
ras and Nicaragua.
Behavioral research activities provided the sci­
entific foundation needed to design effective inter­
ventions 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, pro­

gram-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 inter______________________
ventions in HIV risk
reduction, prevention
options for women in
stable relationships,
and the linkages be­
tween HIV preven­
tion and care.
AIDSCAP ad­
vanced the practice of
HIV/AIDS evaluation
by refining existing
methods and testing
innovative ap­
proaches. Detailed
evaluation plans were
designed for each of
the 19 country pro­
grams at the outset,
and implementation
of these plans yielded
important lessons for
evaluators worldwide
as well as evidence of
changes in knowl­
edge, attitudes and
risk behaviors. New
tools developed by
the project will help
evaluators overcome
some of the limita­
tions 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 aware­
ness 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 train­
ing to help project staff and implementing partners
strengthen their interventions to meet the needs of
both men and women. It also worked with interna­
tional and local women’s organizations to em-

Evaluations of

programs in 19

countries suggest that

AIDSCAP efforts had

an impact on knowl­

edge of HIV, attitudes

toward those affected
by the virus,

perceptions of

individual risk, and

sexual behavior among

the target groups.

6

power women to protect themselves from HIV
infection. AIDSCAP-sponsored research offered
valuable insights into the barriers to sexual com­
munication, 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 head­
quarters, regional and country offices, and host­
country implementing partners created the infra­
structure 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 program, AIDSCAP built the capacity
of more than 500 organizations to design, imple­
ment 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 pre­
vention, create indigenous NGOs to help sustain
interventions, and develop models for integrating
prevention into AIDS care and management pro­
grams.
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 re­
gions. These experiences suggest that programs are
more effective when they address both prevention
and care, but few studies have examined this link­
age. 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 earliest
“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 AIDSCAPsponsored 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, techni­
cal 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 gen­
eration 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.

7

Behavior Change Communication:
From Individual to Societal Change
Behavior change communication (BCC) for
HIV/AIDS prevention has evolved into a special­
ized field that draws on experiences from family
planning, social marketing, anthropology, psy­
chology, education and communication. Because
prevention of a deadly sexually transmitted dis­
ease is significantly different from other health
promotion goals, HIV/AIDS programs have been
challenged to refine traditional communication
approaches to address usually private and sensi­
tive matters such as sex, trust and death.
BCC specialists working in HIV/AIDS have also
begun to broaden their approach to address the
social, political and environmental factors that
influence risk behavior. Experience with HIV/

AIDS has made it clear that an individual can
rarely sustain a change in behavior without a sup­
portive environment.
But certain time-tested elements of health com­
munication remain the foundation of BCC for
HIV/AIDS prevention. These include identifying
and segmenting target audiences, using multiple
communication channels and involving target
audiences in developing materials and messages.
Other principles are being subtly changed to meet
the needs of populations unaccustomed to sharing
concerns about sexuality and of societies whose
customs and structures inadvertently encourage
risky behavior.

Toward Behavior Change

suitants equipped more than 180,000 outreach
workers, health providers, peer educators, counse­
lors and community leaders with the skills needed
to influence and support behavior change.

AIDSCAP’s behavior change communication
strategy used behavioral and communication
theory and research to provide a systematic
framework for efforts to influence individual
behaviors and the social contexts in which they
occur. The project applied this strategy in more
than 580 projects and activities in over 40 coun­
tries. Almost 19 million people received poten­
tially lifesaving messages about HIV/AIDS pre­
vention through drama, music, radio, television,
video, printed materials and interpersonal com­
munication.
AIDSCAP’s BCC approach was considerably
more complex than traditional health education.
In many cases, it required a new way of thinking
about the design and implementation of commu­
nication projects. Training and technical assistance
from AIDSCAP communication officers and con-

A Nigerian peer educator talks to her fellow sex workers about

the importance of condom use.

8

Ukpong/University of Calabar

Technical assistance also came in the form of a
series of practical “how-to” handbooks on various
steps in the communication process. Project man­
agers and BCC officers reported that AIDSCAP’s
series of six BCC handbooks were useful as teach­
ing aides, reference materials, sources of new ideas,
and check lists.1 Managers of AIDSCAP-supported
organizations in Ethiopia used the handbook on
peer education to design all their peer education
projects. The Kenyan government distributed pho­
tocopies of AIDSCAP’s handbook on developing
an effective HIV/AIDS communication project to
200 Ministry of Health communication officers,
who were instructed to use it as their guide. In
Nepal, outreach supervisors carried copies of “As­
sessment and Monitoring of BCC Interventions”
with them so that they could use its monitoring
checklists during supervisory visits. And in Laos,
chapters of two of the handbooks were translated
and used in workshops to develop HIV/AIDS pre­
vention messages for projects at three different
sites. “The three working teams found that the two
books provided them the clearest framework for
communication and BCC intervention,” an
AIDSCAP BCC officer reported.
Because education by members of the target
audience is an integral part of many HIV/AIDS
prevention programs throughout the world,
AIDSCAP encouraged its implementing partners
to take a critical look at peer education projects.
An AIDSCAP study of 21 such projects in ten
countries examined where, when and how peer
education can be used most effectively.2 The
knowledge gained from this study helped project
staff develop the BCC handbook on peer educa-

Nick Shears

SL

tion, which has been used by many AIDSCAP pro­
grams and other HIV/AIDS projects to design peer
education projects and improve peer educator
training curricula.
Peer educators in many countries revealed hid­
den talents through their participation in
AIDSCAP programs. Some performed in plays,
others sang about HIV/AIDS prevention, and some
even showed a flair for creating cartoons to convey
prevention messages. In fact, one of AIDSCAP’s
greatest strengths in BCC was its ability to tap the
creativity of local organizations and communities
to create memorable and influential BCC messages
and materials. One of many examples is the Fleet
of Hope, a metaphor first used by a Catholic priest
in Tanzania to explain the various prevention op­
tions, which inspired actors in Ethiopia and Haiti
to create HIV/AIDS dramas. In Kenya and
Rwanda, groups were encouraged to write songs
about HIV/AIDS in local languages that were
taped and distributed to radio stations for broad­
cast. And the video of “Vibes” by lamaica’s Little
People and Teen Players Club, with its vibrant mu­
sic and its message to “wait until you have the su­
per, safer sexual skills you need before having sex,”
has become an international favorite among En­
glish-speaking adolescents.
AIDSCAP-sponsored folk theater, street theater,
videos, radio and television soap operas, and
magazine and newspaper stories generated enthu­
siastic responses and serious discussion about
HIV/AIDS. For example, a Kenyan radio soap op­
era received 27,000 letters from listeners with ques­
tions and comments on the topics addressed in the
broadcasts. In Jamaica, publication of question and
answer columns about safer sex in local newspa­
pers and youth magazines prompted 65 percent of
the calls to a telephone HIV/STD counseling ser­
vice, “Helpline,” over two years.
Evaluations of AIDSCAP programs in 19 coun­
tries suggest that BCC activities, working in combi­
nation with other behavior change interventions,
moved millions of people along the behavior
change continuum from knowledge to awareness
to action. In Cameroon, for example, the percent­
age of male students who reported having more
than one sex partner dropped from 53 to 36 in

A proposition in the schoolyard opens the popular
Jamaican musical “Vibes,” which encourages parents

and children to talk to each other about sex,
responsibility and HIV/AIDS.

9

Award-Winning Mass Media
Campaign Reaches Youth
in quick succession, four

its head.“AIDS. Just one

among Dominican youth.

the campaign—including

attractive young

time, and never again,” he

One ad posed a series of

radio announcements,

couples—sometimes the

warns.“Protect yourself.

questions to help listen­

brochures, posters and

same person but with a

Don’t change partners.

ers assess their own risk.

roadside billboards—

different partner—are

Use condoms. Because

Another emphasized that

presented the same hard­

each shown embracing on

just one time is enough,

“you can’t guess who has

hitting themes, designed

a couch in a dimly lit living

and never again.”

AIDS” by a person’s ap­

to pierce young people’s

room. In the background

This forceful TV adver­

pearance.The third ad,

sense of invulnerability.

a singer croons the open­

tisement is one of four

“Solamente UnaVez,”

“Young people don’t think

ing lyrics of a popular

produced for a campaign

listed a telephone hot line

death exists,” said

romantic ballad,

by the Al DSC AP program

number to call for infor­

Cumbre President Freddy

“Solamente UnaVez”:

in the Dominican Repub­

mation and referrals.The

Ginebra,“so we looked

“Just one time I loved in

lic targeting adolescents

final ad encouraged par­

for a ‘code’ to challenge

my life, just one time and

and their parents. Created

ents to talk to their chil­

them and to make them

never again.”

by the well-known Do­

dren about AIDS and

think.”

minican advertising

other STDs.

But the mood turns

starkly somber as the last

agency Cumbre, the spots

of the young women

used high-quality produc­

looks up with a grim

tion techniques and at­

expression and stares

tractive young actors to

directly at the camera.

convey well-researched

The word“SIDA” (AIDS)

public health messages.

in bold red letters covers

The two-year cam­

her face, and a narrator

paign confronted the

takes the sweet love song

attitudes and misconcep­

and turns its meaning on

tions revealed in research

r
«

/

Other equally polished
materials developed for

AIDSCAP persuaded
dozens of radio and TV

broadcasters and cable­

“Solamente Una Vez”

J
J

J
CUMBRE

Scenes from an award-winning HIV/AIDS prevention
advertisement in the Dominican Republic show a woman
embracing different partners.

10

three years. In Thailand, 97 percent of brothel­
based sex workers reported using condoms with all
clients in 1996—up from 87 percent in 1993. And
in Jamaica, where the majority of the population
now reports some kind of behavior change to
avoid HIV, the percentage of 12- to 14-year-old
boys reporting sexual experience dropped from 59
to 41.
TV system operators to

coordinated national cam­

carry the ads for free. From

paign launched in collabora­

September 1995 to March

tion with a working group

1997, broadcasters contrib­

of more than a dozen Do­

uted air time worth more

minican youth service orga­

than U.S.$9 million.

nizations. Print materials

AIDSCAP communica­

reinforcing the broadcast

tion officer Ceneyda Brito,

spots’ key messages were

who has worked on other

distributed to government

public health campaigns in

agencies, NGOs working

the Dominican Republic,

with adolescents, radio

believes one reason the

stations, record and video

broadcasters were so re­

stores, and movie theaters.

ceptive was the high quality

The working group also

of the advertisements.The

established a referral net­

spots have also won praise

work for adolescents’ ques­

from advertising and public

tions about HIV/AIDS and

health specialists through­

contributed toAIDSCAP’s

out Latin America.

development of a manual

At a meeting in Mexico,

for example, communica­
tion experts from 20 coun­

for organizations working
with youth.

Such careful coordina­

tries awarded their top

tion of numerous communi­

prize to the AIDSCAP ads.

cation channels was vital to

And the “Solamente Una

the success of the campaign.

Vez” spot was the only

Close collaboration be­

public service announce­

tween organizations work­

ment recognized in a na­

ing with youth and the use

tionwide competition for

of multiple dissemination

Dominican advertisers,

paths ensured that Domini­

receiving the second-place

can youth received a con­

prize.

sistent message from

As attention-grabbing

NGOs, the media, their

and persuasive as the mass

parents and their peers—

media pieces may have

much more often than “just

been, they were just part of

one time.” ■

a comprehensive, well-

Lessons Learned
Beyond Awareness
• In addition to encouraging individual behavior
change, BCC can help create environmental
conditions that facilitate personal risk reduction.

In Jamaica, a focused strategy developed with a
local public relations firm targeted religious
institutions, the media and private businesses to
encourage changed attitudes toward HIV/AIDS
education in the workplace, public discussion of
sexual issues on radio and television, and in­
creased compassion toward people living with
HIV/AIDS.3 Each of the targets required a differ­
ent strategy and a different message.
All these efforts created a more supportive envi­
ronment in which individual Jamaicans received
encouragement to practice safer sexual behaviors
from many sectors. Media gatekeepers became
more receptive to covering HIV/AIDS issues, air­
ing 63 radio and television programs and publish­
ing 121 newspaper and magazine articles on the
subject over two years. Business owners and man­
agers agreed to work with the Ministry of Health
to establish workplace prevention programs, and
some supported the programs with cash or in-kind
contributions. And the influential Jamaica Council
of Churches endorsed a series of workshops that
gave religious leaders a better understanding of
HIV/AIDS and helped them counsel their congre­
gations about the disease.
• If peer educators are only trained to provide
STD/HIV awareness information, they are
unlikely to be effective in later stages of behavior
change.

In a study of 21 peer education projects in Af­
rica, Asia and Latin America, AIDSCAP project
managers reported that they found it necessary
to revisit the needs of target audiences and their
expectations for peer educators.2 When target

11

audiences were already knowledgeable about
STD/HIV infection, peer educators needed train­
ing to acquire the skills and attitudes necessary
to move on to behavior change and mainte­
nance.
To encourage behavior change, peer educators
need to know when to enlarge the basic message,
when to listen, when to empathize and how to
bring information on HIV/AIDS and STDs into
conversations about other issues. If peer educators
do not have these skills, they may be useful only in
the early phases of the behavior change process,
when they can promote awareness and impart
knowledge.

Private Sector Collaboration
• Well-planned BCC can leverage private sector
commitment and financial support.

For example, an AIDSCAP campaign targeting
adolescents in the Dominican Republic received
more than U.S.$9 million worth of free air time
from the local and international media.
AIDSCAP leveraged this media support by in­
vesting $53,000 in development of high-quality
television and radio spots and related print ma­
terials (Box 1.1).
• Collaboration with local communication
professionals may be more cost effective than
training HIV/AIDS program personnel in special
ized communication skills in some settings.

Working with public relations firms, advertising
agencies and media consultants can be expensive
unless they donate their services, but is often
worth the cost. Many local firms and consultants
have the contacts, understanding of culture and
trends, and professional expertise needed to
develop effective BCC campaigns.
AIDSCAP’s experience with such collaboration
was rewarding. For example, a Dominican adver­
tising agency worked with AIDSCAP staff in the
Dominican Republic to design an award-winning
mass media campaign for youth (Box 1.1). A Ja­
maican public relations firm helped AIDSCAP and
the Ministry of Health design and implement a
BCC strategy that created a supportive environ­
ment for individual behavior change.3 And in
Kenya, AIDSCAP worked with a Nairobi commu­
nications consulting firm to place a weekly column
on HIV/AIDS in a popular national newspaper.

12

Written by a well-known Kenyan journalist, the
“AIDS Watch” column reached an estimated
700,000 people every week and generated thou­
sands of letters from readers.

• There is a natural partnership between BCC
projects and condom social marketing projects.
Condom social marketing (CSM) projects often
produce excellent educational and promotional
items, as well as mass media promoting brand
recognition and condom use. The ability of CSM
projects to place their product in the public eye
helps desensitize the issue of condoms, which
lays the groundwork for more focused behavior
change messages.
In Nepal, for example, the CSM program devel­
oped radio and television spots and a film shown
in cinema halls and from mobile film vans, which
were closely coordinated with intensive outreach
efforts throughout the country. By opening the
topic for discussion, these mass media efforts made
it easier for outreach workers to discuss HIV/AIDS
with target audience members (Box 1.2). In many
countries, including Ethiopia, Tanzania and Haiti,
condom advertising on radio and television were
an integral part of national risk reduction cam­
paigns.

Communication Tools
• Because sexual issues are more sensitive for
many people than other kinds of public health
topics, drama and other entertaining forms of
behavior modeling can be a particularly effective
way of helping target audiences move beyond
awareness to behavior change.

Live and taped dramas were used throughout the
AIDSCAP Project to show models of behavior
change situations and to give audience members
a comfortable opportunity to consider the impli­
cations of their behavior. Communication offic­
ers and project managers reported that a dra­
matic format is a good way to introduce and
illustrate serious issues such as sexual negotia­
tion, HIV/AIDS care and support, and stigma
and discrimination.
Jamaica’s Targeted Community Intervention, for
example, enlisted the help of one of the island’s
most famous comedians to broach the subject of
HIV/AIDS with residents of inner-city communi­
ties. Project manager Audrey Wilson Campbell

noted that the use of comedy was very effective
because “it was non-threatening, but we were get­
ting to the root of the issue.” In the Dominican
Republic, “provocative theater” (a type of street
theater performed in bars or on the street, which
an unsuspecting public does not know is a re­
hearsed drama) is used to simulate situations in
which women express themselves confidently and
men learn to listen to their point of view on a
sexually related problem.
AIDSCAP used these models to give women and
men opportunities to rehearse and develop their
own sexual negotiation skills. A Jamaican commu­
nication officer noted that because it depicts the
everyday life of people and “makes room” for dis­
cussion, “community theater is the most effective
tool we have.”3

• The concept of a behavior change continuum is
a useful tool for BCC specialists, helping them
develop messages and approaches that are appro­
priate to the stages of change of their target
audiences.

The continuum adopted by AIDSCAP describes
people’s movement from awareness of a poten­
tial risk to motivation to change, trial of a new
behavior, and adoption and maintenance of the
behavior.
An AIDSCAP study conducted in eight coun­
tries used the behavior change continuum concept
to question BCC officers and program managers
about the perceived impact of their work. Typical

Henry Gakuru

of many responses is this, from Zimbabwe: “In the
beginning we were at awareness—they knew there
was some problem, but they were not particularly
concerned. And now I think we are bouncing back
and forth between motivation and trial. We’re dis­
tributing a lot of condoms—about 450,000 this
year—so that’s some trial.”4
Recognition that change is a process and that
messages must be appropriate to the stage of
change requires considerable ingenuity from BCC
specialists. In Cameroon, projects working with
somewhat cohesive and homogeneous groups such
as sex workers and military personnel found that
members of their target population generally
moved along the change continuum at a similar
rate. However, university students in the same
country presented a greater challenge. Because they
entered the university with different levels of un­
derstanding about HIV and because upper class
students had more exposure to prevention educa­
tion, the large target group of “university students”
was segmented according to their positions on the
change continuum, and messages and approaches
were tailored for these various segments.5
• Some BCC messages and materials have
universal appeal.
Although BCC messages and materials should
always be pretested with members of the in­
tended audience, it may not be necessary to de­
velop new materials for each target group. In
fact, AIDSCAP has found that some messages
transcend culture and nationality. A study of
several AIDSCAP materials that have been used
or adapted throughout the world found that they
appealed to people from many different cultures
because they addressed universal concerns.6
In Tanzania, for example, a brochure about “The
Fleet of Hope,” was designed to help individuals
and communities with diverse religious back­
grounds and moral beliefs understand the impact
of HIV/AIDS and assess their own risk. It advises
readers to board one of three “boats”—abstinence,
monogamy or condoms—to save themselves. This
metaphor and the options it offers proved popular
and effective in at least eight countries in Africa,

A counselor discusses condoms with a woman whose husband has

“inherited” the wife of a brother who died ofAIDS. AIDSCAP found that
performances like this one by Kenya’s Miujiza Players are a particularly
effective way to address sensitive issues.

13

1.2
AIDSCAP in Nepal:
Comprehensive Behavior
Change Communication
One of the first things a

meet a friendly outreach

carefully coordinated

ous condom social mar­

truck driver espies as he

worker or peer educator

them to ensure that the

keting efforts for family

enters the bustling town

who will help him assess

target audiences received

planning in Nepal. Work­

of Hetauda is a ten-foot-

his risk of contracting

consistent messages.

ing with Nepal Contra­

high billboard featuring

HIV/AIDS or other STDs.

Dhaaley Dai, the condom

And if he expresses con­

coordination was the

the Nepali company re­

cartoon character that

cern about possible STD

creation of the program s

sponsible for the social

serves as the logo for

symptoms, the outreach

mascot. Seeking to design

marketing component of

AIDSCAP’s program in

worker will give him a

a communication cam­

AIDSCAP’s program,

ceptive Retail Sales (CRS),

Nepal. Most travelers

referral card for a local

paign that was memorable

Stimulus named its con­

along the road from

center that provides diag­

and not “too preachy,” the

dom character “Dhaaley,”

Kathmandu to the Indian

nosis and treatment.

Stimulus Advertising

an affectionate version of

border are familiar with

Should he decide to go to

Agency contracted by

the CRS condom brand

Dhaaley’s message: “Wear

a pharmacy instead of the

AIDSCAP decided to

name Dhaal (shield), and

condoms. Drive away

STD center, the driver

build on the name recog­

“Dai,” meaning big

AIDS.”

will probably find that the

nition achieved by previ-

brother.

person behind the

When he stops at a
friend’s stand to buy a

counter was trained by

soft drink, the truck

AIDSCAP to dispense the

driver can buy a packet of

appropriate drugs for

the Dhaal condoms

different STD syndromes.

prominently displayed on

This comprehensive

the shelves, and he may

approach to prevention

hear a Dhaal jingle on the

education—one of the

radio. In the early evening,

hallmarks of true behavior

he might join a few hun­

change communication—

dred people gathered

was typical of the

around a video van to

AIDSCAP program in

watch Hindi music videos

Nepal. Designed to reach

and the HIV/AIDS preven­

truck drivers and their

tion film,“Guruji Ra

assistants and sex part­

Antare.”

ners along the main trans­

If the truck driver

port routes in Nepal’s

spends the night in one of

Terai region, the program

Hetauda’s many hotels for

used a variety of commu­

travelers, he is likely to

nication channels and

Dhaaley Dai, the mascot of the AIDSCAP program in Nepal, is

paraded down the streets of Kathmandu.

14

One example of this

Joy Pollack/AIDSCAP

This lovable cartoon

messages in a village or

urged target audiences to

benefited from AIDSCAP

character appeared on

town, outreach workers

use condoms and seek

interventions. More than

program materials, bill­

would follow to reinforce

prompt STD treatment,

half of the clients inter­

boards, signs, advertise­

those messages with

AIDSCAP coordinated its

viewed in the project area

ments, and condom

street dramas about HIV/

BCC efforts with the

reported consistent con­

packages and displays

AIDS and through infor­

services necessary for

dom use with sex work­

throughout theTerai

mal conversations.The

these HIV prevention

ers during the past year.

region and starred in

outreach workers of

measures.The condom

Another sign of the

radio public service an­

AIDSCAP’s NGO partner,

social marketing project

project’s success was the

nouncements. A large

General Welfare

provided convenient

communities’ response to

inflatable Dhaaley Dai

Pratisthan (GWP), and

access to condoms at

the outreach workers. At

even presided at dozens

the peer educators they

hundreds of outlets along

first, people seemed in­

of public events.

trained reported that the

the highway, and STD

sulted when outreach

mass media communica­

training workshops for

workers approached

them to talk about STDs.

The popularity of
Dhaaley Dai was matched

tion—particularly the

health providers, family

only by that of Guruji and

radio spots—enhanced

planning staff and pharma­

But they persevered,

Antare, the title charac­

their credibility with tar­

cists created a reliable

befriending anyone they

ters in AIDSCAP’s film

get audiences and made it

referral network for ef­

met in bars, hotels, restau­

fective STD treatment.

rants and at border check

about the adventures of a

easier for them to talk

truck driver and his hap­

about controversial topics

less assistant. Like the

such as sexuality and

evaluation suggest that

condom character, the

STDs.

The results of a 1996

points. Now the outreach

workers are considered

this comprehensive ap­

part of the community,

But one-on-one out­

proach was successful.

and men and women seek

vey a serious message:

reach was the core of the

Survey responses re­

them out with questions

Condoms are strong,

communication program,

vealed that target audi­

about HIV/AIDS and

durable, and the only way

allowing members of the

ences had received and

other STDs.

to protect yourself from

target audience to ask

understood the project’s

film uses humor to con­

Women who trade in

HIV/AIDS and other

questions and seek advice

messages, and both sex

sex—once an elusive

STDs if you cannot re­

from a trusted source.

workers and their clients

audience in a region

where the sex industry is

main faithful to one part­

Dedicated outreach

reported increased con­

ner. Video van showings

workers and the peer

dom use. In fact, the per­

clandestine and brothels

of the film, along with

educators they had

centage of sex workers

are rare—came to trust

popular music videos,

trained reached some

who said that their most

the outreach workers.

drew hundreds of people

50,000 people during the

recent client had worn a

“Now they bring their

to enjoy the free enter­

four-year project.

condom increased from

friends to us,” said GWP

35 percent in 1994 to 61

Director Mahesh Bhattrai.

tainment, and thousands

The key to effective

more read the companion

BCC is to ensure that

percent in 1996, while

“So sometimes nowadays

Guruji and Antare comic

people can act on pro­

reported condom use

we are not doing out­

book.

gram messages. In Nepal,

actually fell from 48 to 41

reach on the highway.

After the film had

where outreach workers

percent among sex work­

Actually the clients are

introduced the program’s

and mass media messages

ers in areas that had not

doing outreach to us.” ■

15

1.3
Comic Book Character Has
Worldwide Appeal
tion professionals who

All over the world,

local organizations in

HIV/AIDS, and moti­

people listen to what

Tanzania, Ethiopia,

vating a community to

had used the first

Emma says.

Nigeria and

organize a care and

three comics in 20

The star of

Cameroon. And in

support network.The

countries, 83 percent

AIDSCAP’s “Emma

Rwanda, she became a

final comics in the

said that despite

Says” comic book

film star when

series find Emma

Emma’s West African

series has dispensed

AIDSCAP’s condom

helping a teenage

origin, women the

practical, compassion­

social marketing part­

niece seek treatment

world over can relate

ate advice about HIV/

ner Population Ser­

for an STD.

to and benefit from

AIDS prevention and

vices International

care to hundreds of

received funding from

that each of the books

thousands of people

UNICEF to create an

would be relevant to

wisdom is that the

in Africa, Asia, Latin

“Emma Says” video

target audiences in

most effective com­

America and the Car­

and a companion

different countries by

munication materials

ibbean.

photonovella.

developing plots in

are developed locally.

But AIDSCAP’s expe­

AIDSCAP ensured

her messages.
The conventional

Originally devel­

As an aunt, neigh­

conjunction with its

oped byAIDSTECH

bor and friend, Emma

local field offices and

rience with “Emma

(AIDSCAP’s precur­

deals directly with the

partners and by pre­

Says” suggests that

sor) as a character in

difficult issues facing

testing them with

with careful pretest­

a flip chart for peer

individuals, families

audiences in those

ing, creative, well-

education sessions

and communities in

countries. But in many

designed materials

with West African

the era of HIV/AIDS.

cases, the pretests

that address universal

women, Emma has

In her first three

found that little or no

concerns can influ­

become a trusted

comic books, she talks

changes were neces­

ence attitudes and

source of information

to women about how

sary to adapt the

behavior among

about HIV/AIDS in

to introduce condoms

materials. In a 1996

people from very

more than 20 coun­

into a relationship and

survey of communica-

different cultures. ■

tries. Since the cre­

about the importance

ation of the first

of getting prompt,

comic book in 1994,

effective treatment for

“Emma Says” has been

STDs. She also ad­

translated into six

dresses HIV/AIDS

languages and distrib­

care and support in

uted to more than

the series, helping

171,000 individuals

neighbors accept and

and organizations.

care for their HIV­

Thousands more

UET5

face
TOG-ETUER

positive son, showing

have seen dramatic

people how they can

performances about

assist coworkers and

Emma performed by

friends living with

“Emma Says”
Luques Nisset-Raidon

16

Asia, Latin America and the Caribbean. It has been
used in folk media, religious sermons, videos, post­
ers, presentations, and other media and materials.
Another example is “Emma,” a West African char­
acter who has spread HIV/AIDS prevention and
care messages in 20 countries (Box 1.3). AIDSCAP
encouraged such “cross-fertilization” of messages
and materials by developing a computerized data­
base of more than 700 BCC materials produced by
the project and sharing model materials with its
communication officers in all regions.

Capacity Building
• Capacity building in behavior change commu­
nication is critical, even for experienced health
educators.

BCC concepts and techniques of behavior
change communication are not easy to grasp and
apply. And because approaches to HIV/AIDS
prevention continue to evolve, the initial design
and implementation capacity of project manag­
ers and field workers may be weak. AIDSCAP
found one cost-effective way to build capacity is

Mary O’Grady/AIDSCAP

Mil

through the use of practical handbooks that
guide the reader through the various steps of the
BCC process. However, training is necessary to
enable some groups to use the handbooks.

Recommendations
• BCC programs for HIV prevention should
address environmental conditions as well as
individual behavior.

Carefully planned, well-executed BCC strategies
can help change social attitudes and norms, cul­
tural practices, government and industry poli­
cies, and other environmental factors that influ­
ence individual behavior.
• As the epidemic evolves, HIV/AIDS program
managers should ensure that peer educators have
the knowledge and skills required to address the
changing needs of their peers.

Managers should conduct needs analyses to
identify topics to add to their training curricula,
such as care, counseling and family planning.
• HIV/AIDS programs should consider hiring
professional advertising, public relations and
communication professionals to develop BCC
campaigns and materials.

In some settings, contracting with professionals
may be more cost effective than providing spe­
cialized communication training to project staff
whose talents and skills may lie in other areas.
• BCC and condom social marketing projects
should coordinate their communication efforts to
ensure that their shared target audiences receive
reinforcing messages.
• HIV/AIDS programs should use a stages-ofchange continuum to understand the needs of
their target audiences and to develop BCC mes­
sages, materials and approaches that are relevant
to audience members at different stages in the
behavior change process.

Drama performances like this one in Kenya showed audiences
new models of sexual communication.

17

• Before creating new materials, HIV/AIDS
programs should consider whether existing
materials from other programs and even from
other countries might fit their needs.
These materials should always be pretested with
representatives of the target audience before
production to determine whether they are ap­
propriate and to identify any revisions that may
be necessary.

Future Challenges

Understanding Stages of Change
There are at least ten popular models of the pro­
cess of behavior change. Each illustrates stages
that people are likely to go through as they re­
spond to information, make decisions and try
new behaviors. At each stage in the process,
people need different kinds of information, emo­
tional support and skills. An ability to track a
target audience’s movement through these stages
would allow program planners and communica­
tion specialists to target messages more precisely
to the needs of the audience. Research is needed
to clarify societal, rather than individual, indica­
tors of change.

Reaching Mobile Populations
Research is needed to identify ways to communi­
cate with those who are socially marginalized,
including migrant workers, refugees, and those
who are homeless and may be living on the
street. Highly mobile populations pose special
challenges for BCC campaigns because it is par­
ticularly difficult to continue reaching them with
consistent messages as they move from place to
place.

References
I.

AIDSCAP BCC Handbook Series.AIDSCAP/

Family Health International,Arlington,Virginia.
Assessment and Monitoring of BCC Interventions

(1995)
Behavior Change Through Mass Communication

(1996)
How to Conduct Effective Pretests (1996)

Changing Social Norms
The art of designing and implementing commu­
nication programs to bring about changes in
community norms and values is not yet welldeveloped. We know that mass media can play an
important role, but questions remain about its
relative value compared to other channels of
communication, the timing and duration of
BCC campaigns, and the synergy of different
channels and messages. Research is needed on
the best ways to use communication to support
or change social norms and to measure such
change in different settings and with different
audiences.

How To Create an Effective Peer Education Project

(1996)
How to Create an Effective Communication Project

(1996)
HIV/AIDS Care and Support Projects (1997)

2.

Flanagan D,Williams C, Mahler H (1996).

Peer Education in Projects Supported by AIDSCAP.

AIDSCAP/Family Health International, Arling­
ton,Virginia.

3.

BCC Experiences from the Field in Jamaica (1997).

AIDSCAP/Family Health International, Arling­
ton,Virginia

4.

BCC Experiences from the Field in Zimbabwe

(1997). AIDSCAP/Family Health International,
Arlington,Virginia

Maintaining Behavior Change
Maintenance of safer sexual behaviors over time
has not received much attention to date. It is
expected that some behaviors will change as an
individual’s life changes. For example, condom
use may no longer be necessary when an
uninfected person enters a monogamous rela­
tionship with another person who is HlV-negative. However, other changes—or relapses into
less safe behavior—may lead to HIV infection.
Strategies and messages that motivate people to
maintain safer behaviors need to be investigated.

18

5.

BCC Experiences from the Field in Cameroon

(1997). AIDSCAP/Family Health International,
Arlington,Virginia
6.

Mahler H, Flanagan D, Hassig S (1996).

Emma Says and the Fleet of Hope:The appeal of
global messages and icons. XI International
Conference on HIV/AIDS, abstractTu.D. 2862.

Vancouver, Canada, July 7-12.

STD Prevention and Treatment
The more than 333 million curable sexually
transmitted infections that occur every year
worldwide are a significant cause of incapacitat­
ing illness, death, infertility and fetal loss. Yet
until the onset of the HIV/AIDS epidemic, the
global burden of sexually transmitted diseases
was largely ignored.
STD services in most countries show the effects
of decades of neglect. Many, if not most, people
prefer self-treatment—however ineffective or in­
complete—to the inconvenience and embarrass­
ment of seeking treatment at a specialty STD
clinic. Lack of confidence in STD services is com­
mon and often justified: drug shortages, inad­
equate information about drug resistance, limited
access to laboratory diagnosis, and health care
workers’ lack of knowledge or reluctance to treat
STDs all contribute to the poor quality of care.
Recognizing the need to make STD treatment
more effective and accessible, the World Health
Organization’s Global Programme on AIDS pro­
moted an approach that enables health care work­
ers to treat people who have symptoms suggestive
of an STD during a single clinic visit. Syndromic
management—the recognition of a group of clini­
cal findings and patient symptoms and treatment
for the major causes of those symptoms—makes it
possible to manage the majority of symptomatic
STDs without sophisticated laboratory tests or
specialized skills, which means that STD patients
can receive appropriate medications at primary
health care facilities.

Expanding Access to
Effective Treatment
AIDSCAP’s primary accomplishment in STD
programs was to further develop and increase

the use of syndromic management of STDs at
points of first encounter in 18 countries

The development of syndromic management
guidelines and other efforts to improve STD man­
agement and prevention at “points of first encoun­
ter” with the health system were prompted by the
rapid spread of the HIV/AIDS epidemic. One rea­
son for this new attention to STDs is obvious: the
sexual behaviors that lead to STDs also promote
the spread of HIV. But early in the HIV/AIDS epi­
demic, results of epidemiological and laboratory
research suggested that STDs actually enhance HIV
transmission. Given this evidence of a link between
HIV and other STDs, AIDSCAP made improving
STD prevention and treatment one of its main
HIV prevention strategies when the project began
in 1991.
Since then, the results of several important stud­
ies have confirmed the validity of this strategy. In a
landmark pilot study in Mwanza, Tanzania, use of
the syndromic approach to STD treatment that
AIDSCAP has advocated worldwide reduced HIV
incidence by 42 percent. And recent research in
Malawi produced strong biological evidence that
STD treatment can make HIV-positive men less
infectious.1
Along with mounting evidence of the connec­
tion between STD treatment and HIV prevention,
the past five years have brought recognition that
STD control is by no means a purely medical inter­
vention. Policymakers, health care providers and
community members all have important roles to
play in providing accessible, acceptable and effec­
tive STD services.

throughout the developing world. Through re­
search, advocacy, consensus building, training
and information dissemination, the project
made an important contribution to promoting
worldwide acceptance of this proven approach to
improving access to effective STD treatment.

19

2.1
Achieving Consensus on
National STD Guidelines in Haiti
needed to change the

than 70 Haitian health

providers’ minds.The first,

sytematic prenatal screen­

much more common than

care providers and offi­

an assessment of STD

ing at its antenatal clinics.

gonorrhea.This informa­

cials from medical and

case management at five

The Pan America Health

tion paved the way for

community organizations

of the primary health care

Organization donated a

acceptance of the WHO

meeting at a seminar in

centers run by the NGO

one-year supply of drugs

syndromic approach.The

Port-au-Prince agreed on

Centre pour le

for treating common

next year, a coalition of 13

the need for national STD

Developpement et la

STDs; CDS was able to

NGOs working on HIV/

guidelines outlining a new

Sante (CDS) in Cite Soleil,

replenish its stocks by

AIDS prevention in Haiti’s

approach to diagnosis and

revealed that more than

charging patients a mod­

Central Plateau began a

treatment.

90 percent of the clini­

est sum for drugs.

program similar to CDS’s.

CDS also instituted

Evaluations of the two

Just three years earlier,

cians were treating ure­

But other organiza­

many of the same medical

thral discharge with an

tions and providers still

programs showed that

decision makers had op­

ineffective drug.Another

resisted change. Many

they had improved STD

posed changes in the way

cause of urethral and

providers, believing that

case management signifi-

STD cases were managed.

vaginal discharge—

chlamydial infection was

cantly.The percentage of

But in the meantime, they

chlamydial infection—was

rare among Haitians, did

CDS clinicians treating

had learned that lack of

essentially ignored. Sexual

not think it was appropri­

urethral discharge prop­

information about STDs

partners of STD patients

ate to treat both gono­

erly had increased from

often resulted in ineffec­

were seldom referred for

coccal and chlamydial

less than 10 percent to 69

tive treatment throughout

treatment and pregnant

infection in patients seek­

percent. And in the newer

Haiti.

women were rarely

ing treatment for urethri­

NGO coalition program,

screened for syphilis.

tis or cervicitis, as the

56 percent of the clini­

World Health Organiza­

cians who were evaluated

Having results from

local studies that sup­

As a result of these

ported recommendations

findings, CDS adopted the

tion (WHO) recom­

reported giving effective

for new STD guidelines

syndromic approach to

mends. Others were

treatments for urethral

was the key to this break­

STD management in all of

simply opposed to using

discharge. Clinicians and

through, according to Dr.

its clinics. Staff received

the syndromic approach,

nurse-counselors in both

Eddy Genece, then

training and guidelines for

even though most ac­

programs were promoting

AIDSCAP resident advi­

providing STD care at the

knowledged that labora­

condom use.

sor in Haiti. “The resis­

primary health care level.

tory tests were not

Despite this progress,

tance was so strong at

Because clinicians might

always available and labo­

in 1995 there was still no

first,” he said.“I think you

not have time to focus on

ratory results were often

standardized approach to

overcome it with scien­

prevention, nurse-counse­

unreliable.

STD diagnosis and treat­

tific proof.”

lors were trained to

In 1993, a survey of

ment in Haiti.Therefore,

counsel patients and their

STDs among 1,000 pa­

AIDSCAP convened the

supported studies pro­

partners on safer sexual

tients at two CDS antena­

February 1995 seminar to

vided the information

behavior and condom use.

tal clinics revealed that

encourage Haitian organi-

A series of Al DSC AP-

20

chlamydial infection was

In February 1995, more

zations to reach consensus

Most national health

STD case management. It

guidelines are developed by

was during this seminar that

ministries of health. Be­

some clinicians learned for

cause Haiti’s health care

the first time that chlamy­

system broke down during

dial infection was more

its turbulent years of mili­

prevalent than gonorrhea in

tary rule, development of

Haiti and that most strains

national STD guidelines

of gonorrhea were resistant

began with local institu­

to penicillin.

tions, which later collabo­

After discussing the Cite

rated with the Ministry of

Soleil findings and their own

Health—a novel bottom-

experiences in the field,

to-top approach. Now the

participants agreed that

groundwork has been laid,

they should adopt a

and the government and

syndromic approach to

NGOs can work together

managing STDs.

to build a national STD

Representatives from
local NGO and research

institutions and several

international organizations
formed a working group to

develop national guidelines
for STD case management.

In the fall they were joined

by officials from the newly
restored democratic gov­

ernment. The guidelines

were presented and dis­

cussed at a second seminar
for health professionals and

medical decision makers

held in collaboration with
the Ministry of Health in

November 1995, and a small

booklet describing the

guidelines was distributed
to providers in 1996.

control program. ■

Encouraging adoption of syndromic manage­
ment required considerable effort at the policy
level as well as research to validate and adapt
WHO algorithms in different settings. AIDSCAP
worked with local officials and providers to build
consensus on the need for a standardized approach
to STD management and to develop national
guidelines for syndromic management of STDs.
The success of this collaborative process laid the
foundation for subsequent efforts to strengthen
STD services.
AIDSCAP improved STD care at points of first
encounter through technical assistance and train­
ing in syndromic management, communication
and STD program management for providers,
managers and pharmacists. Despite initial resis­
tance to the syndromic approach, follow-up assess­
ments of the STD care provided by trainees in
different countries found marked increases in the
percentages of clients receiving effective treatment.
Management training was critical to ensure that
managers could provide the support and guidance
necessary for successful implementation of
syndromic management. With AIDSCAP support,
managers of STD and HIV/AIDS control pro­
grams in developing countries attended interna­
tional and regional training courses on STD pro­
gram management. AIDSCAP also created a hand­
book for STD program managers—the first publi­
cation of its kind—that is being used in training
courses and as a reference guide worldwide.2
Recognizing that failure to seek prompt STD
care is often a result of stigma, lack of knowledge
about STDs and providers’ attitudes toward STD
patients, AIDSCAP placed increasing emphasis on
improving communication between providers and
clients and between STD programs and communi­
ties. In 1994, the project developed a rapid ethno­
graphic methodology for conducting qualitative
studies to identify ways to make STD programs
and outreach efforts more responsive to the com­
munities they serve. The results of targeted inter­
vention research (TIR) studies conducted in nine
African countries are being used to strengthen
patient-provider relations and to promote symp­
tom recognition, accurate behavioral risk assess­
ment, treatment-seeking, and condom use for STD
prevention. Publication of the Targeted Interven­
tion Research Manual, which was disseminated to
STD programs and international organizations,
will enable program managers to conduct their
own TIR studies with technical assistance from
local social scientists and STD specialists.3

21

2.2
Targeted Intervention Research
Improves STD Programs
Some Zambian

health care providers’

group of local experts,

Results ofTIR

women believe they

ability to treat those

STD program manag­

studies are also being

will miscarry if they

symptoms, or do not

ers can design, con­

used to improve pro­

seek antenatal care

feel comfortable going

duct and analyze the

grams in Benin,

before a pregnancy is

to a local clinic.

results ofTIR studies

Malawi, Morocco, the

in three to six

Philippines, Senegal,

months.

South Africa and

showing—a crucial

A rapid ethno­

time for identifying

graphic research tool

and treating maternal

called targeted inter­

syphilis. In Malawi,

In Zambia,TIR

Swaziland. Bridging the

vention research (TIR)

research sponsored

gap between research

different stages of the

helps program manag­

by AIDSCAP and

and practice is always

same sexually trans­

ers improve STD

UNICEF helped man­

a challenge. But be­

mitted disease are

programs by identify­

agers of a maternal

cause TIR is designed

considered separate

ing such barriers to

syphilis project under­

to provide rapid an­

illnesses. And in

treatment and preven­

stand why women

swers to specific pro­

Senegal, patients say

tion. Developed by

often refused to at­

grammatic questions,

they go straight to a

AIDSCAP in collabo­

tend an antenatal

the prospects for

pharmacist when they

ration with research­

clinic during the early

effective application of

experience STD

ers from Johns

stages of a pregnancy.

findings are good. ■

symptoms because

Hopkins University

The project’s strategy

the local health center

and the University of

was revised to ad­

has long lines and

Washington, the TIR

dress this barrier to

lacks confidentiality.

enables STD program

early detection and

As these examples

managers to gain a

treatment of maternal

illustrate, patients’

better understanding

syphilis, which can

beliefs and percep­

of local perceptions,

prevent spontaneous

tions have a powerful

terminology, practices

abortion, stillbirth,

influence on when,

and beliefs about

prematurity and con­

where—and even

STDs.

genital syphilis. In

whether—they seek

22

A manual produced

Ethiopia,TIR findings

care for an STD. Many

by AIDSCAP provides

were used to design

people avoid formal

step-by-step guide­

messages and materi­

health care systems

lines for organizing a

als to address com­

because they do not

TIR study. With this

munity perceptions

understand the causes

manual and the help

and misconceptions

of their symptoms,

of a multidisciplinary

about STD treatment

lack confidence in

technical advisory

and prevention.

While working with colleagues to strengthen
STD prevention and management through existing
health care and family planning facilities,
AIDSCAP also explored alternative approaches to
expanding access to these services. Field tests in
Nepal and Thailand demonstrated that training in
syndromic management can improve the advice
pharmacists and drugstore personnel give their
customers about STD treatment. AIDSCAP’s expe­
rience with the first pilot study of the provision of
prepackaged STD therapy yielded important les­
sons for future research to assess this approach.
And the preliminary results of an AIDSCAP-spon­
sored study of targeted periodic presumptive treat­
ment in South Africa showed dramatic reductions
in STD prevalence among sex workers and their
clients.
Program-related research on STD prevalence,
antibiotic resistance, community perceptions of
STDs, and partner referral strategies also contrib­
uted to efforts to improve STD prevention and
management. In many cases, AIDSCAP-sponsored
prevalence studies produced the only data on STDs
in a country. Local data on prevalence and resis­
tance were often the key to reversing opposition to
the syndromic approach and revising essential
drug lists.
Studies were conducted in more than 16 coun­
tries to advance AIDSCAP’s STD strategy.
AIDSCAP shared this wealth of experience with
colleagues throughout the world by publishing
more than 25 articles in peer-reviewed journals
and presenting more than 40 abstracts at interna­
tional and regional conferences.

Lessons Learned
Consensus and Communication
• Building the foundation for improving care at
points of first encounter requires intensive effort
at the policy and program management levels.
Engaging the commitment and resources of
public health officials and STD managers and
providers demands significant technical assis­
tance and consensus building. AIDSCAP’s expe­
rience in Haiti, where such efforts led to national
consensus on STD guidelines and improvements
in service delivery, shows that the time and re­
sources necessary to orient and train policy­
makers, managers and providers are well worth
the investment (Box 2.1).4

• Biologic studies of STD prevalence and antibi­
otic susceptibility in a country are essential to
building consensus on national STD treatment
guidelines.

The local data that these studies generate can
help convince STD program managers and
health care providers to adopt the syndromic
approach to STD management. AIDSCAP found
that once managers and providers understood
the magnitude of the STD problem in their
country and the ineffectiveness of many of the
current treatment practices, they were more
likely to appreciate the benefits of a simple, stan­
dardized approach that increases access to effec­
tive treatment.
• Findings from rapid ethnographic studies of
community perceptions of STDs can improve
communication between provider and patient.

AIDSCAP recognized the importance of under­
standing community perceptions, beliefs and
practices related to STDs and developed an eth­
nographic tool to study them.3 The results of
AIDSCAP-sponsored targeted intervention re­
search (TIR) are being used to improve clinicand community-based communication with
STD clinic clients and potential clients in nine
countries (Box 2.2).

Improving Access
• Research findings from several countries
confirm the impression that many people seek
treatment for STDs outside the formal medical
system.

For example, AIDSCAP studies in two African
countries documented a significant amount of
self-treatment and treatment seeking in the in­
formal sector. In Ethiopia, 61 percent of the men
and 41 percent of the women interviewed had
sought treatment at a pharmacy or from a local
injector or traditional healer before consulting at
a health center. In Cameroon, 50 percent of male
patients with a history of acute urethritis during
the previous 12 months had treated themselves
with drugs bought at pharmacies or in the mar­
ket. Their reasons for self-treatment were long
waits at clinics, the need to wait for laboratory
results before getting a prescription, the cost of
lab tests, and the cost and effectiveness of the
drugs prescribed by health providers.

23

2.3
Decentralized Screening Prevents
Syphilis Transmission in Jamaica
Jamaica’s Ministry of

public health workers and

Until 1993, clients who

One study in Jamaica

were screened for syphilis

showed that fetal loss,

Health and AIDSCAP

private physicians were

at Jamaica’s antenatal and

stillbirth or infant death

tackled this problem as

trained in STD manage­

STD clinics had to wait at

were almost twice as

part of a comprehensive

ment and informed of the

least a week and typically

likely to occur when a

effort to strengthen STD

most current local drug

up to six weeks for re­

mother had untreated

diagnosis, treatment and

resistance data, leading to

sults to return from the

syphilis.

prevention.Thousands of

significant improvements

two central government
laboratories in Kingston
and Montego Bay.
“By that time, patients

were gone, and some

Armando Waak/PAHO

women had delivered,’’
said Frieda Behets of the

University of North

Carolina, an AIDSCAP
consultant who provided
technical assistance to
Jamaica’s HIV/STD con­

trol program.
Delays in diagnosis and

treatment resulted in fur­
ther transmission of the
disease by people with

symptomless syphilis and

contributed to increases
in the number of infants

born with the disease.

A young expectant mother sits in

the waiting room of a Kingston
antenatal clinic. Providing syphilis

screening in all Jamaican

antenatal clinics eliminated long

waits for lab test results that had
contributed to high rates of
congenital syphilis.

24

**1

• Although high levels of self-treatment and
limited resources for STD control in many
countries compel policymakers, medical profes­
sionals and donors to consider innovative ap­
proaches to improving access to effective treat­
ment, opposition to providing STD management
outside the clinic setting is strong.

in STD care. All patients
were treated correctly in a
1996 study that involved di­
rect observation of public
health workers’ manage­
ment of gonorrhea, and the
number of private physi­
cians reporting that they
had used ineffective drugs
to treat gonorrhea dropped
from 43 percent to 3.6 per­
cent.
But the most dramatic
improvement in STD ser­
vices in Jamaica resulted
from the decentralization of
syphilis screening.The de­
centralization effort began
at the Comprehensive
Health Centre in Kingston
and was gradually expanded
to other health centers and
clinics. Laboratory aides and
assistants with little labora­
tory experience learned
how to perform syphilis
blood tests at the clinics.
Many people were reluc­
tant to endorse decentrali­
zation at first because they

believed syphilis tests
should be conducted only
by laboratory technicians.
However, a quality control
assessment at the national
reference laboratory
showed that on-site testing
was accurate: more than 96
percent of the results of
syphilis tests performed by
laboratory aides were con­
firmed.
Syphilis screening is now
available at 76 antenatal
clinics and 17 STD clinics in
Jamaica. As a result, 68 per­
cent of those who test
positive for syphilis are
treated the same day and
85 percent receive treat­
ment in less than one
week. More efficient and
effective diagnosis and
treatment contributed to a
significant decline in infec­
tious syphilis from 1994 to
1996. ■

AIDSCAP field tested two alternatives to clinic­
based treatment—training pharmacy workers in
syndromic management and promoting pre­
packaged therapy for urethritis. Two of the pilot
studies encountered resistance from the medical
community, and the prepackaged therapy could
not be tested as planned because of lack of sup­
port from medical professionals and public
health authorities.

• Training pharmacists and other drugstore
personnel in the syndromic approach can im­
prove the management of STDs in many patients
who choose to self-medicate.

In Nepal, training drugstore personnel to dis­
pense antibiotics using the syndromic approach
and to provide clients with preventive education
and condoms markedly improved their prescrip­
tion practices. The percentage of drugstore per­
sonnel suggesting effective treatment to a “mys­
tery shopper” with urethritis symptoms in­
creased from 0.8 to 45 percent. Trained drug­
store personnel were also more likely to suggest
that their customers use condoms and refer
partners for treatment. However, more than half
continued to advise customers to take ineffective
medications, indicating a need for additional
training, supervision and support.
Researchers believe that a number of factors
contribute to continuing problems with the
STD management practices of drugstore person­
nel. Even when a pharmacist or drugstore clerk is
well trained and committed to providing effective
treatment, he or she is unlikely to turn away busi­
ness if a customer can only afford to buy a partial
prescription. Moreover, it is often difficult in a
public business setting to guarantee the privacy
necessary for gaining a customer’s trust.
• Sales of prepackaged STD therapy in pharma­
cies and health facilities could increase access to
effective STD care, but successful implementation
requires the full support of public health officials
and health care providers.

25

The first pilot study of this approach, conducted
by AIDSCAP in Cameroon, faltered because it
lacked the necessary local support. Only T1 per­
cent of the health care providers who had been
trained to prescribe prepackaged therapy for
urethritis actually did so. Without a consensus
on the need for syndromic management of STDs
and other alternatives to traditional STD care, it
was impossible to adequately assess the effective­
ness of this approach.
• Patients may be more receptive to prepackaged
STD therapy than providers.

Follow-up interviews with patients who had
received the kit of urethritis therapy in
Cameroon revealed high levels of compliance
and satisfaction. More than 82 percent reported
taking a full course of medication, 84 percent
said they had used condoms while on the medi­
cation, and 44 percent had used the cards in the
kit to refer partners for STD treatment. Providers
at one of the clinics reported that clients contin­
ued to ask for the kits months after the pilot
study ended.

Detecting Asymptomatic STDs

• Current risk assessment strategies are not a
valid tool for identifying STDs in women without
symptoms.

The main obstacle to managing STDs other than
syphilis in asymptomatic women is the absence
of valid, feasible and affordable case-finding and
screening strategies, particularly for gonococcal
and chlamydial infection. Results of studies con­
ducted by AIDSCAP in Jamaica and Tanzania
and by others attempting to define a risk profile
for infected asymptomatic women have been
disappointing.5,6 These studies found that risk
assessment scores derived from current flow
charts are neither sensitive nor specific enough
for widespread use. However, imperfect ap­
proaches that include risk assessment may be a
better option than doing nothing at all, particu­
larly in areas where STD prevalence is high.
Moreover, risk assessment may continue to play
a role in the management of STDs in asymptom­
atic women because risk scores could be used to
determine who should be tested for a sexually
transmitted infection when an appropriate test
becomes available.
• Partner referral is possible in a variety of
settings.

Luques Nisset-Raidon

Z HERE'S Some
1
i ci ME

7

\

f/
a

Fl2oAXTl4^

I
TO TKEAT
/ YodR iNFECTloH
TAKE AlLTflE
/PVEPiCiNE LiKE
L
1 TEU- you.

Reaching partners of STD patients with treat­
ment—a long-neglected component of STD
management in most countries—has great po­
tential for improving STD control because it
results in treatment of asymptomatic partners,
particularly women. AIDSCAP’s improved part
ner management systems in antenatal clinics in
Haiti and primary health care facilities in
Rwanda attained referral rates of 25 to 35 per­
cent.7,8

• Treating women and their partners for STDs as
part of antenatal care creates opportunities to
motivate men to seek treatment in order to
protect the health of their children and partners.

A doctor talks to a young STD patient about the importance of
taking a full course of treatment in one ofAIDSCAP’s “Emma
Says” comic books.

26

An AIDSCAP pilot study found that almost half
of the women attending two Haitian antenatal
clinics had one or more STDs. Ninety percent of
the women agreed to inform their partners, and
30 percent of the 331 men named by 384 women
sought treatment. Health workers found that
men were more willing to come for treatment
when the problem was framed in the context of
preserving fertility or ensuring healthy offspring.
When men who had come to the clinic were
asked why it was important to them to receive
treatment, one of the most common responses
was “to protect the child.”7
• Health workers with no laboratory experience
can be trained to perform accurate syphilis blood
tests, making it possible to expand syphilis screen­
ing of pregnant women.

An effective, affordable treatment for syphilis is
available, yet hundreds of thousands of undetec­
ted and untreated maternal syphilis cases lead to
fetal loss, infant death or congenital abnormali­
ties every year. Too often, logistical and manage­
rial obstacles impede use of the rapid, simple,
inexpensive syphilis diagnostic test for routine
screening in antenatal clinics. In Jamaica,
AIDSCAP worked with the Ministry of Health to
remove some of these obstacles in a successful
effort to decentralize syphilis testing (Box 2.3).9
• Targeted periodic presumptive treatment of
selected STDs (often referred to as “mass treat­
ment”) among epidemiologically defined “core
groups” holds promise for achieving rapid de­
creases in communities’ reservoirs of STDs.
Mathematical models have demonstrated that
core groups with high rates of sexual partner
exchange disproportionately increase the spread
of STDs within a population. Periodic presump­
tive treatment offers the advantages of achieving
a decline in STDs more quickly than sexual be­
havior change alone and reaching asymptomatic
individuals who would not otherwise seek care.
But careful research is needed to ensure that this
approach does not promote antibiotic resistance,
disrupt individuals’ normal biological resistance
to sexually transmitted infection, or lead to an
increase in high-risk behavior.
Preliminary results of an AIDSCAP pilot test of
empiric periodic treatment among sex workers in a
South African mining community confirm that
this strategy can be cost effective in such a setting.

By offering syndromic STD treatment to all
women with multiple partners referred by peer
educators, the study was able to reduce STD preva­
lence among women using the service by 30 per­
cent. STDs also declined among their clients and
partners: the project found a one-third decrease in
urethritis and a two-thirds reduction in genital
ulcers among miners. Findings from interviews
with study participants and focus group discus­
sions with peer educators, as well as limited data
from miners, suggest that the women and their
clients have fewer casual sex partners and use
condoms more often, although high-risk behavior
continues. Results of a cost-benefit analysis con­
vinced the management of the Harmony Mine to
continue the intervention and expand it to other
areas of the community.10

Recommendations
• AIDSCAP proposes the following steps as a
comprehensive, rational approach to establishing
improved, client-centered STD service delivery.

Many of these steps can take place simulta­
neously, and it is not necessary to complete stud­
ies before adopting provisional national guide­
lines and beginning training.
• Gather existing data or conduct studies to
describe local STD prevalence, antimicrobial
susceptibility patterns, and STD beliefs and
practices.
• Convene local health personnel to review
epidemiological data and reach consensus on
national STD syndromic treatment guidelines.

• Design, conduct and evaluate training of
local providers in syndromic management.
• Use TIR results to redesign services.
• Design, pretest and produce materials for
patients and providers.
• Design and pretest messages and materials
for community members based on TIR findings.
• Provide supportive supervision for trainees
and evaluate service provision.
• Train regional, national and local managers

27

in program management and evaluate the re­
sults of the training.
• Work to ensure required drugs are available.

• To improve communication between providers
and clients, program managers should use rapid
ethnographic studies to understand community
perceptions about STDs and STD services, as well
as provider attitudes toward clients.
• Given the high levels of self-treatment and lack
of access to effective STD treatment found in
many countries, STD and HIV/AIDS control
programs should supplement efforts to improve
traditional STD services with alternatives such as
training of pharmacists in syndromic manage­
ment and selling prepackaged STD therapy in
pharmacies and health facilities.

Greater emphasis on behavior change communi­
cation is also needed in both clinic-based STD
services and community outreach to encourage
early treatment seeking.
• STD programs should institute partner referral
in order to detect and treat asymptomatic STDs,
particularly in women.
• All pregnant women attending antenatal clinics
should be screened for syphilis and treated.
Health care workers with no laboratory experi­
ence can be trained to use the rapid, inexpensive
diagnostic test for syphilis with high levels of
accuracy.

Future Challenges
Adding Strategies
The syndromic approach to STD management is
not the complete solution to STD control. It
works well for urethral discharge in men, genital
ulcer disease in both men and women, and pelvic
inflammatory disease, but is less than optimal for
managing vaginal discharge, even with the addi­
tion of a risk assessment. Moreover, syndromic
management was never designed as a tool for
identifying infection in asymptomatic people.
Greater support is required for additional ap­
proaches, including partner referral and treat­
ment, services targeting high-risk populations,
and comprehensive syphilis screening of antena-

28

tai women. Rapid, inexpensive, simple diagnostic
tests for gonococcal and chlamydial infection are
urgently needed to improve the management of
STDs in symptomatic women and to identify
asymptomatic infections.

Changing Provider Behavior
In spite of efforts to improve management of
STD patients through syndromic management
training, many health care providers are reluc­
tant to change their practice behaviors. Anec­
dotal information suggests that their reasons
include prestige, profit motives and pressure
from pharmaceutical companies, and the belief
that certain STDs syndromes are not serious and
do not warrant antibiotics. Research is needed to
further understand this resistance to the
syndromic approach among different groups of
health care providers and to propose solutions.

Assessing Creative Approaches
The critical constraints to effective STD treat­
ment and prevention found in most developing
countries require innovative responses. More
research is needed to test approaches such as
empiric periodic treatment and prevention mar­
keting of prepackaged STD therapy. These ap­
proaches must be introduced in ways that pro­
vide sound, objective evidence of efficacy that
will enable decision makers to make informed
judgments on the advisability of implementing
them on a wider scale.

Tracking Antibiotic Resistance
A major obstacle to STD control is the ever­
evolving development of resistance against anti­
biotics, particularly for gonococcal infections.
Patterns of resistance to antibiotics may differ
substantially by region and even from one coun­
try to the next, and a lack of reliable and repre­
sentative data makes it difficult to adapt STD
treatment guidelines for national and regional
use. A global network of laboratories using a
common methodology to conduct gonococcal
surveillance would greatly facilitate efforts to
develop, update and disseminate standardized
guidelines for effective STD treatment.

Improving Reproductive Health
Despite the limitations of current tools and
health infrastructures, it is possible to improve
women’s access to STD prevention and manage­
ment by integrating these services into family
planning, maternal-child health (MCH) and

primary health care (PHC) programs, as
AIDSCAP’s experience in Nepal demonstrates
(see page 84). Additional training is needed to
equip the staff at these clinics to counsel clients
on risk reduction and to refer symptomatic
women and women with clinical signs suggestive
of an STD for treatment. At some clinics, staff
could also learn to provide syndromic treatment
for symptomatic women and for asymptomatic
women through partner referral links with clin­
ics treating men. A smaller number of clinics
could provide laboratory diagnosis and treat­
ment. Operations research is needed to deter­
mine what levels of integration are feasible and
cost effective in different settings and to establish
technical guidelines and procedures for incorpo­
rating STD prevention and management into
family planning, MCH and PHC services.

References
i.

Cohen M, Hoffman I, Royce R, et al. (1997)

Treatment of urethritis reduces the concentra­
tion of HIV-1 in semen: implications for preven­
tion of transmission of HIV-1. The Lancet 349

(9069): 1868.

2.

Dallabetta G, Laga M, Lamptey P (1996). Control
of Sexually Transmitted Diseases:A Handbook for
the Design and Management of Programs.

AIDSCAP/Family Health International,Arlington,
Virginia.

3.

Helitzer-Allen D and Allen H (1994). The Manual

for Targeted Intervention Research on Sexually
Transmitted Illnesses with Community Members.

AIDSCAP/Family Health International.

4.

Behets F, Genece E, Narcisse M, Cohen M,
Dallabetta D. Approaches to control sexually
transmitted diseases in a difficult context: the

case of Haiti from 1992 through 1995. Bulletin of

the World Health Organization. In press.

5.

Behets F, Ward E, Fox L, Reed R, et al. Sexually
transmitted diseases are common in women
attending Jamaican family planning clinics and
appropriate detection tools are lacking. Geni­

tourinary Medicine. In press.

6.

Kapiga SH,Vuylsteke B, Lyamuya Ef, Dallabetta

G, Laga M. Evaluation of sexually transmitted

diseases diagnostic algorithms among family
planning clients in Dar es Salaam,Tanzania.

Genitourinary Medicine. In press.

7.

Desormeaux J, Behets F,Adrien M, et al. (1996).

Introduction of partner referral and treatment

for control of sexually transmitted diseases in a
poor Haitian community. International Journal of
STD &AIDS 7:502-506.

8.

Steen R, Soliman C, Bucyana S, Dallabetta G
(1995). Partner referral as a component of

integrated sexually transmitted disease services

in two Rwandan towns. Genitourinary Medicine

72:56-59.
9.

Behets F, Bennett L, Brathwaite A, et al. (1997).
The decentralization of syphilis screening for

improved care in Jamaican public clinics.
American Journal of Public Health 87(6): 1019-

1021.
10.

Periodic Presumptive Treatment of Women at High
Risk:An Intervention to Reduce the Prevalence of

Curable STDs in a South African Mining Community
(1997). Final Report. AIDSCAP/Family Health

International, Arlington, Virginia.

29

Prevention
keting:
Condo
and Beyond
The use of marketing techniques and systems to
promote and deliver methods of protecting pub­
lic health—known as social marketing, is a key
HIV/AIDS prevention strategy. The basic ap­
proach involves packaging, pricing and present­
ing a product or behavior to appeal to the target
market and engaging the participation of whole­
salers and retailers in distribution and conven­
tional trade promotions. Mass media are often
used to convey the benefits of the desired behav­
ior for a particular target audience.
Social marketing has been applied in a wide
range of public health programs, including family
planning, child survival and malaria prevention.
These projects commonly make use of the existing
logistics systems that supply the commercial net­
works delivering most daily necessities. The most
successful projects depend on subsidized products
to ensure retail prices that are within the buying
power of most people in developing countries.

The advantages of a social marketing approach
to promoting condoms for HIV/AIDS prevention
include the ability to make products available to
people when and where they need them and to
saturate geographic areas of special interest with a
product. The privacy—even anonymity—of the
commercial transaction between a vendor and
customer is another benefit. And social marketing
is a cost-effective strategy: even with a highly sub­
sidized product, the cost of distribution, from in­
termediate warehousing to the actual delivery of
product into the hands of the user, is borne by the
purchaser, not by a donor or the public health
system.
The success of condom social marketing (CSM)
efforts has led to a new interest in expanding the
use of marketing strategies in public health pro­
grams. Such prevention marketing can be used to
encourage health-promoting behaviors, as well as
other prevention “products.”

Improving Access,
Increasing Sales

joyed a marked increase in sales under AIDSCAP
support. For example, in Ethiopia the PSI project’s
sales rose 141 percent, from 829,000 a month be­
fore the AIDSCAP program in that country began
to 2 million a month in September 1996.
AIDSCAP support also boosted monthly sales by
more than 100 percent in Haiti and Nepal.
Perhaps even more important, AIDSCAP-supported CSM projects succeeded in providing reli­
able supplies to otherwise difficult-to-reach groups
and individuals at high risk of HIV infection by
adapting traditional commercial logistics systems.
Innovations such as the use of nontraditional sales
outlets (bars, restaurants, kiosks and other small
retailers), NGO sales agents and dedicated sales
forces increased sales while ensuring that condoms
were available to those who needed them most.
Impressive sales figures were achieved despite
formidable obstacles in almost every country. In

FHI worked with its social marketing subcon­
tractor, Population Services International
(PSI), and other organizations to make
condoms accessible, affordable and attractive
to millions of people. By June 30, 1997, the
total number of condoms sold by social mar­
keting projects and distributed for free by
NGOs had exceeded 254 million. AIDSCAPsupported CSM projects sold 87 percent of
those condoms (almost 222 million) in eight
countries.
In those countries AIDSCAP strengthened
existing CSM operations, providing the support
needed to expand sales outlets to new areas and
to target marketing efforts to reach critical audi­
ences. In fact, each of these CSM projects en-

30

Ethiopia, for example, the CSM project was forced
to ration condoms due to limited supplies. The
internecine war in Rwanda claimed the lives of
four PSI staff and forced the project to suspend
sales for almost a year, prompting PSI to distribute
free condoms in Rwandan refugee camps (Box
3.1). Political violence and an economic embargo
in Haiti also posed safety concerns and logistical
challenges to the PSI project there (Box 3.2), and
Brazil was plagued by both tariff and regulatory
barriers that restricted sales and complicated the
administration of CSM operations.
That CSM projects were able to overcome these
challenges to record such remarkable successes is
testament to the resilience and pragmatism of the
social marketing approach. It is also an indication
of the great unmet need for condoms in many
countries throughout the world. AIDSCAP’s expe-

AIDSCAP CSM SALES
Country

Length of Program

Total
Sales

Brazil
July 1993 - March 1997
(states of Sao Paulo
and Rio de Janeiro)

82.0

Ethiopia

January 1993 - Sept. 1996

44.0

Tanzania

August 1993 - June 1997

39.0

Cameroon

January 1993 - August 1996

24.0

Haiti

September 1993 -April 1996 16.3

Nepal

February 1994 - June 1997

12.0

Rwanda

April 1993 - April 1994
March 1995 - August 1996

2.6

April 1995 -April 1997
South
Africa
(Welkom mining communities)

Total

2.0

221.9

rience suggests that providing convenient access to
affordable condoms is the most effective way to
meet that demand.

Lessons Learned
Reaching Those At Risk
• Extending condom sales beyond pharmacies,
supermarkets and other large stores to nontradi­
tional outlets such as bars, brothels, liquor stores
and roadside stands makes condoms available to
individuals who are likely to use them in high-risk
situations.
AIDSCAP’s most significant and successful ad­
aptation of the contraceptive social marketing
model was to emphasize sales through nontraditional outlets to reach those at greatest risk of
HIV infection. Sales through wholesalers and
large commercial outlets are more efficient, but
much less likely to provide access to condoms at
the times and in the locations where people usu­
ally engage in high-risk sex. For example, phar­
macies are rarely located in red-light districts,
and most are not open for business late at night.
By giving sales agents incentives to market
condoms through nontraditional outlets,
AIDSCAP provided convenient access to lowcost condoms at thousands of strategic locations.

• NGOs can become important partners for
social marketing.

The association between NGOs and social mar­
keting is not a natural one. Social marketing
specialists operate in the commercial sector, ap­
pealing to profit motives rather than altruistic
goals. NGO staff who provide assistance to the
poor may object philosophically to selling any­
thing to their clients or members. But both
groups recognize the urgent need to ensure a
reliable condom supply to NGO clients and
members, and that common ground enabled
AIDSCAP to foster productive relationships
between social marketing operations and NGOs.
All social marketing operations were coordi­
nated with the activities of other AIDSCAP part­
ners—primarily NGOs—to ensure that target
populations received comprehensive HIV/AIDS
prevention services. Some NGO personnel even
acted as condom sales agents. For example, Ethio­
pian youth and Nigerian sex workers trained by

31

3.1
Riding the Phoenix:
CSM Sales Rise as Rwanda Rebuilds
In the center of Kigali’s

country’s urban popula­

had to be distributed free

most of the files were

most congested traffic

tion was estimated to be

of charge, PSI nonetheless

gone, and only one vehicle

circle stands a kiosk.

HI V-positive—the

promoted them creatively

from the original office

Once a newspaper stand,

AIDSCAP program was

and aggressively to en­

fleet remained—the one

this modest structure was

also forced to close.

hance their value and thus

staff had used to escape

increase their use.

to Burundi.

a mute witness to one of

Instead,AIDSCAP used

WhenAIDSCAP and

But the real challenge

this century’s bloodiest

country program funds to

tragedies: the 1994

establish an innovative

PSI finally returned to

slaughter of more than a

HIV and STD prevention

Rwanda almost a year

bolts of restocking

half million Rwandans by

and care project for some

later, the staff who had

condoms or reconstruct­

their fellow citizens.

2 million Rwandan refu­

survived the bloodshed

ing records destroyed in

was not the nuts and

Less than a year later,

gees in the Ngara District

faced the difficult and

the looting. Returning

the kiosk—freshly painted

refugee camps in Tanzania

sometimes disheartening

staff perceived a profound

with a rainbow design—

(see page 106). Managed

ordeal of rebuilding the

change in the society

became one of the first

by CARE International,

program from the ground

around them, a population

small businesses to re­

the project included con­

up.AIDSCAP/PSI’s entire

deeply affected by the

open. In the midday heat,

dom distribution by

stock of condoms had

bloody nightmare it had

many stop to buy cold

AIDSCAP’s social market­

disappeared from a

experienced.

drinks, but also take the

ing partner, PSI. Although

nearby warehouse.The

opportunity to ask the

the Prudence condoms

office was a shambles.All

nurse behind the counter

that refugees remem­

the computers and other

Kigali was almost insignifi­

about AIDS and buy pack­

bered so well from home

office equipment and

cant compared to the

“We soon realized that
the physical destruction in

ets of Prudence condoms.

In its new role, the kiosk
has become a bright sym­

bol of hope in a nation

PSI

desperate to renew itself.

When genocidal civil
war broke out in April

1994, most foreign assis­
tance and NGO projects

in Rwanda came to an
immediate halt. Despite
the desperate need for
HIV/AIDS interventions—
before the war, 30 per­

cent or more of the

PSI staff sell

Prudence condoms at a
Rob Marley Festival in Kigali.

32

fa .

fa

trauma the Rwandans had

Salesmen reported that

lived through,” said Kyle

Prudence’s reputation had

Peterson, former PSI coun­

survived the war and the

try representative in

program’s shutdown. “As

Rwanda. “The experience of

survivors slowly returned

the genocide so overpow­

to their homes, overcome

ered everything else that we

with grief and loss, we

began to doubt that any

were amazed to discover

other message might be

how many of them actually

heard at all.”

remembered Prudence and

Peterson and the rest of

recalled their high opinion

the PSI staff decided that

of its quality before the

the best way to both catch

war broke out,” said

the public’s attention and

Peterson.

aid in Rwanda’s long road to

But the key to the as­

healing was to promote

tonishing success of con­

Prudence in the most posi­

dom social marketing in

tive way possible.They

Rwanda may be more fun­

would use colorful, interest­

damental. Social marketing

ing advertisements and

experts attribute the resil­

posters and create catchy,

ience of the program to

upbeat jingles for the radio

society’s basic instinct for

that would lift spirits as they

survival.The marketplace

spread the Prudence brand

has always been central to

name around the country.

the Rwandan culture and

The new messages stressed

economy, and the country’s

the sweetness of life by

commercial infrastructure

emphasizing the benefits of

never disappeared en­

taking responsibility for

tirely—even during the

one’s health.

worst of the violence, even

The program built on the
solid foundation it had es­

in the refugee camps of
Tanzania.

tablished before the war to

“Social marketing, even

resume and expand sales

during catastrophes, always

throughout the country.

make sense because the

Within months, it had suc­

commercial sector always

ceeded in opening 1,500

reappears, like a phoenix,”

new points of sale and had

said Peterson. “The ques­

achieved impressive average

tion is, how can public

monthly sales of more than

health people learn to ride

229,000.

that phoenix?” ■

AIDSCAP as volunteer educators sold condoms to
their peers.
In a number of countries, NGOs emerged as
significant retailers of condoms. For example in
Haiti, where government condom distribution
ceased during years of political turmoil and tradi­
tional social marketing efforts were unable to
reach those living in the most poverty-stricken or
remote regions, the AIDSCAP-supported PSI so­
cial marketing project sold condoms at wholesale
prices to NGOs, who in turn sold them to their
clients at retail (Box 3.2). NGO staff learned that
the (highly subsidized) retail price was bearable to
their clients, experienced the superior performance
of the private sector delivery system, and generated
funds for their organizations through the small
profits they received. Skeptical at first of the ability
of NGOs to handle retail products, the social mar­
keting managers saw NGO staff account for an
increasing share of their sales, reaching 25 percent
of the 540,000 condoms sold every month.
The success of this strategy led to replication in
several other countries. PSI managers of
AIDSCAP-sponsored programs in Tanzania,
Rwanda and South Africa trained more than 2,300
NGO staff as condom sales agents.
• A social marketing project can successfully
target marketing efforts with a sales force dedi­
cated to selling its product.

In Brazil, AIDSCAP’s social marketing partner
DKT do Brasil could not rely on NGO sales
agents to increase access to condoms for NGO
clients because Brazilian law barred nonprofit
organizations from the retail trade. Instead,
A1DSCAP provided separate funds to DKT to
ensure that sales efforts were particularly intense
in the geographic areas served by the NGOs.
Ordinarily DKT would have concentrated its
resources on the most efficient (low-cost) sales,
which in Brazil means large sales to chain stores
and to the biggest retail outlets. With the addi­
tional resources from AIDSCAP, the social mar­
keting operation was able to hire promodoras
who sold to smaller outlets, ensuring adequate
supplies of low-priced condoms in the areas
where the NGO clients lived and worked.
A dedicated sales force also proved an effective
strategy for reaching groups targeted by the
AIDSCAP program in Nepal. These sales agents
concentrated their efforts on the highways into the
country from India—a known route for transmis­
sion of the virus—in nontraditional outlets such

33

as tea shops, liquor stores and roadside stands. As a
result of these efforts, condom access along the
highways increased dramatically (Box 3.3).
• Without subsidies, social marketing projects
cannot make condoms available to those who
need them most.

The efficiency of social marketing projects and
their ability to recover costs tempts donors to
make them entirely self-sustaining. But it is do­
nor support that allows social marketing to sell
condoms at an affordable price. For example, in
Nepal, where social marketing is an important
component of the AIDSCAP program, the retail
price for a condom is less than U.S.$0.01. In
Brazil, on the other hand, subsidies are not avail­
able and government taxes and regulations dis­
courage condom imports. There the cost is $0.30
per condom, largely because management is

DKT do Brasil

forced to sell them at a price that finances new
supplies. This price makes it highly unlikely that
Brazil’s poorest citizens will buy condoms.
Social marketing operations can be self-sustain­
ing, but at a cost. HIV/AIDS is increasingly a dis­
ease of the poor, and social marketing efforts will
have less of an impact on the epidemic if condoms
are not available at affordable prices.
• Providing low-cost subsidized condoms or even
free condoms does not undercut commercial
condom sales.
In fact, AIDSCAP’s experience suggests that con­
dom social marketing efforts can actually help
boost for-profit sales. In Brazil, for example, the
CSM project managed by PSI affiliate DKT do
Brasil stimulated a stagnant commercial condom
market by aggressively promoting its brand in
public and by challenging barriers to imported
condoms. As a result, the total number of
condoms sold in a year tripled to 135 million in
1995, and the market gained at least five addi­
tional condom importers.
A similar effect was documented in Thailand, a
country that distributes millions of free condoms.

Alcool

G

Mu

1 " ^1
y?..
e
AIDSCAP CSM projects used nontraditional sales outlets to expand access to condoms. In Brazil, such outlets included gas
stations and oceanside kiosks.

34

1

An audit by FHI partners John Snow, Inc., and PSI
showed that as the number of condoms distributed
in the public sector increased, the demand for
commercial condoms also rose. This demand en­
couraged three companies to open local condom
manufacturing plants. The government was able to
cut back on free distribution as the private sector
condom market grew, rising from about 1 million
to 60 million a year from 1985 to 1995.

as 1990, the word “condom” was prohibited in
advertising by the Government of Kenya, requir­
ing a wide range of subtlety and creativity on the
part of social markers. Today, more explicit ad­
vertising is permitted there and in many other
parts of the world.

• Encouraging use of condoms through mass
media facilitates their adoption by marginalized
groups.

Mass Media Marketing

• As people watch their friends and relatives die
of HIV/AIDS and as CSM programs relentlessly
educate people through every conceivable media
channel, the old barriers and stigmas attached to
condoms are beginning to evaporate.

The climate for mass media messages about
HIV/AIDS and condoms has improved substan­
tially over the past five years. The image of
Bishop Desmond Tutu endorsing condom use
on South African television may have shocked
some viewers there, but was perhaps even more
surprising to social marketers who for years had
battled to gain access to mass media. As recently

Targeted marketing has sometimes been misun­
derstood to mean developing brands and adver­
tising messages that appeal directly or even ex­
clusively to sex workers and their clients or to
men who have sex with men. Such an approach
associates condom use with behavior that is con­
demned by society and requires condom buyers
to identify themselves as people who practice
that behavior. Portraying condom users in the
media as happy, successful, “normal” people
helps those whose lack of acceptance in society
has been a barrier to their obtaining condoms.
When mass media conveys the message that
“everybody” uses condoms, members of
marginalized minorities can enter a store and

Andy Hutchison

O

ai

o

A PSI staff member in a mobile video van uses a penis model to demonstrate how to put on a condom.

35

3.2
NGO Participation
Boosts Condom Sales in Haiti
In the Haitian coun­

instability and eco­

CSM project—was

shortages that caused

tryside, shopping for

nomic crisis that fol­

the result of the

the breakdown of

condoms once meant

lowed the overthrow

unique approach that

commercial transpor­

a two-hour hike to a

of Haiti’s elected gov­

PSI and AIDSCAP

tation.

distant town or rural

ernment in 1991.

took to improving

clinic. Even in the

Much of the nation’s

distribution. In addi­

outlets remained

cities, commercial

commercial distribu­

tion to working with

stocked throughout

sales outlets were

tion system came to a

some 100 indepen­

difficult periods only

scarce. But today,

standstill, but the CSM

dent and commercial

because NGO sales

Pante condoms, sold

project flourished. In

vendors, the project

agents collected stock

at bars, hotels, beauty

less than four years,

recruited and trained

themselves,” said

shops, kiosks, markets

monthly sales of in­

175 outreach workers

Bertrovna Grimard, a

and nightclubs, are

creased from an aver­

from four of its part­

PSI consultant who

accessible at all hours

age of 3,000 to more

ner NGOs to act as

worked with the Haiti

of the day, even in

than 540,000. In fact,

wholesale distributors

project.

remote regions of

in per capita sales, the

and retail sales agents.

Haiti.

project in Haiti ranked

Each NGO-initiated

sold almost 40 per­

Pante (Creole for

as one of the world’s

sale returned a per­

cent of all the

panther) is the brand

leading CSM projects.

centage of the profit

condoms sold by the

to the organization, an

CSM project from

name of the condom

NGO sales agents

that PSI introduced in

as PSI and AIDSCAP

incentive that simulta­

1991 to l996.Their

Haiti in 1990.Two

established more than

neously built the CSM

role in achieving re­

years later, funding

3,000 points of sale

project and the finan­

markably high sales in

from AIDSCAP en­

throughout the coun­

cial strength of the

a poverty-stricken

abled PSI to create a

try, ultimately pen­

NGOs,

country and in ex­

dynamic condom

etrating into all but

social marketing

one of Haiti’s difficult-

ners helped the CSM

cess to remote

(CSM) project to

to-reach rural depart­

project expand into

regions can serve as a

package, promote and

ements. For the first

rural areas where

model for CSM

sell the top-quality

time, many of the 70

distribution simply

projects throughout

Pante at a fraction of

percent of Haitians

was not profitable for

the world. ■

the cost of commer­

who live in the coun­

commercial sales

cial condoms.

tryside could find

agents. And their

affordable condoms

enthusiasm and com­

close to home.

mitment carried the

Accessibility and
affordability meant

extraordinary success

36

Condom sales rose

“Many condom

This level of na­

These NGO part­

project through when

for the project, de­

tional coverage—

distribution was

spite the political

unusual even for a

threatened by gasoline

panding condom ac­

buy a condom without drawing attention to
their social status.
In Tanzania, for example, one television ad
showed dozens of people—well-dressed young
men and women, athletes, families with young
children—singing the upbeat “Salama” condom
theme song. In a Haitian ad, a beautiful young
woman holds a Pante brand condom package and
says, “Pante—It’s for me.” Then a man puts his
hand lovingly on hers and corrects her: “It’s for us.’
Such advertising helped boost condom sales
among groups targeted by HIV/AIDS programs
and the general population.

Recommendations
• CSM projects should allocate resources to
ensure that condoms are available in the nontraditional outlets most likely to reach those at greatest
risk of HIV infection.
• CSM programs should enlist new partners to
ensure that low-cost condoms are available to
target audiences.

NGO personnel proved extremely successful
sales agents, expanding condom access to areas
seldom reached by traditional CSM projects.
Another effective way to target marketing efforts
is to hire a dedicated sales force that sells to
smaller outlets in neighborhoods where target
audiences live and work.
• Subsidies to CSM projects must be continued
to ensure that condoms are affordable to those
who need them most.
• HIV/AIDS prevention programs should take
full advantage of the emerging greater freedom to
promote condom use and other behavior changes
through the public airwaves and other means of
mass communication.
• CSM programs should design advertising
messages and campaigns aimed at the general
population, not groups at the margins of society.

In countries with mature epidemics, much of the
general population is the target audience; in
others, a more inclusive approach reduces the
stigma often associated with condoms and dis­
courages the perception that HIV/AIDS affects
only marginalized groups.

Future Challenges
Expanding Social Marketing
The ability of social marketing to move physical
goods within the convenient reach of target au­
diences and to create an effective demand for
them has yet to be fully exploited, at least in part
because of donors’ hesitations about becoming
further involved in commodity supply. For ex­
ample, using social marketing to make supplies
of latex gloves available near medical facilities
and promoting the idea that it is a client’s re­
sponsibility to supply the gloves might well be
less costly than making the investments in public
sector logistics systems required to ensure ad­
equate supplies to physicians. As other HIV/
AIDS prevention products become available,
such as female condoms, appropriate virucides,
and STD and HIV/AIDS drugs, social marketing
may provide a more efficient means of delivery
than traditional public health systems.

Marketing Prevention
Throughout the world, advertisements for tooth­
paste, soap and cars show happy, attractive
people seeking to enjoy the thrill of being alive,
conspicuously helped by the product of the mo­
ment. The same approach has made condom use
less problematic in areas with strong social mar­
keting programs, and it could also be used to
promote less tangible “products.” HIV/AIDS
prevention programs need to tap the power of
the media to influence behavior by marketing
healthy sexual behavior as an attractive lifestyle.

Changing Norms
Condom social marketing has a positive impact
on social norms, but the degree to which it does
and mechanisms through which it operates are
not well understood. From Brazil to Ethiopia to
Nepal, AIDSCAP evaluations have found evi­
dence that individual sexual behavior is chang­
ing. It is likely that condom social marketing and
other HIV/AIDS prevention efforts are contrib­
uting to more long-term changes in social norms
as well, but it is too early to detect such change.
The experience of family planning programs in
reducing fertility rates in many countries during
the past 30 years, however, shows the potential
for normative change through social marketing.

37

3.3
Dedicated Sales Force Expands
Condom Access in Nepal
displays promoting CR.S’

In 1994, the Nepal Con­

out that their wives and

the merchants found that

traceptive Retail Sales

daughters usually

the condoms sold quickly,

Dhaal brand condoms.

(CRS) Company dis­

tended shop during the

they asked for more.

They went from store to

patched a sales force of

day. “How can I ask my

Advertising, distribu­

store along the highway,

three men to the

daughter to sell

tion of free Dhaal calen­

handing out free Dhaal

country’sTerai region.

condoms?” was a com­

dars, signs and T-shirts and

materials and encouraging

Part of AIDSCAP’s com­

mon question.

promotional events also

storekeepers to partici­

pate.

The salesmen perse­

helped reduce store­

Nepal, this social market­

vered. One by one, they

owners’ resistance to

Given the original

ing effort was designed to

convinced the owners

selling condoms. CRS

reluctance to stock

help reduce transmission

of tea shops, grocery

organized a contest, offer­

condoms, let alone display

of HIV and other STDs

stores and roadside

ing cash prizes to the

them prominently, the

among the men who

stands to take a single

storeowners who created

response was astonishing.

traveled through the Terai

box of condoms. When

the most creative store

Dozens of shops and

prehensive program in

on the transport routes

between Kathmandu and
India and the women who

were their sex partners
Mary O’Grady/AIDSCAP

along the way.

By improving access to
affordable condoms in the
nine targeted districts of

the region, the salesmen
aimed to increase their
use. But first they had to

get the condoms into the
stores.

Storeowners were

Wr-

reluctant to stock
condoms, fearing that it

would turn customers

away. They also pointed

\, Ji

Dhaaley Dai billboard along

the highway in Nepal from the

Indian border to Kathmandu
also displays Dhaal and
Panther condom logos.

38

Investing in Condom Supplies

stands were adorned with

toward condoms change.

red Dhaal stickers, poster

Storeowners who were

and banners arrayed in

once afraid to ask for the

every imaginable pattern.

condoms by name, simply

The winning entry was a

muttering “I’ll take one of

small, three-dimensional

those,” now ask for four or

house fashioned entirely of

five boxes of Dhaal without

Dhaal stickers.

a trace of embarrassment.

The contest was a turn­

Participants in the work­

ing point, according to CRS

shops on salesmanship and

Sales Manager Depak

HIV/AIDS prevention that

Ryakuryal.**After the display,

CRS organized to enlist

people really wanted to

storekeepers in educating

keep the condoms in their

customers about the im­

stores,” he said.

portance of condom use

Before the contest, he

added, village women

expressed their concern

about the spread of HIV

tended to avoid shops that

and STDs and their desire

displayed condoms because

to help stop it.

they didn’t want people to

CRS sales figures sug­

think that they were buying

gest that condom advertis­

the devices. When most of

ing and other AIDSCAP

the grocery stores in the

communication efforts are

highway area started dis­

also changing the attitudes

playing condoms, that

of the ultimate target audi­

stigma began to disappear.

ences, the men and women

“So now the situation is

who can now buy condoms

changed,” said Pyakuryal.

in almost any commercial

“Now condoms are every­

establishment along the

where.”
In fact, the number of

Meeting the demand for condoms created by
social marketing is a major challenge. For years
USAID has been the only donor providing sig­
nificant condom supplies for public health and
family planning programs. Although additional
donors (notably the European Community and
the German development agency) have recently
entered this area, most are reluctant to support
commodity supply—particularly when the com­
modity is considered controversial. Govern­
ments in the developing world also shrink at the
cost projections for adequate condom supplies.
For example, it would cost a social marketing
project U.S.$25 million to supply the country of
Ethiopia alone with an adequate number of
condoms. But experience to data suggests that
investments in adequate condom supplies would
save millions of lives. A serious effort to contain
the spread of the virus will require political will
and resources to provide enough condoms to
everyone who needs and wants them.

highway. Annual sales in
the region rose from

sales outlets carrying Dhaal

689,328 in 1993, when CRS

condoms in the nine dis­

sold condoms as only one

tricts rose from just ISO in

of several options for fam­

1994 to more than 2,500 in

ily planning, to 1.3 million in

1997.

1996. ■

During those years,

CRS salesmen saw attitudes

39

Policy
/elopment
S Prevention:
and HIV/j
Creating a Supportive Environment for
Behavior change
The social and political environment of a coun­
try, community or workplace has a profound
influence on efforts to reduce the spread of HIV/
AIDS. The laws, rules, policies and practices of
governments, religious organizations and the
private sector can support or constrain preven­
tion activities. Some policies may even inadvert­
ently promote the transmission of HIV.
Although many governments, businesses and
religious organizations have begun to adopt more
appropriate HIV/AIDS policies, this progress has
not kept pace with the spread of the epidemic. Few
countries have responded to HIV/AIDS with com­
prehensive programs or have committed the re­
sources needed to slow the epidemic. Restrictions
on sex education in schools and condom advertis-

Influencing Policy
Recognizing that policy development is a com­
plex, gradual process that must be initiated and
sustained locally, AIDSCAP focused on building
capacity to inform and influence policy. Through
training, technical assistance and information
dissemination, AIDSCAP helped local individu­
als and organizations gain new skills and forge
new partnerships so that they could work to­
gether to create a supportive environment for
effective HIV/AIDS interventions.
AIDSCAP developed and used a range of ana­
lytic tools, such as policy assessments, computer
models of the socioeconomic impact of HIV/AIDS
and cost analyses, to guide policy development
efforts. But these tools did not stand alone. They
were used strategically in a process designed to
empower local advocates and officials to develop
appropriate and effective HIV/AIDS policy.
Policy assessments proved an effective tool for
identifying opportunities to support HIV/AIDS
prevention interventions. These qualitative re­
views, which were completed in eight countries,

40

ing continue to hamper HIV/AIDS programs. And
many employers and governments have adopted ad
hoc discriminatory testing policies that discourage
people from acknowledging their HIV status and
acting to protect others from infection.
Growing recognition of the importance of sup­
portive policies has made policy development a key
strategy for HIV/AIDS prevention in the second
decade of the epidemic. Early policy efforts were
based on the assumption that providing accurate
data to key decision makers would stimulate swift
adoption of appropriate policies. Now it is clear
that informing decision makers must be part of a
long-term policy development process that in­
cludes analysis, strategic planning, dialogue and
advocacy.

identified existing policy responses, important
HIV/AIDS issues, and structures and organizations
for addressing those issues. Their findings also
provided a useful baseline for evaluating the im­
pact of policy efforts.1’2
Other policy tools were used to gain a better
understanding of the HIV/AIDS epidemic and its
social and economic impact. AIDSCAP led the way
in expanding the scope of economic impact analy­
ses to include information on households, gender
and economic sectors and in integrating those
analyses into policy development. Socioeconomic
impact assessments conducted with AIDSCAP
technical assistance in eight countries gave
policymakers a clear picture of the economic im­
plications of the epidemic, and strategic dissemi­
nation of assessment results helped influence
policy.3 In the Dominican Republic and Honduras,
for example, presentations of socioeconomic data
and projections to senior policymakers resulted in
legal reform and increased funding for HIV/AIDS
prevention.
Cost-effectiveness data were particularly useful

in convincing business owners and managers to
support workplace HIV/AIDS prevention policies
and programs. AIDSCAP’s Private Sector AIDS
Policy package, which has been used in more than
ten countries, includes spreadsheets and examples
to help managers calculate the potential financial
impact of HIV/AIDS on their workplaces and the
cost of a workplace prevention program (Box 4.3).4
The project worked with the managers of hun­
dreds of companies in 27 countries to establish
HIV/AIDS prevention interventions for employees
and encourage adoption of supportive workplace
policies.
In many policy development efforts, AIDSCAP’s
technical role was to provide a comparative per­
spective, offering lessons from other countries’
experiences with the epidemic. The project shared
information about what has and has not worked
nationally and internationally, disseminated inter­
national guidelines and policy materials that could
be adapted to meet local needs, and sponsored
study tours to countries with mature HIV/AIDS
epidemics and programs. Study tours to Thailand,
for example, gave key Indonesian policymakers
opportunities to learn about the progressive poli­
cies and comprehensive programs of a country
that experienced the earliest HIV/AIDS epidemic
in Asia. Most of the tour participants formed an
informal group that met regularly in Jakarta and
helped guide the development of Indonesia’s na-

Lance Woodruff

tional HIV/AIDS strategic plan.
Although study tours and some other educa­
tional efforts targeted policymakers directly,
AIDSCAP emphasized training of policy
“influencers”—the technical and policy specialists
inside and outside of government who inform and
advise policymakers. Through this training, many
people who had believed that policy was not their
responsibility came to realize that they had impor­
tant roles to play in policy development. Policy
influencers who participated in AIDSCAP’s train­
ing workshop in Central America were able to
target and time the presentation of socioeconomic
impact projections to influence the actions of
policymakers (Box 4.2). In Senegal, Islamic and
Catholic religious representatives recommended
that assistants and spokespeople for religious lead­
ers be engaged in initial dialogue so that they could
help guide the policy response.
Whether the goal was government or religious
policy change, AIDSCAP found that policy identi­
fication was a good way to create a network of
committed advocates. At the national level,
AIDSCAP’s approach was to support local organi­
zations in soliciting a list of key policy issues from
people working on HIV/AIDS prevention at the
district and provincial levels, expressing those is­
sues as policy recommendations, and presenting
the recommendations to the appropriate national
authorities. The same process was used with
church hierarchies and networks of religious orga­
nizations. As Kenya’s experience with government,
NGO and religious groups illustrates, this process
can help build a constituency for longer-term
policy development (Box 4.1).
AIDSCAP’s experience shows that a strategic
process and a focus on strengthening local capacity
and collaboration can produce results and leave
behind the institutional capacity to develop appro­
priate responses to a complex epidemic. Rigorous
analysis of scientific and sociopolitical data, com­
bined with presentations of persuasive recommen­
dations and building constituencies for HIV/AIDS
prevention, led to constructive dialogue among
political and community leaders on topics such as
workplace HIV/AIDS prevention, the human and
civil rights of people living with HIV/AIDS, private

A company physician discusses H/V/AIDS prevention with an
employee at a Pepsi plant in Thailand. AIDSCAP worked
with hundreds of companies in 2 7 countries to
establish workplace prevention projects.

41

4.1
Changing HIV/AIDS Policy in Kenya
On September 24, 1997,

own consultative process

issues affecting HIV/

result of this collabora­

the Kenyan Parliament

to develop specific rec­

AIDS prevention and

tion between the consor­

care in Kenya.

tium and the MOH, all

approved the country’s

ommendations that were

first comprehensive na­

incorporated into the

tional policy on HIV/AIDS.

national policy. With

This Sessional Paper on

AIDS calls for a more

aggressive response to

eight priority issues were

addressed in the final

technical assistance from

meeting at a national

document.

Al DSCAP, the Kenya AIDS

workshop convened by

But passage of the

NGOs Consortium

KANCO narrowed the

Sessional Paper is hardly

the epidemic, establishes

(KANCO) held a series

original list to eight

the culmination of

an independent National

of district and provincial

priority issues, which

KANCO’s policy develop­

AIDS Council to ensure

workshops in 1996 and

consortium staff then

ment efforts. Continued

political commitment

1997 to solicit the views

developed into policy

advocacy will be needed

across government sec­

and experiences of NGO

recommendations.

to ensure that the papers’

tors, and states the

personnel, religious lead­

Some of these recom­

guidelines are imple­

government’s positions on

ers, civil servants and

mendations were

mented and follow-up

controversial issues such

policymakers. Designed to

shared with partners,

legislation is passed. And

as HIV testing, confidenti­

build consensus among

such as business asso­

the network of KANCO

ality and human rights.

diverse groups, these

ciations, better placed

chapters the consortium

A milestone in HIV/

workshops gave those

to pursue them in the

has built across the coun­

AIDS policy development

working in HIV/AIDS

policy arena. But most

try will continue to iden­

in Kenya, the Sessional

prevention and care op­

were conveyed, in posi­

tify new policy constraints

Paper is the result of

portunities to identify

tion papers, presenta­

and other issues for

years of research, dialogue

common concerns and

tions and discussions, to

policy development and

and consensus-building by

problems and to develop

members of the gov­

advocacy.

HIV/AIDS advocates and

advocacy strategies for

ernment-appointed

technical specialists inside

advancing priority issues.

subcommittees drafting

Participation in policy

the Sessional Paper on

building and advocacy

AIDS.

facilitated by MAP Inter­

and outside of governmentThis process itself

identification workshops

was remarkable, for it

was an eye-opening expe­

A similar process of
policy identification, skills

KANCO worked

national among district

rience for many NGO

closely with the various

and provincial clergy and

and government person­

subcommittees to in­

church members led to a

marked the first vigorous
and inclusive public de­

bate about the Kenyan

nel, noted KANCO Di­

form their members

dramatic shift in the atti­

response to the epidemic

rector Alan Ragi.

and to advocate for the

tudes of Kenyan religious

in a country where HIV/

“Workers at the district

consortium’s recom­

leaders. Once skeptical

AIDS policy had long

level didn’t think they had

mendations. Ragi even

and sometimes even hos­

been neglected.

a role to play in policy

represented KANCO

tile to church involvement

development,” he said.

as a member of the

in HIV/AIDS prevention

MOH subcommittee

and care, the leaders of

responsible for the

many different denomina­
tions came together in

One of the many orga­

nizations that advised the

42

Representatives of

the different groups

KANCO showed them

Ministry of Health (MOH)

that policy was not just

as it drafted the Sessional

the province of the cen­

strategies and interven­

Paper, a consortium of

tral government.The

tions section of the

February 1996 and com­

some 200 NGOs, used its

result was a list of 72

Sessional Paper. As a

mitted their churches to

sector support for prevention, and the orga­
nizational and financial sustainability of
prevention efforts.

Lessons Learned
Policy Development Partners
developing policies to ad­

emergence of a powerful

dress 14 HIV/AIDS issues.

campaign among local

Their statement, later

churches and religious

published in a daily newspa­

organizations to care for

per, urged church action on

those affected by HIV/AIDS

providing education about

and to prevent further

family life and sexuality,

spread of the virus.
The experiences of

developing support groups
for HIV-positive people,

MAP International and

offering premarital counsel­

KAN CO are proof that

ing and HIV testing, caring

policy is not only the re­

for orphans and those living

sponsibility of central bu­

with HIV/AIDS, and sup­

reaucracies, and policy

porting the rights and needs

change is not always simply

of women.The leaders said

imposed from above.

churches should develop

Changes in policy can be

policies on “appropriate and

shaped from the grassroots

acceptable methods of

by carefully executed strat­

protection,” without men­

egies to engage people at

tioning condoms or other

all levels of governmental,

specific methods. And in an

organizational and commu­

unprecedented acknowledg­

nity hierarchies in issue

ment that clergy members

identification and advocacy.

do not always practice what

they preach, they called for

■

• The role of an outside agency such as
AIDSCAP in policy development is one of
advisor, not framer, of policy change.
Outside donors can provide financial sup­
port, information, encouragement and
technical assistance, but actual policies and
processes for achieving policy development
will come from local people and institu­
tions.
For example, AIDSCAP provided technical
assistance to help the Kenya AIDS NGOs
Consortium develop HIV/AIDS policy rec­
ommendations based on the views of local
constituents, which were solicited during a
series of district and provincial policy work­
shops (4.1). AIDSCAP’s role was to assist
consortium staff in facilitating the policy
development process, not to determine the
content of the recommendations. Supporting
such a process requires patience and flexibil­
ity, for donors and indigenous people might
emphasize different priorities, but the poli­
cies that result will be more sustainable.

a revitalization of moral
values in church leadership.
The urgency, unanimity
and commitment of the

• Working with and within coalitions is
often the most effective way to advance
policy goals.

religious leaders’ response

“was immediately and cor­

rectly perceived by local
church leadership as em­

powerment and authoriza­
tion,” said Rev. Chris
Mwalwa, who has served as

a consultant to MAP. By
giving local clergy and con­

gregations the mandate they

needed to respond to the
epidemic, the policy state­
ment strengthened the

Coalitions demonstrate commitment, draw
upon group expertise and provide a diver­
sity of interests and expertise that can be
focused on a single issue. A1DSCAP has
worked with NGO, religious, business and
government coalitions, providing technical
assistance to help these groups remain
focused on a defined agenda.
Similarly, a multisectoral group of techni­
cal specialists, analysts and advocates brings
complementary skills, perspectives and con­
tacts to the policy development process. This
was the approach adopted by AIDSCAP in
Central America, where teams of epidemi­
ologists, economists, policy and financial
analysts, and policymakers from three coun-

43

tries worked together to assess the socioeconomic
impact of HIV/AIDS and to develop strategies for
using their results to achieve policy goals (Box 4.2).
• The best way to reach policymakers is through
their advisors, constituents and already commit­
ted peers.

In Kenya, leaders of major religious denomina­
tions committed publicly to policy adoption as a
result of determined peer interest and constitu­
ent pressures demonstrated over two years of
awareness raising and consensus building (Box
4.1). AIDSCAP also invited Kenyan policymakers
and technical experts to co-author a book about
HIV/AIDS in Kenya, which added legitimacy to
its findings.5 The country’s vice president spoke
at the press conference launching the book in
Nairobi, where he gave the government’s stron­
gest statement to date about the epidemic in
Kenya.
• When they are respectfully engaged in the
policy development process, religious leaders can
play a constructive role in HIV/AIDS prevention.

Many religious leaders are concerned that
condoms are a form of birth control or that they
contribute to promiscuity and youth sexual ac­
tivity by reducing the risks associated with inter­
course. But AIDSCAP’s experience in Kenya,
Indonesia, Nigeria, Senegal and Tanzania shows
that when these concerns are addressed with
respect, many religious leaders are willing to
participate in coordinated, comprehensive pre­
vention efforts.
AIDSCAP and MAP International’s efforts to
facilitate consensus on HIV/AIDS prevention
within religious communities in Kenya were suc­
cessful because they engaged religious leaders
through the hierarchies of their churches, encour­
aged active discussion and networking, used per­
suasive results of youth sexual behavior surveys,
and did not try to involve the senior hierarchy
until near consensus was reached within the lower
ranks (Box 4.1).
• External organizations can support and
strengthen, but not create, effective networks.

Strong networks such as the Kenya AIDS NGOs
Consortium and the National AIDS Convention

El Hadj Momar Dior

Islamic religious leaders participate in an AIDSCAP-sponsored colloquium on “AIDS and Religion: Islam’s response” in Senegal.

44

of South Africa have succeeded because they
serve the needs of a diverse membership, they
have committed, skillful leadership, and they
diversified funding sources at an early stage.
These organizations came to be seen as provid­
ing a service, not only for members, but for gov­
ernment, and they engaged in policy and advo­
cacy activities rather than focusing exclusively on
programs and interventions.

Policy Development Tools
• Government and business policymakers are
responsive to assessments of the potential social
and economic impact of HIV/AIDS in a country
or company.
Data on the effects of HIV/AIDS on national
economies and societies—particularly data gen­
erated and presented by country health officials
and analysts—proved an influential advocacy
tool in the 12 countries where AIDSCAP helped
conduct such assessments. In El Salvador, for
example, numerous presentations on the impact
of HIV/AIDS on the national economy and so­
cial welfare indicators stimulated the Salvadoran
Social Security Institute, which provides health
care to both private and public sector employees,
to work with businesses to develop HIV/AIDS
programs in the workplace (Box 4.2).

• Reports of modeling projections can be highly
influential if disseminated strategically.
For example, dissemination of a non-technical
summary report of modeling projections written
for the general population and the news media
generated extensive coverage of the epidemic in
the Dominican Republic.6 This media coverage
drew public attention to the growing HIV/AIDS
problem in the country, which helped promote
passage of a comprehensive AIDS law by the
National Assembly.
Epidemiologic and economic impact projec­
tions can also strengthen advocates’ case for laws
protecting the civil rights of people living with
HIV/AIDS. In the Dominican Republic, for ex­
ample, a well-timed presentation of the results of a
socioeconomic impact assessment was instrumen­
tal in achieving passage of a law that not only re­
quires each ministry to fund prevention activities,
but also guarantees human rights for people living
with HIV/AIDS. And in Nicaragua, an advocacy
NGO used the results of the assessment made dur-

ing an AIDSCAP training workshop to help pass
legislation protecting homosexuals and HIV-posi
tive people (Box 4.2).

• Policymakers are often prepared to act on
recommendations for HIV/AIDS prevention when
they are presented with clear, precise information.

Specific recommendations, substantiated with
convincing data and supported by advocacy, can
lead to policy change. In Kenya, for example,
recommendations from position papers pre­
pared by the Kenya AIDS NGO Consortium were
incorporated into the government’s Sessional
Paper on AIDS (Box 4.1 ).7 And South Africa’s
minister of health adopted as national policy a
comprehensive plan for a national response to
HIV/AIDS drafted by local NGOs.

Involving Employers
• Workplace HIV/AIDS prevention activities are
acceptable to business managers when the inter­
ests of the business are considered.

By working with managers to help them under­
stand the impact of HIV/AIDS on their busi­
nesses and to tailor interventions to meet the
needs of workers and management, AIDSCAP
and its partners helped establish prevention pro­
grams in hundreds of workplaces throughout
the world.
AIDSCAP’s Private Sector AIDS Policy (PSAP)
materials encourage managers to establish con­
structive HIV/AIDS policies and support preven­
tion programs in the workplace. PSAP uses rapid
analysis of the potential financial impact of HIV/
AIDS on a business and the expected effects of
workplace HIV/AIDS prevention activities to dem
onstrate the benefits of prevention policies and
programs (Box 4.3).
• The greatest impact of HIV/AIDS on the
financial well-being of companies occurs in the
disruption of production because of absenteeism,
labor turnover due to illness or death of
HIV-positive employees, and the need to train
new employees.

Even in low-wage, labor-intensive industries,
productivity is affected, and company profits
suffer. In Thailand, for example, an AIDSCAP
study of the affiliates of two multinational com­
panies found that absenteeism due to AIDS rep-

45

Policy Development Initiative
Reaps Unexpected Benefits
In February 1996, a group

After learning how to

encountered different

diate results.The pro­

of technical specialists,

use computer models and

constraints and opportu­

jected impact on health

policy analysts and policy

costing methodologies to

nities.

costs and ISSS operating

influencers from three

make epidemiologic and

In El Salvador, a pre­

expenses so concerned

Central American coun­

economic projections, the

sentation of the team’s

the institute’s board of

tries met in Guatemala

three country teams

projections at the

directors that it estab­

City to participate in an

developed policy recom­

Institute Salvadoreho del

lished an HIV/AIDS pre­

AIDSCAP-sponsored

mendations and advocacy

Seguro Social (ISSS), a

vention program for its

policy development work­

strategies to support each

parastatal organization

employees and initiated

shop. The skills and

recommendation. Initially

that provides health care

its own project to

knowledge they gained

their action plans for

to private and public

strengthen the HIV/AIDS

there and the collabora­

presenting the results

sector employees and

prevention efforts of its

tive relationships they

were similar, but new

their families through its

private sector clients.

forged continue to have

strategies emerged as the

own hospitals and health

The legislative aides on

an impact on HIV/AIDS

teams returned home and

centers, produced imme-

the Salvadoran team also

prevention in their coun­

tries to this day.
At the workshop, par­

ticipants learned to esti­

Projected Increases in AIDS Cases
in Three Central American Countries

mate the potential
socioeconomic impact of
HIV/AIDS in their coun­

tries and to use their

1500

results to inform and

• • • • Nicaragua

guide HIV/AIDS preven­

tion policymaking.They

Guatemala

1200

agreed to continue work­
ing together after the
workshop to develop

stronger responses to
HIV/AIDS in their respec­

tive countries.

O>
uo
rd

u
'-g

El Salvador

900

_e>
E 600
=5

z
Projections of increases in

300

AIDS cases, HIV infections and
treatment costs were used by

AIDSCAP-trained organizations

to advocate for HIV/AIDS
policy reform in El Salvador,

Guatemala and Nicaragua.

46

L

0

1994

_____ L

_____ L

_____ |________ L

1995

1996

1997
Year

1998

L

1999

______ I

2000

arranged a presentation

National HIV/AIDS Coor­

defined in its action plan.

fostered by the workshop

to members of the Na­

dinating Committee.

Fortunately, however, a

had unanticipated benefits

Another benefit of the

Nicaraguan NGO that

in Guatemala, where it

after the workshop, which

AIDSCAP workshop is the

was unable to participate

contributed to energizing

resulted in commitments

improved relationship be­

in the workshop but was

the National HIV/AIDS

tional Assembly shortly

by Assembly members to

tween the national AIDS

involved in follow-up

Coordinating Committee.

support passage of HIV/

control program and the

meetings and strategic

And in Nicaragua,

AIDS legislation, such as a

Asociacion Guatemalteca

planning used the team’s

Fundacion Nimehautzin—

safe blood law, being pre­

para la Prevencion y Con­

results to work with the

an NGO that could not

pared for consideration in

trol de SIDA, an HIV/AIDS

national AIDS control

send a representative to

the next legislative cycle.

service and advocacy orga­

program to pass legisla­

the AIDSCAP work­

The Guatemalan team

nization, in Nicaragua. De­

tion protecting the rights

shop—linked data gener­

benefited from the par­

spite prior tensions,

of people living with HIV/

ated by the team with

ticipation of the chief of

representatives of the two

AIDS.When this legisla­

advocacy to help steer

the military health service

groups were able to work

tive effort led to the re­

the country’s legislative

(Servicio de Sanidad

together on the socioeco­

convening of Nicaragua’s

response to the epidemic.

The experiences of all

Militar, or SSM), whose

nomic impact project.This

National AIDS Commit­

experience at the work­

collaboration bodes well

tee, the assessment team

shop made him an advo­

for the efforts of the Na­

used the opportunity to

reflect a central lesson

cate for HIV/AIDS

tional HIV/AIDS Coordi­

share its results with

from AIDSCAP’s experi­

prevention and care in the

nating Committee, a

committee members.

ence: that policy develop­

military. After the work­

multisectoral coalition that

shop, the SSM chief

brings together diverse,

opment is often incre­

good data, sound analysis,

quoted the team’s projec­

and in some cases histori­

mental and can take

thorough planning and

Success in policy devel­

three country teams

ment success arises from

tions in a number of me­

cally antagonistic, interests

unexpected forms, as the

true collaboration.The

dia interviews and publicly

and perspectives to

experiences of the three

way that these elements

called for a review of

strengthen Guatemala’s

Central American teams

come together depends,

policies and practices

HIV/AIDS prevention and

illustrate. For example,

in part, on recognition

related to HIV-positive

care programs.

the Salvadoran team’s

that policy development is

members of the military.

A severe economic

work inspired the Social

a process. Like all good

He continues to be in­

downturn, a series of public

Security Institute to use

processes, it can be en­

volved in disseminating

health crises and an up­

socioeconomic impact

hanced with strategic

the study results and in

coming national election

analysis to sensitize other

planning and the ability to

HIV/AIDS policy develop­

made it difficult for the

members of the private

take advantage of unex­

ment as the military rep­

Nicaraguan team to follow

sector to HIV/AIDS. Like­

pected opportunities. ■

resentative on the new

through on the activities

wise, the collaboration

47

4.3
Private Sector AIDS Policy:
Helping Businesses Respond
to HIV/AIDS
cifically for private

velop HIV/AIDS poli­

AIDS (UNAIDS) has

exceptions, private

sector managers in

cies and prevention

included the PSAP kit

industry worldwide

the developing world,

programs.

in its “best practices”

has been slow to

and it is the most

adopt policies and

comprehensive of its

tion in November

available in all

mount programs to

kind. It contains a

1996, PSAP was pre­

UNAIDS offices.

protect workers from

manual to help busi­

tested at business

HIV/AIDS.Through its

nesses estimate the

leader workshops,

originally developed

support of hundreds

potential impact of

luncheon presenta­

for use in Africa, it is

of workplace preven­

the epidemic on their

tions and training-of-

already in demand in

tion projects in 27

operations and profits

trainer seminars in

countries throughout

countries, AIDSCAP

and to plan prevention

Kenya, Nigeria and

the world. Parts of the

With a few notable

library, and copies are

Although PSAP was

found that many busi­

interventions, case

Senegal. Interviews

kit have been trans­

ness owners and

studies of 17 African

with participants and

lated into Spanish for

managers did not

businesses’ responses

questionnaires they

use in Latin America,

understand the threat

to HIV/AIDS, guide­

completed yielded

and the entire kit will

the epidemic posed to

lines for assessing

useful suggestions for

be translated into

their workforces and

prevention needs in

improving the materi­

Portuguese in Brazil.

their businesses. Oth­

the workplace, and a

als, but the response

Zimbabwe’s minis­

ers simply did not

facilitators’ guide for

was overwhelmingly

ter of industry and

know what to do.

trainers working with

favorable. In fact, many

commerce, Herbert

businesses.

business owners and

M. Murerwa, noted

The facilitators’

managers said they

that PSAP is unique

Businesses Managing

guide helps trainers

would be willing to

because it recognizes

HIV/AIDS is designed

use the PSAP materi­

pay to attend addi­

the needs of employ­

to address both prob­

als to give short pre­

tional PSAP work­

ers and goes beyond

lems. Known as PSAP,

sentations to sensitize

shops.

simply offering guide­

AIDSCAP’s Private

Sector AIDS Policy:

48

Before its publica­

Ministries of health,

lines.“This guide pro­

it helps managers

business owners and

gauge the potential

managers to the need

business federations,

impact of HIV/AIDS

for a vigorous re­

unions, individual

rationale for recom­

on their businesses

sponse to HIV/AIDS

businesses, NGOs and

mendations, encour­

and design appropri­

and to conduct two-

international organiza­

ages the generation of

ate workplace policies

day workshops on

tions in at least ten

options, and offers a

process for HIV/AIDS

vides business-based

and prevention pro­

designing appropriate

countries are using

grams to respond to

prevention policies

PSAP to promote

policy and program

the epidemic.

and programs. But

greater private sector

formulation,” he said.

The PSAP kit is

PSAP can also stand

involvement in HIV/

one of the few HIV/

alone as a guide for

AIDS prevention.The

AIDS prevention re­

private sector manag­

Joint United Nations

sources written spe-

ers who want to de-

Programme on HIV/

resented over 40 percent of the total cost of HIV/
AIDS on the businesses. Labor turnover and
training of new workers added up to another 30
percent of total costs. The study estimated that
HIV/AIDS had cost each company $20,000 in
1994 and projected that AIDS-related expenses
would rise to $100,000 per company by 2005.8
• Essential management support for prevention
policies and programs can be gained by identify­
ing key allies in a company and providing data to
support the need for a workplace project.
An assessment of AIDSCAP-supported work­
place programs in three African countries found
that it is often most effective to approach manag­
ers in training, human resources and health de­
partments who are familiar with the impact of
the epidemic on the work force.9
Experience in Africa also showed that working
with an industry association rather than individual
companies makes “entree” and later expansion
easier. In Zimbabwe, for example, regional coordi­
nators of the Commercial Farmers Union recruit
new farms to participate in the AIDSCAP-sup­
ported program and provide training in HIV/AIDS
prevention education to farm employees and their
families. The Organization of Tanzanian Trade
Unions has also trained regional officers who ap­
proach employers in their areas. And in Eldoret,
Kenya, AIDSCAP reached employers through the
local branch of the Kenya Association of Manufac­
turers, which then decided to hold orientation
workshops for business owners and managers in
neighboring districts.

• Requiring some contribution from companies
from the start facilitates increased cost-sharing as
workplace prevention needs and activities expand.

Cost-sharing is introduced most effectively dur­
ing negotiations with an association or company
on the services to be provided. Once a program
proves itself, companies may assume an even
greater share of the costs. For example, two Zim­
babwean companies that have collaborated with
AIDSCAP to establish workplace prevention
programs—the Commercial Farmers Union and
Triangle Industries—now include funds for
HIV/AIDS prevention in their annual budgets.
In Tanzania, companies were asked to contribute
25 to 50 percent of the cost of workplace preven­
tion.

Evaluation
• Changes in policies and the policy envi­
ronment can be measured by using both
quantitative and qualitative indicators.

Evaluation of policy work is complex for a
number of reasons, including the difficulty
of attributing policy changes to specific
interventions and of quantifying changes in
the policy environment. In addition, be­
cause much of policy change is incremental
and attitudinal, it is often hidden from
evaluation efforts.
AIDSCAP overcame these limitations by
using a combination of quantitative and
qualitative indicators of change. Simple
quantitative indicators, for example, can
measure changes in the level of governmental
or business funding for HIV/AIDS preven­
tion. Assessments that include two sets of indepth interviews with key policymakers and
advocates carried out two or three years apart
provide information on changes in attitudes
and policies, institutional mechanisms that
may affect policy, and organizational dynam­
ics. A policy assessment in Kenya found sig­
nificant changes in the policy climate, im­
proved institutional mechanisms for facilitat­
ing policy development, and movement
among major religious groups from institu­
tional denial and occasional open opposition
to HIV/AIDS prevention to a public commit­
ment to develop appropriate denominational
policies (Box 4.1).

Recommendations
• External agencies should limit their role in
policy development to enabling local people
and institutions to develop their own policy
recommendations and plans for enacting
them through training, technical assistance
and information dissemination.
Technical assistance should not be overly
directive, and expatriates should not be put
in a position to act as spokespeople to se­
nior officials. Policies developed locally will
have a stronger constituency and are more
likely to be adopted and sustained.

49

• HIV/AIDS programs should work with reli­
gious communities and their leaders to encourage
their active participation in prevention efforts.
Religious leaders are playing a constructive role
in HIV/AIDS prevention in several countries as a
result of approaches that respected their values
and engaged them through the hierarchies of
their churches.

• Outcomes of technical assessments and analysis
must be translated into concise, nontechnical
summaries accessible to both policymakers and
the media.

• To ensure that policymaker education results in
policy initiatives, presentations of the projected
social and economic impact of the epidemic
should be accompanied by specific recommenda­
tions for preventing HIV/AIDS.
These recommendations should be supported by
persuasive data, including estimates of imple­
mentation costs when possible. Local advocates
should follow up presentations with additional
information, reminders of the proposed actions,
and advocacy.

• Workplace HIV/AIDS prevention programs
should begin with a concerted effort to identify
allies in a company and to provide data to support
the need for such a program.

Managers need to understand how HIV/AIDS is
affecting their industries and the potential im­
pact on labor costs and productivity if preven­
tion efforts are not instituted.
• HIV/AIDS programs should require an em­
ployer contribution to workplace prevention
projects from the beginning to ensure further
cost-sharing as prevention needs and activities
expand.

Future Challenges
Encouraging Early Response
Engaging the interest, concern and support of
policymakers at early stages of the epidemic con­
tinues to be challenging, particularly when
prevalence is low and the potential for a future
problem may not be apparent. Exchanges be­
tween policymakers from countries at different
stages of the epidemic have helped raise aware­
ness of the need for early intervention in a few
countries, but appropriate measures to contain
early HIV/AIDS epidemics are rare. Early inter­
ventions are particularly important to offer vi­
able protection to monogamous women and to
youth.

Leveraging Private Support
Businesses are often reluctant to dedicate re­
sources for HIV/AIDS prevention, though most
owners and managers are willing to allow such
projects to operate in the workplace as long
someone else pays for them. Systematic advocacy
campaigns, better information about the impact
of HIV/AIDS on businesses, and delivery of pro­
fessional prevention services on a fee-for-services
basis are needed to encourage businesses to dedi­
cate more of their own resources to prevention.

Understanding Impact
Although it is clear that social and economic
factors contribute to HIV vulnerability and
transmission of the virus, more specific data are
needed to make a persuasive case. The relation­
ship between HIV/AIDS vulnerability and pov­
erty is assumed but has not been sufficiently
described or analyzed. Socioeconomic data on
specific groups of people are needed to clarify
this relationship and provide a better under­
standing of the link between HIV/AIDS and
multisectoral development.

Improving HIVTesting Policies
As HIV testing becomes less expensive and more
available, there will be a growing need to ensure
that it is not used to discriminate against people
living with HIV and that voluntary testing is
linked with effective counseling. Policymakers
need to be educated about the negative effects of
discriminatory testing policies.

50

Supporting Prevention and Care

References

The emerging availability of and options for HIV/
AIDS treatment will place greater demands on
medical systems and national governments to pro­
vide new, expensive drugs. Some countries may
respond by moving funding allocated for HIV/
AIDS programs from prevention to treatment,
care, support and mitigation. Competition for
scarce resources would ill serve those who need
these services. Advocacy efforts are needed to con­
vince policymakers of the importance of increasing
funding for both care and prevention

i.

Rau B, Forsythe S (1996). A Review of Policy

Dimensions of HIV/AIDS in Kenya, with an Update.
Policy Working Paper WP3. Al DSCAP/Family

Health International,Arlington,Virginia.

2.

Parker R (1996). An Overview of Brazil’s HIV/AIDS

Policies and Programs. Policy Working Paper WP6.
AIDSCAP/Family Health International,Arlington,
Virginia.
3.

Siegel G (1996). Policy Development and Advocacy
in Three Central American Countries: Lessons

Learned. Policy Working Paper WPI .AIDSCAP/

Family Health International,Arlington,Virginia.

4.

Rau B, Roberts M, eds. (1996). Private Sector

AIDS Policy: Businesses Managing HIV/AIDS.

AIDSCAP/Family Health International,Arlington,
Virginia.

5.

Forsythe S, Rau B. eds. (1996). AIDS in Kenya.

Family Health International,Arlington,Virginia.
6.

Arbaje M, Gomez E, Butler de Lister M, Sweat
M. Sida en la Republica Dominica: Situacion Actual

e Impacto Socio-Economico. AIDSCAP/Family
Health International,Arlington,Virginia, and
Santo Domingo, Dominican Republic.

7.

Republic of Kenya, Ministry of Health (1997).

AIDS in Kenya. Sessional Paper No. 4 of 1997.

8.

Forsythe S (1996). Opportunities for Long-Term
Sustainability of HIV/AIDS Prevention in Bangkok’s

STD Clinics and Workplaces. Policy Working Paper
WP4.AIDSCAP/Family Health International,

Arlington,Virginia.
9.

Hayman J, Sonnichsen C, Naamara W, Ochola P

(1996). Comparative experience with worksite
prevention programs in Africa: Zimbabwe,
Tanzania and Kenya. XI International Confer­
ence on AIDS, abstract Th.D. 373.Vancouver,

Canada, July 7-12, 1996.

(tC

CPHE - SOCHAhA>
) O
Koramangala
Bangalore - 34^

51

Behavioral Research:
Using Results to Design Behavior Change
Interventions
Understanding the behaviors that put people at
risk of HIV infection is the fundamental chal­
lenge of HIV/AIDS prevention. Since the begin­
ning of the epidemic in the early 1980s, behav­
ioral research projects have investigated such
sensitive issues as sexual behavior and drug use
and have illuminated many of the cultural and
social factors that influence risk behavior.
In response to rapid shifts in the epidemiology
of the HIV/AIDS pandemic, strategies for conduct­
ing behavioral research have changed over the past
six years. Well-designed rapid studies increasingly
received priority over more long-term thematic
research, and scientists moved away from repetitive

Understanding
Risk Behavior
Behavioral research conducted under AIDSCAP
examined issues central to both global and local
prevention efforts. Research projects ranged
from small, rapid, program-related studies to
large-scale, multisite efficacy trials.
AIDSCAP’s behavioral research was designed to
expand the scientific knowledge of HIV risk behav­
ior and to have a direct impact on the development
of prevention programs. Program-related research
addressed critical issues such as barriers to condom
use among young women in the Dominican Re­
public, strategies for heterosexual couples to use in
renegotiating sexual relationships to change highrisk behavior, and whether knowledge of HIV sta­
tus leads to behavior change.
Behavioral research results were used to design
effective interventions in many countries. In Sao
Paulo, Brazil, for example, the success of a con­
trolled intervention trial targeting young adults
completing their primary and secondary education
in night schools led to an HIV/AIDS prevention
program for adolescents in 2,800 public secondary
schools. A total of 300,000 manuals based on the

52

studies of knowledge, attitudes, beliefs and prac­
tices toward research that provided practical infor­
mation to guide interventions.
As the epidemic expanded, behavioral research
also moved beyond studying the behavior of tradi­
tional “high-risk groups” to research with popula­
tions previously considered at low risk of HIV
infection, such as adolescents and women. And as
the number of people living with HIV increased
dramatically, understanding the risk behavior of
those who are HIV-positive and testing interven­
tions to support their behavior change began to
receive more attention.

curriculum developed for the trial were distributed
to students throughout Sao Paulo. And in Thai­
land, a pilot intervention study using the Royal
Thai Army’s command structure and informal
networks among conscripts was adapted by the
military to provide HIV/AIDS prevention services
for all recruits.1
AIDSCAP’s largest intervention trial, cospon­
sored by the Joint United Nations Programme on
HIV/AIDS (UNAIDS) and implemented with re­
search institutions from Kenya, Tanzania, Trinidad
and the United States, was a multisite study of the
efficacy of voluntary HIV counseling and testing
(Box 5.1).2 The results of this study will offer guid­
ance to policymakers on the cost effectiveness of
such services.
AIDSCAP also advanced the science of HIV/
AIDS prevention by addressing emerging global
issues such as the role of structural and environ­
mental interventions in reducing HIV incidence,
prevention interventions to help protect women in
stable relationships, and the linkages between HIV
prevention and care. A series of concept papers
reviewed the research on each of these issues and
defined research questions for the future.3 5 These

questions led to research studies and pilot inter­
ventions that offer recommendations and models
for the next generation of HIV/AIDS programs.
In Kenya, for example, an in-depth study of
communication between men and women in stable
relationships identified the best ways to encourage
dialogue between partners about HIV risk and
condom use. This research study showed that
through counseling, couples could learn to discuss
sex and HIV risk reduction within their relation­
ships. In the Dominican Republic, formative re­
search among sex workers and their clients, em­
ployers and steady partners was used to design a
demonstration project adapting a highly successful
structural and environmental intervention from
Thailand (Box 5.2). And in Tanzania, one of the
first studies to examine the links between care pro­
grams for HIV-positive individuals and their moti­
vation to adopt safer sexual behavior to protect
others will be used by program staff and policy­
makers to design HIV/AIDS support programs
that include prevention activities (see page 100).
Findings from these and many other behavioral
research projects were disseminated through publi­
cation of peer-reviewed articles and presentations

Raphael Tuju/ACE Communications

at national and international scientific conferences.
AIDSCAP’s contribution to the scientific literature
on HIV risk behavior and prevention includes
more than 50 journal articles and more than 75
conference presentations.
In addition to guiding program interventions
and addressing global research issues, AIDSCAP’s
behavioral research strategy emphasized capacity
building. Through collaborative partnerships,
training and technical assistance, the project en­
hanced the capacity of more than 150 social scien­
tists and 100 institutions to conduct behavioral
research for HIV/AIDS prevention. AIDSCAP also
supported the Visiting Scholars Program for devel­
oping country researchers of the Center for AIDS
Prevention Studies (CAPS) at the University of
California at San Francisco, an FHI partner in the
project’s behavioral research activities (Box 5. 3).
Each of AIDSCAP’s ten competitive research
grants was awarded to a research team of scientists
from developing and developed countries. Most of
the research the project commissioned to answer
important questions in HIV/AIDS prevention and
all program-related studies were also conducted
with host-country partners. This collaborative
approach encouraged the transfer of knowledge
and skills, enhanced the acceptability of research
results and gave local researchers a stake in ensur­
ing that their findings were used to improve pre­
vention programs.

Lessons Learned
• HIV/AIDS prevention requires a multi­
disciplinary approach to research.

Answering many of the most important research
questions requires perspectives from such dis­
parate fields as STD management and preven­
tion, social marketing, medicine, counseling,
psychology, epidemiology, communications and
family planning.
AIDSCAP’s HIV Counseling and Testing Study,
implemented in Tanzania and Kenya by AIDSCAP
and in Trinidad by UNAIDS, is a good example of
a multidisciplinary research project.2 A random­

The results of an HIV-antibody test were good news for this
couple, who participated in AIDSCAP’s counseling and testing
study in Kenya.

53

5.1
Study Examines Counseling and
Testing for HIV/AIDS Prevention
When 22-year-old Anne

one counseling can influ­

Study participants at

Kanjiri of Nairobi found

ence individuals to adopt

the three sites were as­

AIDS and other STDs,

out that she had tested

preventive behaviors and

signed randomly to one of

and care-seeking for

negative for HIV, the news

lower their risk of HIV

two interventions, coun­

STDs.The STD test re­

was more than just an

infection. In the past, a

seling and testing (C&T)

sults will supplement the

opportunity to celebrate.

limited number of

or health information.

self-reported behavioral

It was a chance to make

nonrandomized studies of

Subjects in the C&T arm

data, providing a more

some changes in her life.

C&T’s impact among

received pretest counsel­

objective measure of

specific populations had

ing and had blood taken

behavior change.

yielded mixed results.

for HIV antibody testing.

The results of the

After test results were

study will be available by

“I used to have many

sexual partners before I

was counseled and tested

for HIV,” she said. “When

4,298 volunteers who

available, each C&T par­

the end of 1997. But be­

I got my results, I decided

participated in the study

ticipant received counsel-

fore the data analysis had

to get married instead.”

at the AIDSCAP-spon-

ing.Those in the health

even begun, researchers

To researchers from

sored sites in Kenya and

information group—the

had already learned a

the Kenya Association of

Tanzania and at the site in

study’s control arm—

great deal from their

Professional Counselors

Trinidad funded by

were shown an informa­

experiences in Kenya and

(KAPC), her response is

UNAIDS. Because of the

tional video about HIV

Tanzania. Early fears that

as significant as the results

breadth of the study and

and STD prevention and

they would not be able to

of her test. Kanjiri* was a

the size of the popula­

given condoms, along with

recruit enough partici­

participant in the first

tions,AIDSCAP and

training in how to use

pants soon disappeared as

randomized study of the

UNAIDS expect the re­

them.

the enthusiastic response

impact of counseling and

sult to be significant for

testing (C&T) on behavior

change for HIV/AIDS
prevention among people

All participants were

to the study revealed a

prevention programs

invited to return to the

great demand for HIV

worldwide.

study center twice. At six

counseling and testing in

months, participants in

both Dar es Salaam and

An international effort,

voluntarily seeking such

the research was con­

both groups were tested

Nairobi. Even after re­

services in developing

ducted by the KAPC in

for STDs and offered the

cruitment had ended, four
to ten people came to

Kenya, the Muhimbili

option of counseling and

University College of

an HIV test. Researchers

each center every day to

controlled trials con­

Health Sciences in Tanza­

also administered a fol­

seek counseling and test­

ducted in Nairobi by the

nia and the Queens Park

low-up questionnaire to

ing.

KAPC and at other cen­

Counseling Center in

those in both groups at

People’s willingness to

ters in Tanzania,Trinidad

Trinidad, with The Center

six months and again at

return for the their test

and Indonesia, the co­

for AIDS Prevention Stud­

12 months.

sponsors of the study

ies at the University of

hope to discover whether

countries.
Through randomized

54

Kanjiri was just one of

and attitudes about HIV/

During the interviews,

results was another sign

of how much they valued

California at San Fran­

data were collected on

the service. An unusually

HIV testing accompanied

cisco serving as the coor­

sexual behavior, psycho­

high proportion of those

by personalized, one-on-

dinating center.

logical status, knowledge

assigned to the C&T

ized, controlled trial of the impact of voluntary
HIV counseling and testing on risk behavior, the
study examined psychological, behavioral, epide­
miologic, operations and cost-effectiveness issues
(Box 5.1).

Collaboration and Capacity Building

arm—more than 85 per­

policymakers clear guid­

cent—returned for their

ance on whether C&T is

results one week after the

effective—and ultimately

test without any prompting.

worth the expense. ■

Researchers at both sites

did have trouble recruiting

enough people to partici­

^Confidentiality was strictly

pate in the study as couples.

observed in this study. Anne

Most people preferred to

Kanjiri later agreed to be

enroll alone, often bringing a

interviewed by a journalist

partner to the center

and quoted by name.

months later for counseling

and testing. Counselors
reported that although
couple counseling was ex­

• Matching local research institutions with
NGOs that implement interventions is a particu­
larly effective way to organize research.
Such partnerships can offer NGOs a sustainable
source of technical assistance and help
strengthen local research capacity. For example,
a Tanzanian NGO collaborated with a researcher
from Muhimbili University on an AIDSCAPsponsored study of how care and support ser­
vices for people living with HIV/AIDS affect risk
behavior (see page 100). This collaboration en­
abled the Tanga AIDS Working Group to con­
tinue focusing on providing HIV/AIDS services,
including counseling and home-based care,
while the researcher provided technical assis­
tance in research methodology and data analysis.

tremely challenging at the
beginning of the study, they

found it more effective

• Collaboration with international institutions
generates support and a high profile for projects.

because it gave them oppor­
tunities to assist couples in
negotiating behavior change.

Economic data gathered
during the study will help
determine whether volun­

tary HIV counseling and
testing is a cost-effective
prevention intervention in

developing countries, and
whether such services can
be sustained. Researchers

already know that more
than half the study partici­
pants would be willing to

Bringing together highly skilled and experienced
people from international institutions to col­
laborate on research is time consuming, but it
facilitates acceptance of the findings because key
institutions have been involved in the research
process. AIDSCAP’s counseling and testing study
linked host-country and international scientists
through an executive committee that included
the local principal investigators, AIDSCAP and
CAPS scientists, and collaborators from the
World Health Organization’s Global Programme
on AIDS and UNAIDS. The committee made
decisions about the study through regular meet­
ings and conference calls.

pay up to the equivalent of

U.S.$2 for C&T services.

Appropriate Scale

Concerns about the cost of
such services will undoubt­
edly continue, but further

analysis of the data will give

• Large, multisite intervention trials such as
AIDSCAP’s HIV counseling and testing study
have an important but specific role to play in
HIV/AIDS prevention.

Such projects can create opportunities to share
resources, make cross-site comparisons, and
sometimes even pool data to enhance statistical

55

5.2
100 Percent Condom Use:
Adapting Thailand’s Policy in
the Dominican Republic
recommendations for

use in commercial sex

adapting the Thai policy to

would not only protect

of STD and HIV infection

condom use in all the

the Dominican context.

their health, but also

from steady, non-paying

country’s brothels. En­

Rapid ethnographic

make it easier to negoti­

partners.

forcement of this policy

research conducted in the

ate condom use with

These findings were

through legal sanctions

summer of 1996 included

clients.The women re­

used to design a pilot 100

against brothel owners,

participant observation in

ported that they spent a

percent condom inter­

combined with a mass

five brothels and other

great deal of time and

vention that included

media campaign, has led

commercial sex establish­

effort trying to convince

training for brothel staff

to dramatic increases in

ment and repeated in-

clients to wear condoms.

to promote group solidar­

condom use and de­

depth interviews with

Owners and managers

ity as well as promotion

creases in STD rates.

brothel owners, clients,

believed that having an

of a government policy on

and sex workers and their

STD-free establishment

mandatory condom use.

condom policy” has been

steady partners. In just six

would increase prestige,

Such a policy would be

hailed as an example of

weeks, researchers con­

clients and profits. Steady

enforced by sanctions

the kind of structural and

ducted more than 200

partners of sex workers

(fines and brothel clos­

environmental interven­

interviews.

and—for the most part—

ings) against Dominican

clients were also support­

commercial sex establish­

The Thai “ 100 percent

tions needed to reduce

The most surprising

barriers to individual HIV

finding was the positive

ive, citing fears about

ments that did not en­

risk reduction. But would

response from sex work­

their own health and the

force consistent condom

the policy work in other

ers, brothel owners and

health of their partners

use and certificates for

countries?

clients to proposals to

and children.

those that did. Compli­

The study results sug­

ance would be monitored

Results of a study

promote and monitor

conducted by AIDSCAP

condom use in commer­

gested that a program

and the NGO COIN

cial sex establishments.

promoting condom use

STD screening of sex

(Centro de Orientacion e

Instead of considering

through both policy

workers.

primarily through regular

AIDSCAP began test­

Investigacion Integral)

medical check-ups of sex

change and solidarity

suggest that in the Do­

workers and legal sanc­

among sex workers and

ing some components of

minican Republic, the

tions oppressive, most

brothel owners was likely

the pilot project in May

answer to that question

respondents saw such

to be most effective in

1997 in ten sex establish­

the Dominican Republic.

ments. Brothel owners

The results also revealed

and managers, sex work­

the importance of ad-

ers and other brothel

may be yes. Formative
research identified strong
support and practical

56

dressing sex workers’ risk

Since 1989,Thailand’s
government has required

policies as supportive.

Sex workers said poli­
cies requiring condom

power. But they should only be used to test tech­
nologies and approaches that have global signifi­
cance and have not already been the subject of a
rigorous efficacy trial.

employees all received

continues in order to en­

training in the principles,

courage the policy changes

rights and responsibilities of

needed for effective struc­

a “collective agreement” to

tural interventions to sup­

promote and support con­

port 100 percent condom

dom use in commercial sex.

use among sex workers

COIN held the first of a

and their clients in the

series of special workshops

Dominican Republic. ■

on communication and

sexual negotiation for sex
workers and their steady
partners. It also organized

• Rapid, relatively inexpensive studies are useful
for projects that are: (1) linked to interventions
under development, (2) of local or regional
interest, (3) associated with interventions that are
highly culturally specific or that vary significantly
by population type, or (4) adaptations of success­
ful interventions from other regions or target
populations.

For example, results from a nine-month qualita­
tive study of the contributing factors and moti­
vations for risk behavior among Nicaraguan sex
workers, their clients, and men who have sex
with men provided information critical to the
development of a national HIV/AIDS communi­
cation strategy. And in the Dominican Republic,
rapid research techniques were used to assess the
feasibility of adapting Thailand’s “100 percent
condom policy” (Box 5.2).

and supervised the effort to

institutionalize structural

Ethical Issues

strategies such as STD

screening, cards certifying
that sex workers are STD-

• Interventions tested in efficacy trials can be
both feasible and of high quality.

free, improved condom
access, and spot checks for

used condoms in brothel

rooms.
Full implementation of

the pilot project and even­
tual expansion nationwide,

however, will require a for­
mal government policy
mandating condom use

during all commercial sex

acts and imposing legal
sanctions for noncompli­

ance.The dialogue that

AIDSCAP and COIN initi­
ated with the government

The tradeoffs involved in testing interventions in
resource-poor countries are a source of continu­
ing debate. Some argue that it is unethical to test
“gold-standard” technologies or approaches in
countries that cannot afford to implement them.
Others contend that the only way to encourage
adaptation of innovations and to attract finan­
cial support for their implementation in devel­
oping countries is to first establish their efficacy.
AIDSCAP’s experience shows that ensuring the
feasibility of interventions to be tested does not
necessarily mean that quality must be compro­
mised. For example, research among military re­
cruits in Thailand assessed the impact of an inter­
vention designed to be used at other military
bases. Instead of testing an intensive, one-on-one
intervention that would have been too costly to
replicate, the study used the military’s leadership
structure and the natural social networks among
the soldiers to reach recruits with education, coun­
seling, HIV testing and peer support. When study
results showed that the intervention had led to
changes in behavior, the Thai military adopted it
on a wider scale.

57

5.3
Building Local Capacity
in HIV/AIDS Research
Dr. Maria Eugenia Lemos

research skills of scien­

dor, Sao Paulo and Rio de

Fernandes arrived at the

tists from developing

Janeiro.

University of California at

countries, Dr. Fernandes

San Francisco in the sum­

was able to take the study

scientists participate in

strong international net­

mer of 1989 with an idea.

protocol she developed in

the CAPS program. Dur­

work of HIV/AIDS re­

projects in more than 23

countries and forged a

A physician and director

San Francisco, conduct

ing their time in San Fran­

searchers. Alumni from

of the HIV/AIDS preven­

the research in her own

cisco, they attend semi­

the program have pub­

tion program in the De­

country and publish the

nars on epidemiology,

lished a number of ar­

partment of Health in the

results.1 This research

research design, data

ticles in peer-reviewed

state of Sao Paulo, she

provided the baseline data

management, biostatistics,

journals, including nine

wanted to find out more

for interventions imple­

and the behavioral and

articles featured in a spe­

about the epidemiology of

mented as part of the

psychosocial aspect of the

cial issue of the journal

HIV-1 and HIV-2 among

AIDSCAP program in

HIV/AIDS epidemic. But

AIDS in 1995, and many—

one of the groups most as

Brazil and the rationale

the program’s main em­

like Dr. Fernandes—have

risk of infection—women

for important financial

phasis is helping the scien­

assumed leadership posi­

involved in commercial

support from the World

tists design HIV/AIDS

tions in national and inter­

sex—and the factors that

Bank for HIV/AIDS pre­

prevention research

national HIV/AIDS

influenced that risk.

vention in the state of Sao

projects to carry out in

prevention efforts.

Paulo.

their own countries.

During the next ten
weeks, she spent much of

Eight years later. Dr.

CAPS provides pilot

AIDSCAP supported

scientists’ participation in

her time working with

Fernandes is still working

project funding and offers

the Visiting Scholars Pro­

colleagues at the Center

to help women and men

continuing technical assis­

gram for six years. Recent

for AIDS Prevention Stud­

in Sao Paulo and other

tance to enable the scien­

behavioral research

ies to design a study that

parts of Brazil protect

tists to implement these

projects conducted by

would provide the back­

themselves from HIV/

research protocols. A

AIDSCAP-funded schol­

ground information

Al DS. As head of the

number of participants

ars include:

needed to develop pre­

NGO Associa^ao Saude

have returned to San

•

vention interventions to

da Familia and the former

Francisco to participate in

of a peer-led educa­

reach sex workers in

resident advisor of the

a writing sabbatical pro­

tional intervention that

three cities with high HIV

AIDSCAP program in

gram that gives them time

reached Balinese youth

prevalence: Sao Paulo,

Brazil, she manages an

to work with CAPS fac­

through a network of

traditional youth orga­

Santos and Campinas.

a study on the impact

HIV/AIDS program that

ulty analyzing their data

builds the capacity of local

and preparing manu­

the CAPS Visiting Scholars

organizations to develop

scripts.

Program, an intensive

effective and sustainable

This collaboration

behavior among male

program designed to build

prevention projects in the

between CAPS and visit­

clients at a Bombay

the HIV/AIDS prevention

states of Fortaleza, Salva-

ing scientists has resulted

STD clinic and forma-

Like other graduates of

58

Each year up to ten

in quality research

nizations in Bali.
•

an assessment of risk

• Ethical review of behavioral research protocols
by local review boards ensures that the research is
culturally sensitive and responsive to the needs of
the communities where it is carried out.
A local committee typically offers the best per­
spective on local sexual and social more and
practices and often has greater credibility with
local scientists than committees overseas.

Research Tools
tive research to design

programs in my country,”

an HIV prevention inter­

she said. ■

vention for clients.
•

a pilot study on the use
of social networks to

I.

Lurie P, Lemos

empower young, unmar­

Fernandes ME,

ried women in Senegal

Hughes K, et al.

to negotiate for safer

(1995). Socioeco­

sex.

nomic status and

As these examples illus­

the risk of HIV-1,

trate, one of the strengths

syphilis and hepati­

of the CAPS program is its

tis B infection

focus on practical research

among sex workers

in developing countries. For

in Sao Paulo, Brazil.

a relatively modest invest­

AIDS 9(suppl I):

ment of $ 10,000 or less for

S3I-S37.

each study, the program
produces quality collabora­

tive research and develops a
strong local research capac­
ity. The visiting scientists
serve as principal investiga­
tors for the studies they

• Theoretical behavior change models provide
useful frameworks for examining HIV risk-taking
behavior in a variety of cultures and societies.
Behavior change interventions appear to be in­
fluencing risk behavior, but without a theoretical
framework, the reasons why some individuals
have adopted prevention measures and others
have not remain elusive. AIDSCAP’s use of be­
havioral theories developed in the United States
to study sexual behavior in a number of devel­
oping countries confirms that theory can be a
flexible and valuable tool for HIV prevention
worldwide.
In northern Thailand, for example, an applica­
tion of the Health Belief Model and the Theory of
Reasoned Action revealed that both models were
useful for analyzing consistent condom use in
commercial sex. The Theory of Reasoned Action,
however, was more useful because of its more ac­
curate incorporation of peer group effects on risky
sexual behavior.6

design, ensuring their com­

mitment to the research
and involvement in all as­

pects of the research pro­

• Research that helps target audiences identify
solutions to their own problems can lead to
extremely effective program development.

cess.

For Dr. Fernandes, the
experience has had an en­

during impact. “My partici­
pation gave me a new vision

of public health that cer­
tainly influenced my profes­

sional life and consequently
the quality of my work in
designing and implementing

Such research is particularly useful for designing
programs and policies to remove or overcome
structural and environmental barriers to behav­
ior change. One example is a pilot effort to adapt
Thailand’s “100 percent condom policy” in the
Dominican Republic, which was designed based
on formative research results from intensive
discussions and in-depth interviews with sex
workers and their employers and clients (Box
5.2). In Haiti, the local NGO Groupe de Lutte
Anti-Sida (GLAS) used participatory action
research with factory workers to continually
adapt and improve its workplace prevention
programs.7

59

Recommendations
• Research for HIV/AIDS prevention should not
focus exclusively on behavioral issues.
Understanding sexual behavior and identifying
ways to influence that behavior requires a
multidisciplinary perspective with contributions
from diverse fields such as STD management
and prevention, social marketing, medicine,
counseling, psychology, epidemiology, commu­
nications and family planning.

• International organizations and donor-funded
programs should foster mutually beneficial
partnerships between local research institutions
and the NGOs that implement HIV/AIDS inter­
ventions.

Such collaboration builds important connections
between research and interventions and offers a
sustainable source of technical assistance to the
NGOs.
• Large-scale, multisite efficacy trials should be
reserved for tests of interventions that have not
been rigorously evaluated and that have (1) global
significance, (2) important policy implications
and (3) complex intervention components.

• HIV/AIDS programs should support research
that allows target audiences to propose solutions
to their own problems.

Such research is particularly useful for identify­
ing ways to remove or overcome structural and
environmental barriers to behavior change.

Future Challenges
Assessing Biological Data
There is growing interest in the use of biological
data, such as sexually transmitted infection and
HIV serostatus data, as proxy measures of risk
behavior. Data on self-reported behavior may be
biased as a result of poor recall and the social
stigma associated with risk behaviors. But collec­
tion of biological data brings its own unique set
of problems, including the social and psycho­
logical impact of receiving positive HIV and STD
results, the need to provide STD treatment,
misclassification bias due to the limits of STD
diagnostic capacities, and the high cost of bio­
logical testing and associated counseling and
treatment. Research is needed on the combined
use of biologic and behavioral data to assess
HIV/AIDS interventions.

Examining Care and Support
• HIV/AIDS programs should put more empha­
sis on rapid research that provides the informa­
tion needed to improve interventions or to adapt
successful interventions for application in differ­
ent geographical areas or with new populations.
• Proposals for behavioral research should be
reviewed and approved by an ethical review
committee whose members are thoroughly
familiar with the customs and traditions of the
community in which the research is being con­
ducted.

People living with HIV/AIDS experience severe
social and psychological stress, particularly soon
after learning that they are infected. The results
of some studies suggest that people who are in­
fected with the virus are more likely to infect
others when there are few social and psychologi­
cal services available to assist them in coping
with their HIV status. But as the numbers of
people with HIV and AIDS increase, more re­
search is needed to identify support services that
encourage preventive behavior.

Understanding Social Change
A local review board is usually best placed to
provide this perspective.
• HIV/AIDS researchers should expand the use
of formal behavioral theories of HIV risk behav­
ior.

Even though these theories were developed in
the United States, they have also proved useful
for understanding risk behavior in developing
countries.

60

Most HIV/AIDS research examines sexual be­
havior and behavior change among individuals.
While this research and the interventions it gen­
erates have demonstrated some success in chang­
ing individual behavior, there is an urgent need
to focus on interventions that influence social
norms and other factors beyond the individual.
Developing tools to measure such change at dif­
ferent levels of social organization and testing
those tools should be a research priority for
HIV/AIDS programs.

References
i.

Celentano D, Nelson K, Suprasert S, et al.
(1996). Risk factors for HIV-1 seroconversion

among young men in Thailand. Journal of the
American Medical Association 275(2): 122-127.

2.

De Zoysa I, Phillips KA, Kamenga MC,et al.
(1995). Role of HIV counseling and testing in

changing risk behavior in developing countries.
AIDS 9(suppl A): S95-SI0I.
3.

Sweat MD, Denison JA (1995). Reducing HIV
incidence in developing countries with struc­

tural and environmental interventions. AIDS
9(supplA):S25l-S257.

4.

DeZoysa I, Sweat M, Denison J (1996). Faithful

but fearful: reducing HIV transmission in stable
relationships. AIDS 10(suppl A):S 197-S203.

5.

MacNeil J,White RA (1995). HIV care: moving

from rationale to research.AIDSCAP/Family
Health International,Arlington,VA.
6.

VanLandingham M, Supraset S, Grandjean N and
Sittritai W (1995).Two views of risky sexual
practices among northern Thai males:The

Health Belief Model and the Theory of Rea­
soned Action. Journal of Health and Social

Behavior 36(March): 195-212.
7.

Dadian MJ (1996).Turning obstacles into

opportunities: Haitian workplace project breaks

new ground in HIV/AIDS prevention.
AIDScaptions 3(3):4-7.

61

Evaluating HIV/
Prevention
Programs: Develo ng New Tools for
Meaningf
e urement
One of the greatest challenges in HIV/AIDS pre­
vention is determining what impact prevention
efforts have had on the epidemic. Evaluators
must track changes in people’s most private be­
havior, assess program impact in environments
where sexual behavior is influenced by a variety
of factors, and develop evaluation measures that
are reliable, valid and meaningful.
Early in the epidemic, it was assumed that bio­
logical indicators could be used to evaluate HIV/
AIDS prevention programs. Many evaluation plans
called for collecting data on the incidence of HIV
and other sexually transmitted infections, as well as
information on self-reported behavior, at the be­
ginning and end of a program cycle. During the
early 1990s, the World Health Organization’s Gio-

bal Programme on AIDS (WHO/GPA) developed a
set of behavioral and biological prevention indica­
tors for national AIDS control programs and stan­
dardized protocols to facilitate cross-country com­
parisons.1
Experience with HIV/AIDS prevention has dem­
onstrated that many of the early expectations about
evaluation were unrealistic. Lack of resources has
resulted in inconsistent collection of biological
data, and pre- and post-project measures of behav­
ior change have provided an incomplete and im­
perfect understanding of the impact of prevention
efforts. As the epidemic and our understanding of
the complex process of behavior change have
evolved, evaluators have begun to develop more
feasible and sensitive evaluation methods.

Refining
Evaluation Methods

many of their “subprojects” were adjusted during
the project as programs were revised and evalua­
tion methods evolved.
Another unique feature of AIDSCAP evaluation
strategy was its emphasis on diverse and comple­
mentary data collection methods. To an extent
unusual for a large, donor-funded health program,
AIDSCAP was able to complement quantitative
process and behavioral data with more qualitative
information from in-depth interviews, focus
groups and rapid ethnographic studies. “Triangula­
tion” of the results of quantitative and qualitative
research yielded a wealth of information about the
process of behavior change, the environmental
factors that influence behavior, and how HIV/
AIDS interventions affect knowledge, attitudes and
behavior.
Tools and methodologies developed and dis­
seminated by the project will ensure that other
HIV/AIDS programs can continue to benefit from
AIDSCAP’s evaluation experience. These include a
series of guidelines on different aspects of evalua-

Evaluation was a key strategy for AIDSCAP from
the beginning of the project in 1991. With its
early emphasis on evaluation and the breadth of
its experience, the project had an unprecedented
opportunity to improve existing methods and
test innovative approaches to evaluation.
It seems a truism that evaluation should be con­
sidered at the beginning of a project or program.
In practice, however, this is not common. One of
AIDSCAP’s strengths was its incorporation of
evaluation into the design of each country pro­
gram. Each strategic and implementation plan for
a country program, developed in collaboration
with government and NGO partners and other
stakeholders in the country, included a detailed
evaluation plan that outlined the indicators to be
used and how the data would be collected and
disseminated. These customized evaluation plans
designed for each of the 19 country programs and

62

tion, such as incorporating evaluation into pro­
gram design and conducting effective focus group
discussions. Originally developed as references for
AIDSCAP staff and partners in the field, these
“Evaluation Tools Modules” have been used in
HIV/AIDS programs, training workshops and
university courses in many parts of the world.2
One of AIDSCAP’s most important modules
offers guidelines for conducting behavioral surveil­
lance surveys (BSS), a methodology pioneered by
AIDSCAP in Bangkok. Consisting of a series of
repeated behavioral surveys in key target groups,
the BSS enables national programs to track trends
in HIV risk behaviors and to assess the combined
impact of various HIV/AIDS interventions in a
country. Inspired by the success of the surveys in
Thailand, national and state HIV/AIDS control
programs in Cambodia, India, Indonesia, Nepal
and Senegal worked with AIDSCAP to establish
BSS systems. A meeting of 28 experts from ten BSS
projects in eight countries, which AIDSCAP con­
vened in August 1997, produced recommendations
for conducting these surveys worldwide (Box 6.1).3
In another emerging area of program evalua­
tion—capacity building assessment—AIDSCAP
developed and tested a methodology that includes
instruments for organizational needs assessment
and determining the outcomes of capacity building

efforts. Capacity building evaluations in nine
countries used a collaborative approach that em­
phasized self-assessment and use of the results as a
tool for strategic planning.
AIDSCAP also collaborated with international
organizations to advance the practice of evaluation
in HIV/AIDS programs and provide guidance for
prevention programs. For example, project staff
worked with colleagues at WHO/GPA, USAID and
the Centers for Disease Control and Prevention to
develop the GPA prevention indicators. More re­
cently, they helped the USAID Office of Population
design a larger set of indicators for assessing the
impact of interventions to improve reproductive
health.4

Lessons Learned
• Involving project implementers in evaluation
throughout a project encourages the use of
evaluation data to improve programs and
projects.

Deciding what information and how much data
to gather in an evaluation involves difficult
methodological decisions and trade-offs between
the quality and utility of information. It is im-

Carol Hooks/PATH

71
■
PS?

Students from the University of Calabar participate in a pretest of a questionnaire for a knowledge, attitudes, beliefs and

practices survey. AIDSCAP used the results of KABP surveys and other more qualitative evaluation research to assess

behavior change among target populations.

63

portant to involve project staff in the evaluation
process from the beginning to ensure that the
research will produce data that are not only valid
and reliable, but also useful for program plan­
ning.
AIDSCAP collaborated with indigenous NGOs
and government ministries in the evaluation pro­
cess, emphasizing the use of data to improve pro­
grams. In both Jamaica and Brazil, for example,
biannual or annual evaluation meetings brought
together representatives from the organizations
implementing the AIDSCAP program in the coun­
try, the Ministry of Health or national AIDS con­
trol program, USAID, and the AIDSCAP office to
review evaluation results. These meetings provided
forums for discussing evaluation data and identify­
ing ways to refine project or country program
strategies based on the data. Frequent one-on-one
meetings leading up to each review ensured that all
participants were familiar with the evaluation re­
sults, and consultations between AIDSCAP’s resi­
dent advisor and project staff after the meeting
strengthened the recommendations and action
plans adopted.

Prioritizing Research Designs
• Because resources for evaluation activities are
limited, rigorous research designs are not feasible,
or even appropriate, for every project.

AIDSCAP’s recommended practices have evolved
to reflect what is appropriate and possible at the
national program level and the individual
project—or service-delivery—level. This multi­
level approach to prioritizing the degree of rigor
needed for evaluation alleviates some of the ten­
sion that arises as a result of the sometimes con­
flicting evaluation needs of individual projects
and national programs.

• At the service-delivery level, it is more efficient
to limit evaluation activities to conducting
formative research, monitoring process indicators
and assessing capacity building efforts.

From the perspective of a national or regional
program, it is not practical for every individual
project to assess behavior change. AIDSCAP’s
experience with hundreds of projects showed
that such assessments are time-consuming and
require technical expertise that many service­
delivery organizations do not have. Even when
these organizations can collect and analyze data
on behavior change, without an expensive study
that uses control groups it is not possible to at­
tribute changes that have occurred to the inter­
ventions of one project.
Only in the case of a demonstration project to
test a new intervention or answer a research ques­
tions would there be justification for a more rigor­
ous research design. Otherwise, when projects
deliver services based on proven prevention strate­
gies, the focus should be on ensuring that the ser­
vices are delivered as intended. This can be done by
tracking process indicators such as number of
people trained, number of people educated about
HIV/AIDS and number of condoms distributed.
Projects that work to strengthen HIV/AIDS pre­
vention skills should also assess whether they have
succeeded in building capacity.
• In environments where many donors are
supporting multiple interventions with overlap­
ping target groups, certain types of evaluation are
only appropriate at the national or regional level.
In such environments, it is impossible to at­
tribute any changes detected by an evaluation to
the efforts of a single project or organization.

AIDSCAP Evaluation Research

KABP

Surveys

Focus Group
Discussions

167

144

64

Studies Using
In-Depth
Interviews
61

Capacity
Building
Assessments
9

STD Service
Assessments
(Pls 6 & 7)

Condom
Audits

16

23

Therefore, it is more appropriate to combine the
resources of national programs and donors to
monitor national or regional trends in behavior
among different target groups, condom availabil­
ity and sales, STD case management, policy de­
velopment efforts and epidemiologic impact.
In Senegal, for example, where AIDSCAP
worked with 25 organizations, various target audi­
ences were reached by many different interven­
tions. So instead of trying to assess the contribu­
tion of each of its projects to behavior change in
Senegal, AIDSCAP helped the Senegalese Ministry
of Health develop a behavioral surveillance survey
to track the combined effect of all HIV/AIDS pre­
vention efforts on sexual behavior among target
audiences.

Moving Beyond “Pls”
• Surveillance of trends in HIV risk behavior
among specific population groups is an effective
tool for monitoring and evaluating HIV/AIDS
prevention efforts.

Most HIV/AIDS prevention programs measure
progress toward meeting predetermined targets
at the end of a project. For example, evaluators
might look at whether a project has achieved a
30 percent increase in consistent condom use
among youth in the project area. But setting such
targets for expected behavioral outcomes re­
quires precise estimates of baseline levels and an
understanding of how much change is meaning­
ful in each setting. And even when such targets
are reached, the observed behavior change can­
not be attributed to the activities of a single
project.
The behavioral surveillance surveys methodol­
ogy that AIDSCAP developed in Bangkok5 and
later adapted in five countries offers a practical
alternative for evaluating HIV/AIDS prevention
efforts. It allows evaluators to monitor trends in
HIV/AIDS knowledge, attitudes and preventive
behavior over time rather than taking one end-ofproject reading and measuring it against a some­
what arbitrary target. And, recognizing that attri­
bution is rarely feasible, it looks instead at the

A Multilevel Approach to Evaluation Design
Level

Type

Example

National

Behavioral trend analysis

Behavioral surveillance surveys (BSS)

Outcomes of technical strategies

STD care provider behavior (PIS 6 & 7)

Policy

AVERT model, socioeconomic impact studies

Structural/socioeconomic barriers

Monitor changes in social norms

Formative research

Special studies conducted when needed for
program planning

Process monitoring

Tracking process indicators to monitor
implementation of activities

Intervention-linked outcomes research

Special studies designed to respond to
specific research questions

Capacity building assessments

Rapid organizational assessments,
capacity building inventories

Service-delivery

65

6.1
Behavioral Surveillance Surveys:
A Promising Tool for HIV/AIDS
Evaluation and Monitoring
In August 1997,28 epide­

surveillance surveys (BSS)

are interested in whether

miologists and behavioral

in Thailand as part of a

the combined interven­

commercial encounters

scientists from eight

project administered by

tions are working to­

with “indirect” sex work­

countries met in Bangkok,

the Bangkok Metropolitan

gether to change risk

ers who do not work in

Thailand, to discuss what

Administration from 1991

behaviors,” Mills ex­

brothels.Their use of

they had learned about

to 1996. Since then, the

plained. “The BSS helps us

condoms with clients,

conducting behavioral

Thai Ministry of Health

answer that question. It

which had lagged behind

surveillance surveys for

has begun behavioral

can also give us an early

that of brothel-based sex

HIV/AIDS prevention.

surveillance modeled

warning of increases in

workers, rose from 56 to

Their goal was to reach a

after the BSS in most of

risk behavior so that we

89 percent during the

consensus on recommen­

the country’s provinces.

can respond with timely

study period.

dations for using this

AIDSCAP also helped

interventions.”

exciting new tool to

establish behavioral sur­

In Bangkok, an analysis

monitor and guide pre­

veillance surveys in Cam­

of five rounds of BSS data

identified some areas for

vention efforts.

bodia, India, Indonesia and

collected at approxi­

concern. Condom use by

Senegal and began work

mately six-month inter­

the nonpaying partners of

on a BSS in Nepal.

vals from individuals in

sex workers showed no

Behavioral surveillance

involves administering

Why all this interest in

Bangkok’s BSS results

from 1993 to 1996 also

eight different socioeco­

apparent increase, and sex

to individuals from differ­

behavioral surveillance?

nomic and occupational

workers were the only

ent target populations in

Stephen Mills, evaluation

groups helped confirm

women in the study who

specific geographic areas

officer and epidemiologist

that declines in HIV inci­

reported having changed

at regular intervals.These

in AIDSCAP’s Asia Re­

dence and prevalence

their behavior to avoid

structured questionnaires

cross-sectional surveys

gional Office in Bangkok,

were due to behavior

HIV infection.These find­

are designed to collect

believes that the BSS fills

change. Reported patron­

ings suggest that targeted

detailed information

two critical gaps in HIV/

age of commercial sex by

prevention efforts are

about the sexual behav­

AIDS evaluation by pro­

three groups of men from

needed to reduce high-

iors that increase or re­

viding information about

different socioeconomic

risk behavior in noncom­

duce people’s risk of HIV

the short-term impact of

backgrounds fell dramati­

mercial sexual relation­

infection and to allow

prevention interventions

cally, with the overall

ships.

managers and evaluators

and the trends in risk

mean proportion of men

In the state ofTamil

to track trends in those

behaviors among vulner­

visiting sex workers de­

Nadu, India, data from the

behaviors over time.

able groups.

creasing by 48 percent

first round of the BSS in

AIDSCAP designed

66

significantly, particularly in

“Even though we can’t

over three years. Consis­

1996 provided a baseline

one of the developing

separate the impact of

tent condom use in com­

for future analysis of

world’s first behavioral

different interventions, we

mercial sex increased

behavioral trends and

•

Groups sampled for

•

Complementary quali­

helped set the agenda for

guide current prevention

prevention research and

efforts are high levels of

behavioral surveillance

tative research is es­

interventions.The results

HIV/AIDS knowledge but

should not necessarily

sential to help establish

point to the need to

a general lack of informa­

be those chosen for

reliability and validity

dispel widespread mis­

tion about the signs and

HIV serologic surveil­

as well as to provide

conceptions about casual

symptoms of STDs. Since

lance. For example,

the contextual infor­

transmission of HIV, im­

five of the six sample

antenatal clinic

mation necessary for

prove risk perception

groups reported low

attendees, a frequent

understanding risk

among groups reporting

levels of HIV risk behavior,

HIV surveillance group,

high levels of HIV risk

future rounds of the BSS

are not a viable group

behavior, and increase

will survey individuals

for behavioral surveil­

can be used to set

condom use.These

from groups considered

lance because preg­

behavioral targets for

baseline data, gathered

to be at higher risk of

nancy affects their

prevention interven­

from more than 6,000

infection, such as truck

sexual behavior. Other

tions. However, such

respondents, represent

drivers and market

community sites are

target-setting should

the most comprehensive

women.

recommended for

be guided by realistic

tracking the sexual

expectations of behav­

ior change based on

behaviors.
•

Behavioral surveillance

source of information

Such revisions are an

about HIV/AIDS knowl­

important part of the BSS

behavior of married

edge, attitudes and risk

development process. In

women.

historical evidence and

behaviors in Tamil Nadu

each country, program

Validity and reliability

on the limitations of

to date.

managers, evaluators and

studies on behavioral

behavioral surveillance

•

The breadth of the

key stakeholders must

surveillance and other

designs.These designs

data from the first round

work together to ensure

sexual behavior re­

typically cannot (and

of behavioral surveillance

that the BSS provides the

search indicate that

should not, because of

surveys in four regions of

most relevant information

reliable measurements

cost) detect behavioral

Senegal—the first use of

for monitoring and evalu­

of such behavior are

changes below 10

the BSS in Africa—was

ating prevention pro­

feasible if strict survey

percent. ■

also unprecedented in

grams.

quality control stan­

that country, prompting

Their experiences to

dards are maintained.

the head of the national

date informed the recom­

The validity of specific

AIDS control program to

mendations developed at

point estimates is

promote expanding the

AIDSCAP’s consensus

more difficult to assess,

BSS into all regions of the

meeting in Bangkok. Key

and magnitudes should

country. Among the find­

recommendations include

be verified by other

ings that will be used to

the following:

quantitative surveys.

67

combined effects of interventions on a na­
tional or regional level.
AIDSCAP found that the BSS, a series of
cross-sectional surveys among different age,
socioeconomic and occupational groups, is a
particularly useful way of determining whether
sexual behavior change is occurring in specific
segments of the population. It provides more
targeted information than systems that collect
data only on the general population, and it
ensures standardization, providing a degree of
comparability that is rare when a number of
different organizations are collecting evalua­
tion data in a country or region. BSS also takes
outcome evaluation to a more appropriate
national or regional level, eliminating the need
to collect data separately in a multitude of
projects that reach the same target groups (Box
6.1).

• “End-stage” indicators measuring adoption
of a preventive behavior, such as having fewer
sex partners or consistently using condoms,
do not adequately reflect the intermediate
stages of sexual behavior change taking place
among various target groups.

Early AIDSCAP evaluation plans called for the
use of core indicators similar to those being de­
veloped by WHO/GPA to measure program im­
pact on behavior in the general population.
AIDSCAP used the basic constructs of these
prevention indicators (Pls) but adapted them for
specific target groups, such as youth, women, sex
workers and men who have sex with men. The
constructs focus on knowledge of prevention
measures (an early stage of behavior change) and
end-stage behavior changes such as partner fidel­
ity and consistent condom use.
As it became evident that these indicators failed
to address changes occurring in some groups,
AIDSCAP added behavioral indicators that reflect
intermediate stages of change along the continuum
between knowledge and adoption of preventive
measures. Quantitative and qualitative evaluation
research in Haiti found evidence of important
intermediate stages of behavior change, with less
impact on end-stage behavior. For example, consis­
tent condom use with a nonregular partner (as
measured by WHO PI 5) did not increase substan­
tially among workers who participated in a work­
place education project. But the evaluation of the
project did find significant increases in knowledge

Percentage of Men Reporting Sex with a Sex Worker
During the Past Year in Bangkok,Thailand, 1993-1996
100

STD Clients
80 —

Factory Workers

Vocational Students
£

60

o

o

Q_

40

20

••••••

0
1993

1993-94

1994-95
Survey Year

68

1995

1996

of HIV transmission and prevention methods and
in the percentage of workers who felt confident
discussing HIV/AIDS with their partners and ne­
gotiating condom use.
• Using a variety of methodologies and “triangu­
lating” their results can help evaluators overcome
many of the limitations they face in assessing the
impact of HIV/AIDS interventions.

Valid assessment of the effectiveness of behavior
change interventions presents numerous meth­
odological and practical problems, including the
bias inherent in self-reported data, the inability
to attribute changes in behavior to specific inter­
ventions without a rigorous controlled study,
and the insensitivity of HIV prevalence as an
indicator of short-term behavior change.
A combination of quantitative and qualitative
data is particularly helpful for assessing the com­
plex and uneven process of sexual behavior change.
Quantitative data on self-reported behavior may
not provide convincing evidence of change in the
short term (one to two years). Qualitative data
gathered through interviews and group discussions
can help evaluators detect movement in the direc­
tion of change that may not yet be discernible us­
ing the statistical techniques of knowledge, atti­
tudes, beliefs and practices (KABP) surveys or
seroprevalence studies. Qualitative data also enable
evaluators to interpret the context in which behav­
ior change occurs and helps program managers
identify how to revise programs to reach and influ­
ence those who are not reducing their risk of HIV
AIDSCAP used a variety of qualitative and
quantitative methods to gain a more complete
picture of the complex process of sexual behavior
change. Qualitative data collected through focus
group discussions, individual (key informant)
interviews and rapid ethnographic studies were
triangulated with quantitative data from KABP
surveys or behavioral surveillance surveys. The
addition of epidemiological data on HIV and other
STDs, in the few cases where the appropriate data
were available, enabled evaluators to compare
trends in sexual behavior among target groups
with trends in the epidemic among those groups
(Box 6.2).

A lack of consensus among HIV prevention or­
ganizations and donors on the appropriate indi­
cators for evaluating capacity building has ham­
pered the effective measurement of organiza­
tional change in the past. In addition, many or­
ganizations overlook the importance of baseline
research in capacity building, and subsequently
find it difficult to measure the extent, quality and
types of the capacity that have been enhanced.
AIDSCAP developed multiple, complementary
methods to monitor and evaluate capacity. These
methods include organizational needs assessments,
detailed inventories of the project’s capacity build­
ing efforts, and a rapid organizational assessment
that collected quantitative information on techni­
cal skill building, organizational management skill
building, systems development, networking and
sustainability. Organizations have used the results
from these surveys to identify lessons learned and
as the basis for strategic planning.

Measuring Potential Impact
• Models and other innovative evaluation
methods can help evaluators gain a better under­
standing of program impact.

Given the difficulties and high costs associated
with direct measurement of the impact of HIV
prevention programs through large-scale inci­
dence studies, evaluators are developing alterna­
tive methods of impact assessment. Their focus
is establishing linkages between outcome data
from program interventions and patterns of HIV
prevalence and incidence. These methods fall
under several categories, including application of
simulation models, models to estimate HIV inci­
dence rates and prevalence in selected popula­
tions, methodologies for linking behavioral and
biological data, and tools for cost-effectiveness
analysis.
AIDSCAP has created the AVERT model to esti­
mate the impact of intervention outcomes on the
number of HIV infections averted among the tar­
get population. These estimates provide a better
understanding of the effect of current prevention
strategies and can help program managers and
other stakeholders set priorities for future HIV/
AIDS programs (Box 6.3).

Assessing Capacity Building
• Progress in building the capacity of organiza­
tions can be measured using a combination of
quantitative and qualitative methods.

69

Triangulation:
Using Multiple Evaluation Methods
to Assess Progress in Cameroon
AIDSCAP’s final evalua­

tion services. An aggres­

most important achieve­

he said.“And as a result,

tion of its HIV/AIDS pro­

sive social marketing

ments was an increase in

they won’t hesitate to go

gram in Cameroon illus­

project sold more than 35

people seeking appropri­

there.”

trates how data gathered

million condoms, with

ate treatment for STDs—

Attitudes toward

using a variety of evalua­

monthly sales during 1996

a serious health problem

condoms also changed, as

tion methods can enrich

exceeding the total num­

that also contributes to

condom use rose among

our understanding of the

ber of condoms sold in

the HIV/AIDS epidemic in

female university students,

outcomes and impact of

1989, and over I million

Cameroon.The percent­

sex workers and their

prevention efforts. Pro­

educational materials

age of those reporting

clients, and military men,

cess data, complementary

were disseminated, includ­

they had sought STD care

with particularly notable

qualitative and quantita­

ing videos, radio and TV

from a health professional

increases during commer­

tive behavioral data, and a

spots, and printed materi-

rose among university

cial sex.The proportion of

limited amount of biologi­

als.These process data

students, military person­

sex workers who re­

cal data were used to

show that prevention

nel, sex workers and their

ported ever using a con­

assess how the program’s

activities did occur on a

clients, with a dramatic

dom rose steadily from

efforts had made a differ­

large enough scale to

four-year increase from

28 percent in 1988 to 88

ence.

influence behavior.

34 to 86 percent among

percent in 1996, and the

sex workers.These re­

proportion of clients who

In six years the

AIDSCAP program in

on sexual behavior

sults suggest that the

had ever used a condom

Cameroon reached more

change, promoting absti­

program’s emphasis on

also increased, from 55

than 180,000 youth, uni­

nence for young adults,

improving STD services at

percent in 1990 to 81

versity and secondary

fidelity for couples, part­

health care facilities and

percent in 1996.

school students, sex

ner reduction and con­

referring people to those

workers, military person­

dom use. Results of KABP

services was successful.

group discussions with

nel, transport workers

surveys conducted with

Training to change

sex workers and their

and owners of bars and

members of all the target

providers’ attitudes to­

clients provided further

hotels through peer edu­

audiences at the beginning

ward STD patients was

evidence of a dramatic

cation and community­

and end of the program

instrumental in improving

shift in attitudes toward

based outreach. Almost

showed significant in­

STD treatment-seeking

condoms.“There has

2,000 peer educators

creases in knowledge of

behavior, according to Dr.

certainly been a change in

were trained to teach

HIV/AIDS prevention

Mpoudi Ngolle,the chief

behavior because most of

their families, friends,

methods among all the

of Cameroon’s national

the sex workers today,

Interviews and focus

neighbors and coworkers

groups and decreases in

AIDS control program.

you will notice that they

about HIV/AIDS and to

high-risk behavior among

“Now everybody knows

all use condoms,” said

refer them for STD treat­

most of the groups.

how well people are

one sex worker from

treated in the hospital,”

Yaounde: “Ten years ago

ment and other preven­

70

The program focused

One of the program’s

Recommendations
• Evaluators should work with project staff and
local stakeholders to match research methods to
the nuances of particular evaluation questions
and to the time and resources available for evalua­
tion. Project and program managers should also
establish mechanisms for assessing evaluation
data at regular intervals and using those data to
improve interventions.
you could not see such a

target groups—sex work­

thing in this country.These

ers in the cities ofYaounde

condoms which have been

and Douala—suggest that

so decried, so condemned

infection rates may be

at one time, are now appre­

stabilizing or even decreas­

ciated.”
Sex workers reported

ing among sex workers in

cities where use of

significant increases in con­

condoms in commercial

sistent condom use, from

sex is relatively high after

52 percent in 1990 to 75

more than seven years of

percent in 1996, but only

comprehensive HIV/AIDS

with men who were not

prevention campaigns.

regular clients. Evaluation
results suggest that the

• Evaluation designs should reflect what is
feasible and appropriate for a project or program
to measure. AIDSCAP recommends that small
individual projects concentrate on evaluating
service delivery and capacity building, leaving
assessment of behavior change to national or
regional evaluation efforts.
• In order to detect progress toward behavior
change, HIV/AIDS programs should track inter­
mediate indicators, such as the ability to negotiate
condom use with a partner or perception of risk,
as well as reported condom use and other “end­
stage” indicators.

closer the relationship, the

less likely women are to
request condom use. About
63 percent say they use

condoms consistently with

• HIV/AIDS programs should consider establish­
ing behavioral surveillance systems to track trends
in knowledge, attitudes and behavior among
target audiences within the overall population.

regular clients, and only 13
percent report condom use

with their regular, nonpaying
partners.

Few biological data are

AIDSCAP’s BSS methodology has proved an
effective way of monitoring these trends and
assessing the combined impact of various inter­
ventions.

available to confirm the
AIDSCAP behavioral find­

ings in Cameroon. Sentinel
surveillance among women

attending antenatal clinics

• Because sexual behavior is an extraordinarily
difficult area to assess, HIV/AIDS programs
should use a variety of evaluation indicators and
data collection methods.

indicates that HIV preva­
lence is rising in the general
population. However, the

results of seroprevalence
studies conducted between

Triangulation of qualitative and quantitative data
enables evaluators to interpret intervention out­
comes and offers valuable insights into how to
improve future interventions.

1992 and 1997 among one
of the program’s primary

• Capacity building needs to be measured both
quantitatively and qualitatively, and staff mem­
bers from participating organizations should be
directly involved in the process. Plans for evaluat
ing capacity building should be built into the
original design of a project or program to ensure
that baseline data are available.

71

6.3
AIDSCAP’s AVERT Model:
A South African Case Study
HIV/AIDS programs typi­

seek treatment other­

impact these interven­

prevalence of ulcerative

cally measure progress by

wise.

tions might have had on

and nonulcerative STDs,

HIV transmission. Esti­

and condom use.They

assessing changes in be­

monthly examinations,

mates produced by the

assumed that the 400

ences. But financial, logisti­

treatment and counseling,

AVERT model showed

women who used the

cal and technical con­

combined with commu­

them just how powerful

STD treatment and coun­

straints usually make it

nity-based peer education

an HIV intervention pre­

seling services regularly

impossible for them to

on STD/HIV prevention,

sumptive STD treatment

had had sexual contact

answer the most impor­

to women who trade in

could be in such a high-

with 4,000 miners living in

tant question about a

sex and others at high

risk environment.

the nearby hostels—an

prevention intervention:

risk of STDs in a South

did the reported behavior

African mining community

rates the most current

conservative estimate

change lead to reductions

where migrant employees

research on the probabil­

that only 40 percent of

in HIV transmission?

live far away from their

ity of HIV transmission

the miners were engaging
in commercial sex.

The model incorpo­

assumption based on the

AIDSCAP’s AVERT

families for much of the

under different conditions,

model offers an excellent

year. All the women who

such as the presence or

After nine months, it

tool for answering that

used the services were

absence of sexually trans­

was estimated that overall

question.This computer

treated for the most

mitted disease. By model­

prevalence of genital ulcer

model was designed to

prevalent STDs in the

ing pre- and post­

disease (GUD) had

estimate the number of

area with a single-dose

intervention scenarios of

dropped by 30 percent

infections averted through

antibiotic.

high-risk behavior among

and nonulcerative STD

behavior changes resulting

Study results showed

pairs of target popula­

rates had fallen by 32

that this approach was

tions, AVERT can produce

percent.The women had

effective in reducing STDs,

estimates of the subse­

reduced the number of

with dramatic decreases

quent difference in new

clients they had by 20

standing of the impact of

in STD prevalence among

HIV infections.

percent, and reported

one of the first pilot stud­

the women using the

ies of targeted periodic
presumptive STD treat­

ment in the developing

from prevention efforts.
AIDSCAP used AVERT

to gain a better under­

world. Such treatment has

For the analysis of the

condom use by the clients

service and their miner

pilot study in South Africa,

had increased from I 3 to

partners after just nine

AIDSCAP researchers

29 percent. Modeling

months of intervention.

constructed scenarios

these scenarios,AVERT

based on reported behav­

estimated that the inter­

STD treatment and peer

ior and STD test results.

vention had averted a

option for reducing STDs

education are key HIV/

These scenarios included

total of 237 new HIV

in groups at high risk of

AIDS prevention strate­

the average number of

infections for the year: 41

infection—particularly in

gies, the researchers—and

sexual partners and

among the women and
196 among the miners.

been proposed as an

72

The study offered free

havior among target audi­

Since prompt, effective

high-risk women, who

the mining company man­

sexual contacts per part­

often experience no STD

agers—were also inter­

ner that the men and

The model was also

symptoms and may not

ested in learning what

women had had, overall

used to project the po-

tential impact of the inter­

years, the estimated an­

abled the researchers to

lated illnesses among its

vention should it con­

nual cumulative incidence

do a cost-benefit analysis

employees.This conclu­

tinue. It showed that if the

of HIV would decline

showing that for every

sion persuaded the Har­

project goals of 50 per­

from 52 to 12 percent

dollar spent on presump­

mony Mine management

cent condom use in com­

among the women and

tive treatment and peer

to continue and expand

mercial sex and an 80

from 13 to 2 percent

education, the mining

the intervention. ■

percent reduction in STD

among their miner clien­

company had saved more

rates were achieved dur­

tele.

than eight dollars in treat­

ing the next two to three

ment costs for HlV-re-

AVERT estimates en-

Modeling the Impact of
an Intervention in South Africa:
AVERT Assumptions and Results
Assumptions
Average annual partners (women)

Average annual contacts (women)
Average annual partners (miners)
Average annual contacts (miners)

GUD prevalence
Non-GUD prevalence
Condom use

Scenario I

40
10
4
10
10%
25%
13%

Scenario 2

32

10
3.2

10

7%
17%

29%

Results
Probable HIV infections (women)
Probable HIV infections (miners)

103
405

62
209

Difference

Percent

41
196

-40%
-48%

73

Future Challenges

References
i.

Monitoring Sustained Change
HIV/AIDS prevention programs that have been
operating for several years may find it increas­
ingly difficult to detect changes in behavior be­
cause interventions have reinforcing rather than
new effects. As a result, the potential size of
changes in a target group will become smaller,
and the sample sizes necessary to measure these
effects will increase accordingly. Maintenance of
reported behavioral change should receive
greater emphasis in future evaluations.

2.

Improving Data Quality
Data collection systems require substantial atten­
tion and maintenance to ensure the integrity of
the data they provide. Active participation of key
stakeholders is probably the single most impor­
tant factor in ensuring that evaluation data will
be reliable, valid, relevant and timely. Besides
building local capacity to collect, analyze and
disseminate evaluation data, an additional chal­
lenge for prevention programs is identifying and
involving implementing partners who have a
vested interest in the quality of evaluation re­
sults.

3.

4.

Evaluating Intervention Strategies
The Mwanza trial in Tanzania demonstrated that
syndromic management of STDs in a population
can reduce HIV incidence. A limited number of
well-designed trials are needed to test the efficacy
of other intervention strategies, particularly be­
havioral interventions to reduce sexual transmis­
sion of HIV and other STDs. These studies must
be of sufficient size to yield clear results and
should be designed to allow inferences about
cause-effect relationships.

Linking Behavioral and Biological Data
Our understanding of how different behaviors
and epidemiological factors influence epidemic
patterns is still incomplete. There is an emerging
consensus among evaluation experts that assess­
ing the long-term impact of multiple HIV/AIDS
prevention interventions requires investigation
of trends in HIV infections along with trends in
behaviors that may lead to infection. Political
support and resources are needed to enable pro­
grams to collect and analyze HIV/STD surveil­
lance data in combination with behavioral, so­
cioeconomic and sociodemographic data.

74

5.

Mertens T, Carael M, Sato P, et al. (1994).
Prevention indicators for evaluating the
progress of national AIDS programmes. A/DS
8:1359-1369.
AIDSCAP Evaluation Tools Modules Series.
AIDSCAP/Family Health International,
Arlington,Virginia.
Introduction to AIDSCAP Evaluation (1993).
Conducting Effective Focus Group Discussions
(1994).
Incorporating Evaluation Into Project Design
(1994).
Application of a Behavioral Surveillance Tool
(1995).
Qualitative Evaluation Research Methods
(1996).
AIDSCAP/FHI (1997). Behavioral Surveillance
Surveys (BSS): Issues and Recommendations for
Monitoring HIV Risk Behaviors. Summary from the
“Workshop on HIV Risk Behavioral Surveil­
lance: Country Examples, Lessons Learned and
Recommendations for the Future,” August I I14, 1997, Bangkok,Thailand.
Dallabetta G and Hassig S, eds. (1996). Indicators
for Reproductive Health Program Evaluation. Final
Report of the Subcommittee on STD/HIV. The
Evaluation Project/Carolina Population Center,
Chapel Hill, North Carolina.
Mills S, Benjarattanaporn P, Bennett A, et al.
(1997). HIV risk behavioral surveillance in
Bangkok,Thailand: sexual behavior trends
among eight population groups. AIDS I I
(suppl. I):S43-5I.

Women, Me and HIV/AIDS:
Building Gender-Sensitive Programs
One of the most significant changes in HIV/
AIDS prevention during the second decade of
the epidemic has been a growing appreciation of
the need to reduce women’s vulnerability to the
virus. Once considered a disease of homosexuals,
injecting drug users, sex workers and other
“high-risk” groups, HIV/AIDS is now recognized
as a serious threat to most sexually active
women—including those who are monogamous.
Rising rates of HIV/AIDS among women and
young girls throughout the world confirm that
they are at increasing risk of infection. Worldwide,
the proportion of adults living with HIV/AIDS
who are women rose from about 25 percent in
1990 to 42 percent in 1995. By the year 2000, the
annual number of AIDS cases among women will
equal or exceed those among men. Today six out of
ten new infections worldwide occur in women 15
to 24 years of age, and in that age group, twice as
many young women are infected as young men.
Biology plays an important role in women’s
heightened susceptibility to HIV. In fact, sexual
transmission of the virus is at least four times
more efficient from men to women than from

women to men. But research and experience have
shown that the imbalance of power between men
and women is at the root of women’s vulnerability
to HIV. Women’s economic dependence on men
and society’s acceptance of different standards of
sexual behavior for men and women put women at
risk and make it difficult, if not impossible, for
many of them to negotiate safer sex with their
partners.
During the past six years, AIDSCAP and other
international organizations have begun to define a
more gender-sensitive approach to prevention that
addresses some of the root causes of HIV’s rapid
spread among women. Based on a deeper under­
standing of the economic, legal and social factors
that fuel the epidemic, this approach aims to edu­
cate policymakers about the deadly consequences
of gender inequities, empower women to protect
themselves from unwanted and unprotected sex,
develop and test prevention methods that women
can initiate and control, improve communication
between the sexes, and give boys and girls positive
models of mutually supportive relationships be­
tween women and men.

Gender Initiatives

programs and those of its partners. Through its
Women’s Initiative, established in 1994 with sup­
port from USAID’s Office of Women in Develop­
ment and HIV/AIDS Division, AIDSCAP inte­
grated a gender focus into many existing projects,
expanded a number of interventions to address
broader issues of gender inequality and women’s
social and economic empowerment, and developed
dozens of new projects and activities.
With the creation of the Women’s Initiative,
AIDSCAP staff and their partners were challenged
to take a critical look at their projects and pro­
grams to ensure that they addressed the needs of
women. The results ranged from the development
of regional and national gender and HIV/AIDS

AIDSCAP advanced a gender-sensitive approach
to HIV/AIDS prevention through pilot interven­
tions, training of policymakers and grassroots
leaders, research and information dissemination.
Millions of women and girls acquired knowledge
and skills to help them reduce their risk of HIV
infection, and hundreds of policymakers, health
care providers, educators and grassroots lead­
ers—both men and women—were sensitized to
the gender aspects of the epidemic.
The reach and scope of the activities and inter­
ventions described in this chapter and in previous
chapters reflect the success of AIDSCAP’s efforts to
institutionalize a gender perspective in its own

75

strategies, such as the one developed for the Latin
America and Caribbean region (Box 7.1), to incor­
poration of seemingly small but critical design
features.
In India, for example, AIDSCAP-supported
NGOs found innovative ways to reach Indian
housewives who would not have been able to at­
tend other public HIV/AIDS education events,
combining outreach efforts with competitions in
traditional household arts.1 Worldwide, AIDSCAP
was successful in gaining widespread acceptance
among its partners of the importance of collecting
and analyzing separate evaluation data on men,
women, young women and young men in order to
understand the true impact of their interventions
on these populations.
Many of the most innovative gender initiatives
were additions to projects already underway. A
South African prevention project targeting sex
workers and their clients and partners was broad­
ened to address the harassment and violence that

Stephen R Huyler

wTrtti

the women often face from law enforcement offic­
ers and clients (Box 7.2).2 An Ethiopian NGO gave
its young peer educators gender training and cre­
ated a drop-in center where facilitators encouraged
discussions between young men and women about
sex and sexual risk.3 And a Senegalese project built
on an earlier intervention with market women to
use their credit associations to help a particularly
vulnerable group of market women and their
daughters learn to access credit and protect them­
selves from HIV/AIDS.
AIDSCAP programs also designed new projects
to address the expanding epidemic among women.
Examples include training and supporting HIV­
positive women to serve as outreach educators in
Thailand,4 integrating STD treatment and preven­
tion into family planning services in Nepal (Box
7.3), creating a dynamic mass media campaign in
the Dominican Republic emphasizing women’s
right to protect themselves from HIV infection,
and training women community leaders in Hon­
duras as advocates for better sexual health educa­
tion and HIV/STD prevention services.
Financial and technical support from the project
encouraged governments and other groups work­
ing in HIV/AIDS prevention to devote more re­
sources and attention to gender-sensitive activities.
In Haiti, for example, AIDSCAP sponsored a series
of forums to encourage collaboration between
governmental and nongovernmental organizations
and to reach consensus on recommendations
about women and HIV/AIDS for the National Plan
of Action on HIV/AIDS. The Honduran Women’s
Government Office worked with AIDSCAP’s office
in that country to develop strategies for reaching
rural women with prevention messages and activi­
ties. And in India’s Tamil Nadu State, an AIDSCAP
grant supported the creation of a network of influ­
ential women, including policymakers, health care
providers, lawyers, journalists, educators and film
stars, to advocate for legal, economic and social
change to reduce women’s risk of HIV infection.
Collaboration with other development organi­
zations, particularly women’s groups and networks,
was a key strategy. One of the most successful col-

In the traditional art of rangoli, Indian women create intricate
patterns with colored powders. Sponsoring rangoli competitions
on World AIDS Day helped an AIDSCAP-supported project
reach women who might not feel comfortable attending
other public events.

76

laborations, a coalition of ten organizations spear­
headed by AIDSCAP, raised awareness about HIV/
AIDS in women at the United Nations Fourth
World Conference on Women in Beijing in 1995 by
organizing 14 panel discussions, two film festivals
and three press conferences and distributing over
50,000 printed materials. In 1996, AIDSCAP and
UNAIDS cosponsored a journalists’ contest to
encourage accurate reporting on HIV/AIDS and
women that attracted almost 200 entries from 50
countries.5 And in 1997, AIDSCAP brought to­
gether 130 scientists, policymakers, women’s advo­
cates and program managers from 19 countries to
develop recommendations for increasing access to
and use of the female condom.
AIDSCAP-sponsored studies on the female con­
dom featured an innovative research design to
explore introduction of the device through
women’s organizations. Conducted in Brazil and
Kenya in 1996, the research gave women from all
levels of society an opportunity to try female
condoms and demonstrated the potential for
women’s peer support groups to sustain the use of
this woman-initiated device.6 Other AIDSCAP
studies identified ways to improve communication
between Kenyan mothers and their daughters,
Senegalese market women and their male suppliers
and partners, and young Dominican men and
women.
Research results and tools developed by
AIDSCAP’s Women’s Initiative (AWI) will con­
tinue to help other organizations and programs
carry out more gender-sensitive HIV/AIDS inter­
ventions. The initiative created the first training
manual developed specifically for integrating a
gender perspective into HIV/AIDS policies and
programs, based on training workshops held for
policymakers and NGO leaders from five coun­
tries. (Box 8.2 ).7 And a resource guide on the use
of dialogue as an HIV/AIDS prevention strategy
will promote more constructive communication
between men and women about sex, sexuality and
HIV/AIDS prevention.8
The Women’s Initiative’s most important legacy,
however, may be its contribution to raising aware­
ness about the need for a gender-focused approach
to HIV/AIDS prevention. Working in close col­
laboration with members of its Women’s Council
and with other HIV/AIDS and women’s organiza­
tions, AIDSCAP sought to educate policymakers
and programs managers through information dis­
semination and advocacy. These efforts helped put
women and HIV/AIDS on the agendas of interna­
tional organizations, national governments and

local organizations, contributing to the growing
recognition that slowing the spread of the epi­
demic requires fundamental changes in gender
power relations between women and men.

Lessons Learned
Gender Sensitivity
• Although gender is a cross-cutting issue,
organizations need specific mechanisms for
strengthening and sustaining a focus on gender
concerns.

AIDSCAP’s experience confirms that policy and
resource support are essential for institutionaliz­
ing a gender perspective. By providing an explicit
focus on gender and the resources needed to
carry out training, research and interventions,
the project’s Women’s Initiative made it possible
to achieve a broader integration of gender con­
cerns into AIDSCAP policies and programs. A
core staff of four professionals at headquarters
and designation of an AWI “point person” in
each of AIDSCAP’s three regional offices and
many of its country offices ensured that analysis
and monitoring of gender concerns occurred
throughout the project. Support from USAID’s
Women in Development Office, USAID Missions
and AIDSCAP core funding enabled resident
advisors to devote more resources to identifying
and addressing gender issues, empowering
women, involving men in efforts to protect
women and girls from HIV/AIDS, and improv­
ing communication between the sexes.
• Training is an effective tool for making HIV/
AIDS prevention programs and projects more
gender-sensitive.
Gender training workshops sponsored by AWI
for project staff, implementing partners and
policymakers inspired participants to initiate
gender-focused programs and activities. For
example, participants in a 1995 gender and AIDS
training workshop AIDSCAP conducted for 41
policymakers and program managers in five
eastern and southern African countries agreed
that it had improved their understanding of how
to recognize and analyze gender issues and inte­
grate them into HIV/AIDS prevention policies
and programs. Projects with a gender perspective
were launched in each of the participating coun-

77

LAC Regional Gender and
HIV/AIDS Strategy:
A Catalyst for Change
Throughout much of Latin

AIDSCAP resident advi­

efforts and offered mod­

organizations to develop

America and the Carib­

sors and their colleagues

els for designing gender­

consensus on goals and

bean (LAC), many people

from the region led to the

sensitive interventions in

strategies for preventing

still believe that HIV/AIDS

development of a strategy

the future.

the spread of HIV/AIDS

strikes only those who

that encompassed training

live at the margins of

in gender analysis, re­

society.Yet three out of

search and pilot projects

implement a regional

ued during the final year

every four HIV infections

and sharing of lessons

gender strategy was more

of AIDSCAP’s program in

in the region result from

learned.

far-reaching than the

Haiti through a series of

results of the pilot

forums in four regions of

among Haitian women.
This dialogue was contin­

heterosexual transmis­

Under the regional

sion, and in many coun­

strategy, each AIDSCAP

projects. After AIDSCAP

the country organized by

tries, HIV rates are rising

program in the region

established its Women’s

a coalition of 34 women’s

faster among women than

carried out a study, train­

Initiative in 1994, project

organizations.The recom­

in any other group.

ing program or pilot inter­

staff reviewed all their

mendations of forum

In this decade alone,

vention. For example,

activities in the region to

participants were re­

the male-to-female ratio

AIDSCAP’s program in

determine how to reach a

ported to the new Haitian

of reported AIDS cases

Brazil trained 100 govern­

broader range of women

National AIDS Commis­

throughout LAC shifted

ment and NGO health

and to address the needs

sion for incorporation

from 4.9 to I in 1991 to

care providers from three

of both women and men.

into its five-year National

2.8 to I in 1996. In the

states to ensure that they

This new emphasis on

Plan of Action.

Dominican Republic, the

were sensitive to gender

gender sensitivity was

male-to-female ratio of

issues that affect service

soon reflected in the

Honduras, which was

AIDSCAP’s program in

HIV infections went from

delivery and to promote

strategies, plans and ac­

launched in 1995, ad­

7 to I to 1.5 to I in eight

integration of HIV/AIDS

tivities of AIDSCAP pro­

dressed gender issues

years.And in Haiti, equal

prevention into other

grams in the region—and

from the beginning.

numbers of men and

reproductive health ser­

even in the language staff

Baseline survey results

women are infected with

vices. In Honduras an

used to describe them.

were analyzed to identify

the virus.

AIDSCAP-supported

In Haiti,AIDSCAP

gender-based constraints

project enhanced the

worked with HIV/AIDS

to prevention for both

to these alarming trends

leadership skills of 50

and women’s organiza­

men and women, and

in HIV among women

women in two municipali­

tions to ensure that gen­

educational materials

with a concerted effort to

ties, enabling them to

der concerns would be

were revised to ensure

strengthen the capacity of

become advocates for the

addressed in the country’s

they were gender-sensi­

AIDSCAP responded

78

But the impact of the
effort to develop and

HIV/AIDS programs in

reproductive health needs

future prevention strate­

tive.The project also

LAC to address the gen­

of women in their com-

gies. In May 1995, a “Day of

made special efforts to

der issues that make

munities.These and other

Reflection on Women”

reach women at all levels

women so vulnerable to

projects strengthened

brought together 30 rep­

of society. One project,

infection. Meetings with

HIV/AIDS prevention

resentatives from 18

designed in collaboration

■

:

with the Honduran

AIDS prevention on the

three months later.

about integrating a gender

perspective into HIV/

Women’s Government

air and helped them pro­

AIDSCAP also spon­

Office, trained peer edu­

duce two radio spots on

sored numerous studies,

AIDS programs with

cators to lead discussions

prevention for women. In

training workshops, inter­

colleagues from other

about HIV/STD preven­

Rio de Janeiro, a project

ventions and policy initia­

countries in the region at

tion in their communities.

designed to generate

tives to address gender

a workshop in April 1997.

Another project linked

dialogue about HIV and

and HIV/AIDS in the

Twenty-five participants

education and discussions

STDs among women in

Dominican Republic. Most

from six LAC countries

about HIV/AIDS,sexuality,

the waiting room of a

notably, a women and

met to discuss strategies

domestic violence and

busy gynecological clinic

HIV/AIDS plan created by

for addressing gender

women’s rights with

was expanded to reach

AIDSCAP and the Do­

issues in HIV/AIDS pre­

credit programs for

men attending other

minican public health

vention and to develop

women in rural areas.And

clinics at the same health

association, in collabora­

mechanisms for sharing

interventions in factories

care center.

tion with other govern­

their experiences in the

mental and nongovern­

future.The resulting part­

with large numbers of

And in the Dominican

female employees worked

Republic,AIDSCAP

mental organizations, was

nerships between HIV/

to prevent sexual harass­

worked with the

incorporated into the

AIDS organizations in

ment as well as HIV

government’s department

National AIDS Control

Brazil and Bolivia and in

transmission.

of women’s affairs, the

Plan.

Honduras and Nicaragua

In Brazil, a total of 16

national STD control

Gender training con­

will ensure that

new “rapid-response”

program and local NGOs

ducted in January 1997

AIDSCAP’s strategy for

grants for gender-sensi­

to develop a strategy for

reinforced the commit­

gender and HIV/AIDS

tive interventions were

preventing HIV and other

ment of AIDSCAP pro­

continues to influence

awarded during 1996 and

STDs among young

gram managers to

prevention efforts

early 1997. One NGO

women.This strategy

gender-sensitive program­

throughout the LAC
region. ■

distributed targeted HIV/

included a mass media

ming. It also strengthened

AIDS educational materi­

campaign modeled after

their capacity to plan,

als to more than 500

the program’s successful

implement and evaluate

newly elected council­

campaign for adolescents

such programs as they

women throughout the

(see page 8). Local and

began to make the transi­

state of Sao Paulo to

cable television stations

tion from managing

encourage them to

began airing the public

AIDSCAP programs to

strengthen the legislative

service announcements

running their own indig­

response to the epidemic.

created for the campaign

enous HIV/AIDS NGOs

Another NGO trained

in May 1997 and contin­

(see page 93).

women radio broadcast­

ued to broadcast them

ers from four states in

after AIDSCAP activities

opportunity to share

ways to present HIV/

in the country ended

what they had learned

AIDSCAP staff had an

79

.2
Gender Training Produces Results
In Pietermaritzburg, South

The Al DS Training,

Southern Africa, represen­

ment and intimidation of

Africa, as in many parts of

Information and Counsel­

tatives of the NGO iden­

sex workers.The project

the world, women who

ing Centre had been

tified the widespread

developed a training pack­

trade in sex often face

working with sex workers

disregard for sex work­

age designed to help law

harassment, violence and

and their clients in

ers’ human and legal

enforcement officers and

sexual assault, not only

Pietermaritzburg, educat­

rights as a major obstacle

others who work with

from clients and brothel

ing them about HIV/AIDS

to HIV/AIDS prevention.

the public confront nega­

owners, but also from the

and condom use. But in

The pilot project they

tive and potentially dan­

police.The South African

an environment where

developed during the

gerous attitudes toward

NGO Lawyers for Human

sex workers had almost

workshop and launched in

marginalized members of

Rights has collected the

no protection against

January 1996 with sup­

society. And on the na­

stories of many women

physical abuse and sexual

port from AIDSCAP in­

tional level, it established

who were raped by those

assault,“negotiating” con­

cluded interventions to

a network of advocates to

entrusted with enforcing

dom use seemed a re­

educate both sex workers

work toward the long­

the laws against sexual

mote possibility.

and law enforcement

term goal of decriminal­

officers about the

ization.

abuse.

between women and men

women’s legal rights, as

years old, reported being

are often overlooked in

well as national advocacy

project was one of five

forced to have oral sex

the design of HIV/AIDS

efforts to decriminalize

initiated as a result of

with five police officers,

prevention projects.

sex work.

AIDSCAP’s gender train­

who left her naked on a

Driven by the urgent

remote road outside of

need for prevention edu­

women had received

Mombasa, Kenya, in Octo­

town. On her way home

cation and methods and

training to help them

ber 1995.The structure of

she was raped by a drifter

constrained by the diffi­

understand and assert

the training, which in­

who demanded sex in

culty and cost of address­

their rights and to em­

cluded a follow-up work­

return for a ride. Another

ing more complex issues,

power their peers with

shop to assess project

woman was arrested for

many projects ignore the

this information. Lawyers

results, and the provision

soliciting and locked in a

long-term social, eco­

for Human Rights reports

of seed money made it

cell for several hours by

nomic and legal problems

that sex workers are

possible for participants

two policemen, who re­

that make people vulner­

beginning to use their

to put their new knowl­

leased her only after she

able to HIV infection.

new knowledge and the

edge and skills into imme­

support they received

diate practice.

agreed to have unpro­

80

Such power imbalances

One woman, only 19

In Pietermaritzburg,

By April 1997, some 24

The Pietermaritzburg

ing workshop held in

tected sex with each of

however, Lawyers for

from the NGO to do

them in the back of a

Human Rights recognized

what few had dared to do

gram managers from

police van.

government agencies,

Forty-one senior pro­

the problem early on. As

before—to bring charges

In both cases—and

participants in a regional

of rape and assault against

NGOs,AIDSCAP offices

many others—no charges

gender training workshop

their attackers.

and USAID Missions in

were filed. Considered

organized byAIDSCAP’s

Some progress was

criminals under South

Women’s Initiative with

also made in sensitizing

African law, sex workers

support from USAID’s

police officers, as evi­

babwe participated in the

are easily intimidated by

Regional Economic and

denced by a decline in the

five-day workshop, which

threats of police retalia­

Development Services

number of reported inci­

was designed to give

tion.

Office for Eastern and

dents of police harass-

them the skills needed to

Ethiopia, Kenya, South
Africa,Tanzania and Zim­

incorporate a gender per­

conceptual frameworks for

spective into HIV/AIDS

gender analysis, guidance

programs.Their enthusiastic

on developing gender­

response led to plans to

sensitive projects, case

hold similar workshops

studies and facilitators’

elsewhere in Africa.

guidelines.

In fact, workshop partici­
pants from the Al DSC AP-

In July 1997, facilitators
used the manual to con­

supported Tanzania Al DS

duct a regional training

Project (TAP) developed

workshop for 26 senior

their own plan to train

program managers from

NGO personnel in leader­

five West African countries.

ship skills for identifying

Early reports on follow-up

gender issues and modifying

by the participants were

interventions. Forty-two

encouraging. Less than two

NGO representatives from

months after the work­

the nine regions covered by

shop, for example, the

TAP participated in a train-

executive director of the

ing-of-trainers workshop,

national AIDS control pro­

then went back to their

gram in Cote d’Ivoire had

districts to hold similar

already scheduled six gen­

workshops for a total of

der and AIDS workshops

239 NGO staff throughout

for local AIDS and repro­

the country. Al DSCAP’s

ductive health coordina­

resident advisor in Tanzania

tors, NGO personnel and

reported that the impact of

private sector managers.

this gender training was

AIDSCAP’s experience

reflected in the design of

suggests that targeting

new projects and in the new

senior program managers

roles men and women had

for gender training is an

assumed in prevention and

effective strategy, noted E.

care efforts.
A manual produced by

Maxine Ankrah, associate

director of AIDSCAP’s

AIDSCAP, A Transformation

Women’s Initiative. “Those

Process: Gender Training for

who make or influence

Top-Level Management of

policy, plan and monitor

HIV/AIDS, will facilitate fur­

programs, and provide

ther replication of such

resources are ultimately

workshops.The first gender

the ones who determine

training manual for senior

whether gender concerns

HIV/AIDS program manag­

are addressed as an integral

ers, it is available in English

part of HIV/AIDS pro­

and French and includes

grams,” she concluded. ■

tries (Box 7.2) And in the Latin America and the
Caribbean region, AIDSCAP resident advisors
and their implementing partners used the gen­
der analysis skills they had acquired at an
AIDSCAP regional workshop to develop pilot
intervention and research projects to improve
HIV/STD prevention services for women across
the region (Box 7.1).

Dialogue
• The dialogue approach to communication
between men and women holds great promise for
stimulating and supporting sustained behavior
change to prevent transmission of HIV and other
sexually transmitted infections.

AIDSCAP promoted the use of dialogue, de­
signed to give men and women the gender
awareness and skills they need to communicate
openly and honestly about sex and other issues
that affect their sexual health, at the interper­
sonal, community and policy levels. Representa­
tives from T1 countries who helped field test the
methodology in a satellite meeting at the Xlth
International Conference on AIDS in Vancouver
responded enthusiastically, calling this initiative
“long overdue.” One woman noted that dialogue
is “the only way that women can approach men
in my culture. We cannot ‘negotiate’ with our
men.” After the meeting, groups from around
the world requested assistance in replicating the
dialogue among policymakers, communities and
couples.
Most participants in the first operations re­
search project to test the dialogue process—a series
of facilitated sessions with truck drivers and their
spouses conducted in Jaipur, India, in 1997—re­
ported that the experience made them feel com­
fortable discussing sexual matters with spouses
and friends. Many of the truck drivers said they
had started to use condoms with their spouses for
the first time. These encouraging results convinced
the John D. and Catherine T. MacArthur Founda­
tion to fund a two-year pilot intervention using
the dialogue process with Indian truck drivers and
their wives.

• Although the ultimate goal of dialogue for
HIV/AIDS prevention is to improve communica­
tion between men and women, it may be neces­
sary to first build sexual communication skills in
single-sex groups.

81

In Zimbabwe, for example, the Women and
AIDS Support Network found that initially it
was better to separate boys and girls for school­
based HIV/AIDS education sessions, giving the
girls opportunities to ask questions without feel­
ing inhibited. Once the girls gained confidence in
their ability to discuss sexual issues, they asked
that the boys be included in future sessions. And
in the operational study of the dialogue process
with Indian truck drivers and their spouses, only
one of the five facilitated sessions involved a
mixed-sex group. The researchers found that
they had to convene single-sex groups for the
other rounds of dialogue because of cultural
constraints against unacquainted women and
men discussing sexual issues. Nevertheless, par­
ticipation in these groups helped truck drivers
and their wives talk to each other about sex and
sexual health. Policymakers and policy
influencers meeting at a national conference
organized by AIDSCAP in New Delhi in May
1997 recommended same-sex approaches as a
means of initiating dialogue between women
and men on HIV/AIDS programs and policies as
well as personal protection.

Men as Prevention Partners
• Although it is critical to empower women so
that they are better able to protect themselves
from HIV, prevention interventions for women
must also address men’s behavior and communi­
cation between the sexes.
Research data from around the world consis­
tently demonstrate that many women’s risk of
HIV stems from their partners’ unsafe behavior,
not their own. In most societies, men still have
greater control over sexual decision making than
their female partners, and are in a better position
to act on messages that focus on individual be­
havior change.
Moreover, AIDSCAP found that strategies for
empowering women were most successful when
they involved men as well. In Nigeria, for example,
several AWI projects reached out to include men
after the women they were working with said that
it would be easier to use their new skills if their
male partners were also aware of the importance of
prevention. In Brazil, the NGO Grupo Pela Vida
expanded a project that offered education and
facilitated discussion about HIV/STD risk reduc­
tion in the waiting room of a large gynecological
clinic to reach the primarily male clientele of a

82

tuberculosis and pneumonia clinic at the same
health center and to encourage discussion about
HIV/AIDS among male and female clients.
• HIV/AIDS prevention programs should
address men not only as sexual beings, but in their
roles as fathers, husbands, workers and commu­
nity members.

For example, gender-sensitivity training for driv­
ers of Kenyan matatus (vans that serve as infor­
mal public transport) succeeded in convincing
the young men to be more courteous to female
passengers by appealing to them to treat all
women as they would like their mothers, sisters,
wives and daughters to be treated. They were also
encouraged to extend the same courtesy to their
partners. A study at two Haitian clinics revealed
that the most important motivations for men to
seek STD treatment were preserving fertility and
ensuring healthy offspring (see page 27).

Woman-Initiated Methods
• Peer support can help women who are vulner­
able to HIV/AIDS and other STDs convince their
partners to use female condoms.
AIDSCAP’s research in Kenya and Brazil, as well
as UNAIDS-sponsored studies in Costa Rica,
Indonesia, Mexico and Senegal, found that group
discussions with peers helped women overcome
obstacles to using the female condom, including
unfamiliarity with the device and the need to
communicate with one’s partner about its use.
During the sessions, women encouraged each
other and shared strategies for introducing fe­
male condoms into a relationship.
• The female condom is an acceptable alternative
to male condoms for some couples.

In AIDSCAP’s studies in Brazil and Kenya, 70
percent of the Kenyan women and 97 percent of
the Brazilian women said that they would like to
continue using female condoms after the re­
search ended. The majority of their male part­
ners also wanted to continue using the new
condoms. While none of the women were able or
willing to buy male condoms regularly, most said
they would be willing to pay for female condoms
if they were available.
Results from acceptability and intervention
research discussed at a conference on the female

condom AIDSCAP convened in suburban Wash­
ington, D.C., in May 1997 support these findings.
For example, successful pilot projects in Bolivia,
Guinea, Haiti, South Africa and Zambia demon­
strated that women and men will buy female
condoms at prices about twice as high as male
condoms.

Women’s Organizations
• Women’s organizations are effective partners
for empowering women to protect themselves
from HIV/AIDS and integrating HIV/AIDS
prevention into other health and development
programs.

More than 70 percent of the projects funded
under AWI were carried out by women’s groups,
which provided the access and structure needed
to reach women and built on the formal and
informal support networks women themselves
had established. Through these groups,
AIDSCAP helped influential women become
spokespeople and advocates for HIV/AIDS pre­
vention and other women’s health and develop­
ment issues in their communities.
In Nigeria, for example, working with five estab­
lished women’s organizations enabled AIDSCAP to
institutionalize discussion of HIV/AIDS preven­
tion and other health issues among groups that
reached hundreds of women and girls and their
families and friends. Now these issues are on the

Jemimah Mwakisha

agenda for each regular meeting of the Federation
of Muslim Women’s Associations Nigeria
(FOMWAN) in Jigawa State and of several
branches of the NGO Women in Nigeria (WIN).
Women trained by WIN/Cross River State started
grassroots women’s health clubs to continue to
disseminate information and promote health­
seeking behavior, while the market women’s
daughters trained by WIN/Lagos formed peer
leader groups to help them continue educating
other youth in the market.
Working with women’s organizations that ad­
dressed other health and development issues also
encouraged a more integrated approach to HIV/
AIDS prevention. In Senegal, for example, HIV/
AIDS interventions for market women were car­
ried out by an organization that also provides
credit and literacy programs, establishing a link
between prevention education and practical mea­
sures to empower the women. And in Honduras,
the Association for the Development of Youth and
Rural Women integrated HIV/AIDS and STD pre­
vention with credit programs and other efforts to
improve the lives of rural women by training 20
women leaders from communal banks and solidar­
ity groups. These women became facilitators for
discussions about HIV/AIDS, sexuality, domestic
violence and women’s rights in their communities.

• Some women’s groups may be reluctant to
become involved in HIV/AIDS prevention work.

Although AIDSCAP found many women’s orga­
nizations that were eager to implement preven­
tion interventions and others that had already
begun to do so, some groups did not want to
address HIV/AIDS. Leaders of some develop­
ment and family planning organizations thought
that such work would dilute their mission, while
others feared it would stigmatize their organiza­
tions. Fear of stigma was most common in coun­
tries or regions with less advanced epidemics.
Education and advocacy are needed to sensitize
women’s leaders to the threat HIV/AIDS poses to
all women and to promote an understanding of
how HIV/AIDS organizations and women’s
groups can work together to achieve shared
goals.

Participants in AIDSCAP’s female condom study in Kenya
listen as a woman describes her experience with the device.

83

Integrated Services Improve
Women’s Access to STD
Treatment in Nepal
A woman comes to the

The nurse asks the

diagnosis and treatment

pilot project to test an

Chitwan State Clinic in

woman to stop in the

and HIV/STD prevention

integrated reproductive

the Nepalese city of

clinics’ health education

counseling and education

health model in Chitwan

Bharatpur seeking contra­

room on her way out.

along with family planning

district.

ceptives.While discussing

There she meets with a

and maternal-child health

her family planning needs

woman health educator

services. Prevention of

1996, FPAN’s Chitwan

with a provider, she men­

who demonstrates how

STDs, including HIV, has

branch recruited addi­

tions that she has been

to use a condom and

also been integrated into

tional nursing and health

experiencing pain in her

gives her a simple bro­

the work of the clinics’

education staff, upgraded

lower abdomen.The pro­

chure about STDs and

outreach staff and volun­

the clinic’s facilities and

vider carefully explains

HIV/AIDS. Before leaving

teers, who distribute

extended its hours.All

that this symptom could

the clinic, the woman sits

condoms, talk to commu­

staff received an orienta­

be a sign of a sexually

for a few minutes to

nity members about

tion in the basics of HIV/

transmitted disease, and

watch a short, entertain­

STDs, and refer people to

STD prevention.Then

suggests that the woman

ing videodrama about

the clinic for STD ser­

targeted training sessions

condom use and HIV/

vices.

see the clinic’s physician.
The doctor talks to
the woman about her

AIDS prevention.

This woman and hun­

in STD syndromic man­

Just a few years ago,

agement, risk assessment,

FPAN provided no STD

prevention counseling and
laboratory support pre­

symptoms, does a pelvic

dreds like her received

services, and most provid­

examination and asks her

STD treatment from a

ers were reluctant to talk

pared medical, counseling

some questions to assess

trusted source—the

to their clients about STD

and laboratory staff to

her risk of sexually trans­

providers at their local

prevention. Outreach

provide quality STD ser­

vices.

mitted infection.Then he

family planning and mater­

workers distributed

tells the woman that she

nal-child health clinics—as

condoms, but only for

probably has an STD and

a result of an AIDSCAP-

family planning.

explains the importance

supported pilot project

of taking all the pre­

implemented by the Fam­

Dr. Bijaya Neupane,the

scribed medicine, even if

ily Planning Association of

physician at the FPAN

planning alone to inte­

she feels better after a

Nepal (FPAN).AIthough

clinic in Chitwan, at­

grated reproductive

few days. He advises the

the goal of integrated

tended anAIDSCAP-

health.They learned to

woman on how to pre­

reproductive health ser­

sponsored training

promote condoms for

vent further infection, and

vices remains elusive in

session on STD case

disease prevention as well

the assisting staff nurse

much of the world, it has

management conducted

as contraception, and to

gives her a wallet of

become a reality in the

by the Nepal Medical

help people assess their

condoms and a referral

FPAN clinics in the Cen­

Association. Believing that

risk of contracting an

card for her husband.The

tral Region districts of

FPAN had an important

STD. Outreach workers

nurse also provides tips

Chitwan, Makawanpur and

role to play in improving

not only referred women

on how to convince the

Dhanusha.

women’s access to STD

whom they believed to be

The clinics offer

treatment, he proposed

at risk for STDs, but ac­

prompt, effective STD

that AIDSCAP support a

companied them to the

husband to seek treat­
ment.

84

Beginning in January

That all changed when

Outreach staff and
volunteers also received
training to help them
make the shift from family

FRAN clinic to ensure

contributions from drug

the three clinics repre­

project had achieved its

proper follow-up.

wholesalers.

sents one of a few suc­

goal of improving

cessful attempts to

women’s access to STD
services.

A revolving drug fund

Impressed with what

begun with U.S.$l,700 in

FRAN had accomplished

integrate STD diagnosis,

seed money from FRAN

in Chitwan, AIDSCAP

prevention and treatment

enabled the clinic to sup­

provided funding in De­

into family planning and

of the family planning

ply STD drugs to clients

cember 1996 to expand

maternal-child health

workers who had feared

at a cost about 15 per­

STD services to the

services. In just 15

any association with the

cent below the retail

FRAN clinics in the cities

months, 1,275 patients—

stigma of STDs, the new

price.When patients

of Hetauda and Janakpur.

both men and women—

STD services actually

cannot afford to buy the

During the first four

were treated for STDs at

enhanced FPAN’s reputa­

prescribed drugs even at

months, more than 100

FRAN clinics and outreach

tion for providing high-

discounted prices, FRAN

people sought STD diag­

sites in the three districts.

quality, client-centered
services. For Chitwan,

Much to the surprise

staff tries to supply them

nosis and treatment at

More than 87 percent of

free from sources such as

each of these clinics.

those patients were

offering STD services had

women, evidence that the

a dramatic impact on the

FPAN’s experience in

physicians’ samples or

demand for all reproduc­
tive health services. For
example, the number of
Mary O’Grady/Al DSC AP

W fJ

clients requesting steril­

ization services climbed
by 65 percent from 1995

to 1996.
These results im­

\

pressed Nepali family

planning managers and
policymakers attending a

lessons learned workshop
* iFiik

in April 1997, and they
recommended further

integration of STD ser­

vices into family planning

*
*

and maternal-child health
programs. FRAN and

Family Health Interna­
tional plan to begin this

expansion in Nepal’s

Eastern and Western

Nepali women wait to see the doctor on a Saturday afternoon at a reproductive health

regions. ■

outreach clinic organized by FRAN and a local NGO in the village of Malekhu.

85

Recommendations
• Gender orientation of policies and programs
should be an explicit policy of an organization
from its inception. HIV/AIDS prevention pro­
grams should build in specific structures and
mechanisms, such as gender training of staff,
point people in field offices and earmarked
funding, to integrate a gender perspective into
projects and monitor all activities for gender
sensitivity.
• Additional operations research should be
conducted to explore the use of dialogue as a
strategy and tool for improving sexual communi
cation between men and women and promoting
HIV risk reduction.
• HIV/AIDS interventions should not target just
women or men, but should focus on improving
understanding and communication between
them. Men should be addressed in their roles as
fathers, husbands, workers and community
members, and not merely as sexual beings.

• HIV/AIDS programs should work together to
make the female condom more available and
affordable to women and men in developing
countries. Efforts to increase availability should
begin with large-scale introduction in a few
countries; efforts to improve affordability should
include expediting research on whether the female
condom can be used more than once and provid­
ing incentives for alternative, less expensive
product designs.
• HIV/AIDS organizations should collaborate
with women’s groups, particularly those that
address other health and development issues, to
empower women and promote a more integrated
approach to prevention. They should also con­
tinue to promote a better understanding among
these organizations of the threat that HIV poses to
health and development efforts and of the need to
work together for women’s empowerment and
gender equity.

Jeremy Hartley/Panos Pictures

SB

Women sell second-hand clothes in a market in Dakar, Senegal. AIDSCAP worked with an NGO that offers credit and
literacy programs to empower Senegalese market women and their daughters to protect themselves against HIV/AIDS.

86

Future Challenges

References
I.

Understanding Stable Relationships
Few studies have explored the dynamics of
sexual communication and control between
couples. More research is needed to understand
how to help couples develop safe, respectful,
mutually satisfactory sexual relationships.

Dadian MJ (1997). Inclusive Prevention Efforts
Fight Stigma in Rural India. AlDScaptions

4(I):48-5I.

2.

Al DSCAP Women’s Initiative (1997). ATransfor-

mation Process: Gender Training for Top-Level

Management of HIV/AIDS Prevention (report).

AIDSCAP/FHI, Arlington,Virginia.
3.

Henry K (1997). Saving a Generation: Ethiopian

Increasing Women’s Options

Youth Rally to Prevent HIV/AIDS. AlDScaptions

The enthusiastic response to the female condom
in studies and pilot projects throughout the de­
veloping world confirms the urgent need for
HIV/STD methods that women can initiate and
control. Female condoms are a promising op­
tion, but their cost has limited their availability
to all but a handful of countries. Research to
develop microbicides that protect women against
HIV and other STDs and simultaneous efforts to
improve access to affordable female condoms
must be a top priority for prevention programs.

4(l):32-35.

4.

Chomsookprakit C. Life with Hope: HIV-

Positive Support Group Helps Others Avoid
Infection. AlDScaptions 3(3):39-41.
5.

AIDSCAP Women’s Initiative (1996). One Strong
Voice: Writings on Women and HIV/AIDS.
AIDSCAP/FHI, Arlington,Virginia.

6.

The Female Condom: From Research to Market­
place (conference proceedings). AIDSCAP/FHI,

Arlington,Virginia.

7.

AIDSCAPWomen’s Initiative (1997). ATransfor-

mation Process: Gender Training for Top-Level

Integrating Reproductive Health

Management of HIV/AIDS Prevention (manual).

The promise of integrating family planning, HIV
and STD prevention, and STD treatment services
to reach millions of women through family plan­
ning, maternal-child health and primary health
care clinics has yet to be realized. Obstacles in­
clude inadequate resources, providers’ reluc­
tance, a lack of clear technical guidance on how
to provide integrated services in different set­
tings, and an emphasis on treating and counsel­
ing women rather than couples. Operations re­
search is needed to address these constraints to
achieving a truly integrated approach to repro­
ductive health.

AIDSCAP/FHI, Arlington,Virginia.

8.

AIDSCAPWomen’s Initiative (1997). Dialogue:

Expanding the Response to HIV/AIDS. A Resource
Guide. AIDSCAP/FHI, Arlington,Virginia.

Empowering Women
In many developing countries, women’s vulner­
ability to HIV/AIDS will continue without fun­
damental changes in their social, economic and
legal status. Income-generating activities linked
with HIV/AIDS prevention can empower some
women to protect themselves from infection, but
the scope of such activities is far too small to
have a significant impact on the status of women
in society as a whole or on the spread of the epi­
demic among women. Political commitment,
human and financial resources, and true collabo­
ration among health and development agencies
and organizations are required to empower
women through legal reform, education and
greater access to employment and credit.

87

Managing HIV/AIDS Programs and
Building Capacity to Sustain
Prevention Efforts
Sound technical strategies and state-of-the-art
technical skills are essential for HIV/AIDS pre­
vention, but they do not guarantee the success of
a prevention program. Planning, management
and monitoring create the infrastructure that
makes it possible to deliver effective technical
services to those at risk of or affected by HIV.
During the past decade, government agencies
and nongovernmental organizations have
strengthened their management skills and sys­
tems as well as their technical skills to meet the
challenges posed by the epidemic.
NGOs have played an important role in the
response to HIV/AIDS and remain one of the most
effective channels for reaching and influencing
target audiences. Once wary of NGO involvement
in HIV/AIDS prevention, most governments now
recognize the value of NGOs’ contributions and
accept them as partners.
Some of these NGO partners were established to
respond to the epidemic, while others added HIV/
AIDS prevention to their other health and devel­
opment objectives. The new organizations often
lack basic institutional and financial capability, and
many NGOs—new and established—lack technical

Managing Programs

Worldwide
One of the largest donor-funded health pro­
grams ever mounted, with some 584 projects and
activities in more than 40 countries and more
than 500 implementing partners, the AIDSCAP
Project offered a unique opportunity to develop
innovative management systems for interna­
tional HIV/AIDS programs and to build the
capacity of local partners to sustain such pro­
grams.
From 1991 to 1997, AIDSCAP worked with local
partners to design, manage and evaluate compre-

88

expertise in HIV/AIDS prevention. Governments,
on the other hand, have longer experience in man­
aging HIV prevention efforts, but face daunting
new management challenges. Erstwhile strong,
centralized programs bolstered with international
technical and financial support now struggle with
the complexities of decentralizing planning and
management to regional and district health au­
thorities and with the need to expand care and
support services to people infected and affected by
HIV/AIDS as financial resources diminish.
Strengthening the capacity of developing coun­
try NGOs and government agencies to plan, man­
age and evaluate HIV/AIDS programs has become
an even great priority during this second decade of
the epidemic with the explosive growth in the
number of HIV infections in developing countries
and the realization that a cure or vaccine is still a
long way off. The crisis mentality of the early years,
when governments, donors and NGOs moved to
mount an emergency response to AIDS, has been
replaced by an understanding that the epidemic is
a long-term development problem requiring a
long-term multisectoral response.

hensive, multiyear programs in 19 countries
throughout the world. These ranged from a prima­
rily grassroots, nongovernmental program to ad­
dress prevention, care and orphan support in Tan­
zania (Box 8.1) to a program housed in and di­
rectly supportive of the government’s national
HIV/STD control program in Jamaica. AIDSCAP
also provided targeted expertise to national and
regional efforts in more than 20 countries. Ex­
amples include strengthening Zambia’s national
STD service, infusing state-of-the art HIV preven­
tion expertise into the design and implementation
of a reproductive health project in West Africa,
training epidemiologists and social scientists to

conduct socioeconomic impact studies in Central
America, and evaluating non-AIDSCAP HIV/AIDS
prevention projects in Uganda.
Two AIDSCAP grant programs offered special
opportunities for strengthening community-based
responses to the epidemic. A competitive grants
program that paired U.S. private voluntary organi­
zations with host-country NGOs awarded nine
three-year, $400,000 grants to support innovative
projects that were integrated into existing
AIDSCAP programs. And by providing more than
200 “Rapid-Response Fund” grants of U.S.S900 to
$5,000, AIDSCAP was able to expand the number
and type of community-based organizations deliv­
ering client-centered HIV/AIDS prevention ser­
vices in countries around the world (Box 8.2).
Other initiatives were designed to address
emerging needs and opportunities. AIDS care and
management grants enabled organizations in se­
lected countries to test interventions to link and
strengthen prevention and care efforts at the com­
munity level. A “Domestic Areas of Affinity” pilot
project encouraged networking and sharing of
experiences between Dominican and Haitian pro­
grams and U.S.-based programs that serve similar
populations. And the lessons from a demonstra­
tion project providing HIV prevention and STD
services to Rwandan refugees in camps in Tanza­
nia—the first to test the viability of integrating
such services into primary health services in a refu­
gee setting—have been used by the United Nations
High Commission on Refugees and others to shape
subsequent programs for refugees.
Systems and tools developed for managing these
initiatives and the AIDSCAP Project as a whole
may serve as useful models for future international
HIV/AIDS programs. These include a program
management manual to guide field implementa­
tion, processes for increasing local participation in
project design (Box 8.3), and database manage­
ment tools for indexing and tracking projects, re­
search studies, BCC materials and program docu­
ments.
Strengthening the capacity of local organiza­
tions to design, implement, manage and evaluate
HIV/AIDS programs was a key objective of the

AIDSCAP Project. The vast majority of its projects
and field activities were carried out by host-coun­
try NGOs, community-based organizations, gov­
ernment agencies and universities, with technical
assistance and management support from
AIDSCAP staff and consultants.
During the first half of the project, capacity
building efforts emphasized project design and
technical skills. Strengthening financial, manage­
ment and networking skills became increasingly
important during the second half of the project as
AIDSCAP prepared its implementing partners to
continue and sustain HIV/AIDS prevention pro­
grams. The project developed new tools for assess­
ing, monitoring and evaluating capacity, including
an instrument to help organizations identify their
own strengths and weaknesses and a strategic plan­
ning manual, and trained all its resident advisors to
use these tools to integrate comprehensive capacity
building efforts into the programs they managed.
AIDSCAP’s commitment to building local ca­
pacity was apparent in its 20 field offices, where 80

Evaristo Fa/Revista Cara

Sales of this T-shirt displayed by Brazilian First Lady

Ruth Cardoso (right) will support the HIV/AIDS prevention work

of the Asocia^ao Saude da Familia in Brazil. This NGO is one of

seven thatAIDSCAP helped establish through its

NGO Partnership Initiative.

89

8.1.
NGO “Clusters”:
A Coordinated Approach to
HIV/AIDS Prevention and Care
One of the few lawyers in

port in a city or region to

monthly meetings, dis­

do, we share our prob­

Tanzania who advises

coordinate activities,

persing funds, overseeing

lems,” Mazora said. “This

people living with HIV/

share resources and infor­

financial management of

is what happens in a clus­

AIDS and their families,

mation, and avoid duplica­

activities and submitting

ter. Sometimes you’re so

Nuru Mazora meets half

tion of effort.

reports.TAP facilitates

depressed you regret you

The USAID-funded

meetings among the clus­

took the job, and you

referrals from local

TAP, which was imple­

ters and provides techni­

have somebody to boost

NGOs.

mented byAIDSCAP

cal assistance and training

your morale.”

from 1994 to 1997, orga­

to help cluster members

For Margaret Mshana,

nized these clusters in the

strengthen their technical,

director of a grassroots

NGOs had nowhere to

nine regions of the coun­

management, planning and

women’s organization

refer people living with

try most affected by HIV/

evaluation skills.

called KIWAKKUKI in the

AIDS who had legal prob­

AIDS. In each region,TAP-

lems,” she said, explaining

facilitated workshops

mechanisms within the

est benefit of cluster

that clients usually come

enabled representatives of

clusters include monthly

participation is the train­

to her with questions

participating NGOs to

meetings of a cluster

ing provided by TAP. Par­

of her clients through

“Before they found out
about my work, these

town of Moshi, the great­

about discrimination,

understand the individual

steering committee of five

ticipation in training-of-

inheritance laws, writing

and collective strengths

to six NGO representa­

trainers workshops TAP

wills and protections

and weaknesses of their

tives to review the

held for members of the

against rape and domestic

organizations, and this

progress of their joint

Kilimanjaro cluster

violence.

understanding allowed

program and quarterly or

equipped KIWAKKUKI’s

The NGOs learned

them to rapidly design

semiannual meetings of a

volunteers to go out into

about the legal aid ser­

joint plans for a compre­

subcommittee consisting

the villages and train

vices provided by

hensive, region-wide HIV/

of two representatives

others as HIV/AIDS peer

Mazora’s employer, Com­

AIDS prevention, care and

from each NGO in the

educators and commu­

prehensive Community

support program.To­

cluster. But informal com­

nity-based counselors.

Rehabilitation in Tanzania,

gether they developed

munication among cluster

when they joined the Dar

project goals and strate­

members is much more

nities are rare for groups

es Salaam HIV/AIDS “clus­

gies and mapped out

frequent, as people from

as small as hers, explained

ter.” Their experience

which target populations

the different NGOs con­

Mshana, whose organiza­

illustrates one of the

and technical areas each

fer to plan joint events,

tion has about 450 mem­

advantages of the cluster

NGO would cover.

seek advice and assis­

bers but a staff of only

strategy employed by the

In each cluster, an

tance, make referrals or

three.

“anchor” organization

just give other each some

Mazora agrees that the

training available to small

organizations as members

Tanzania AIDS Project

selected by the participat­

much-needed encourage­

gether the NGOs work­

ing NGOs is responsible

ment.

ing in HIV/AIDS

for hiring staff to manage

prevention, care and sup-

the cluster, holding

(TAP), which brings to­

90

Formal coordination

Such training opportu­

“I find that people who

of a larger cluster is an

work in the same field as I

important advantage. As

an example she cites the
training she received in
counseling, which helped
her cope with the hardest
part of her job—knowing
what to say to a client
who is distraught, angry,
depressed or even sui­
cidal.
“When I started work­
ing, I never knew anything

about counseling,” she
said. “So I would say,‘I can
provide legal service, but I
cannot ta/k to them.’ I’ve
been able to attend some
seminars on counseling
and have greater skill and
knowledge.”
Like Mazora and
Mshana, cluster partici­
pants believe that the

experience has been a
positive one. Although
inevitable disagreements,
misunderstandings and
rivalries arise as cluster
members struggle to
cooperate, the benefits of
their collaboration—and
the urgency of their
shared goals—help them
overcome these difficul­

ties.The results have been
more efficient division of
responsibilities, less un­
healthy competition for
support, strong collabora­
tive relationships among
NGOs and, ultimately,
more effective HIV/AIDS
prevention, care and sup­
port services.

Margaret Dadian/AIDSCAP

-

•
•

wi' pit

Tanzanian NGO leader Margaret Mshana makes a point at an HIV/AIDS workshop for policymakers in the Kilimanjaro
cluster.

91

Promoting a Rapid
Community Response to
HIV/AIDS
In Lagos, the largest city in

32,000 people in just 12

with the NGO’s ability to

NGOs to respond to

Nigeria, traffic jams are an

weeks.The NGO’s six

manage the grant funds.

community needs while

inescapable part of daily

mobile health educators

As a result,AIDSCAP

developing their own

life. Many people spend as

also distributed 1,500

contracted with Health

organizational capacity to

long as four hours a day

posters, 8,000 pamphlets,

Matters to expand the

manage HIV/AIDS activi­

traveling to and from

7,540 bumper stickers

traffic jam intervention to

ties, learning from the

their jobs.

and 21,600 condoms in

ten additional sites and to

experience before taking

the three most congested

train 20 more mobile

on larger projects.

areas of Lagos.

health educators.

But for the Nigerian
NGO Health Matters Inc.,

AIDSCAP worked with

Health Matters Inc. is

its resident advisors in

advisor in Nigeria was

one of 214 local organiza­

each country to stream­

Taking advantage of the

impressed with what

tions that benefited from

line application and re­

large captive audience

Health Matters had ac­

the AIDSCAP Project’s

porting procedures.

mired in Lagos traffic each

complished with a small

rapid-response grants.The

Applicants were asked to

day, Health Matters’ mo­

amount of money and

grants enabled these

fill out a simple form,

a traffic jam is an oppor­

AIDSCAP’s resident

tunity, not an annoyance.

providing brief statements

bile health educators
weave their way through

on what an activity would

lines of cars and buses,

accomplish, why it was

stopping to talk to com­
muters and pedestrians

needed, how it would be
Al DSC AP/Senegal

implemented and evalu­

about HIV/AIDS preven­

ated, and a short descrip­

tion and to distribute

tion of the applying

condoms and educational

organization. A typical

materials.

application consisted of

With U.S.$3,000 from
AIDSCAP’s Rapid-Re­

six to seven paragraphs.
These applications were

sponse Program, a flexible

reviewed by the country’s

funding mechanism for

AIDSCAP resident advi­

supporting small, innova­

sor, who awarded grants

tive interventions, Health

ranging from $900 to

Matters was able to reach

$5,000. At the end of an
activity, the grantee sub­

mitted a two- to three-

page narrative report and

Community members exchange

ideas during a meeting spon­
sored byARLS.

92

a one-page financial report.

deaf leaders and sign lan­

With these simple appli­

guage professionals to

cation and reporting proce­

educate the country’s

dures, the Rapid-Response

200,000 deaf adults about

Program made it possible

prevention and developed

for AIDSCAP to respond

and distributed posters and

quickly to community inter­

other printed materials on

est in HIV/AIDS prevention

HIV/AIDS in sign language.

without overburdening the

And in India, the Media

developing infrastructures

Foundation established a

of new community-based

resource center that gives

organizations. It also gave

local NGOs access to

AIDSCAP programs the

international sources of

flexibility to fund creative

HIV/AIDS information,

projects that were not

helps them identify sources

envisioned when country

of technical assistance and

strategies were designed.

educational materials, and

Rapid-response grantees

developed educational ma­
terials, organized special

events, and trained outreach

provides AIDS counseling

Lessons Learned
Planning and Monitoring

services.
AIDSCAP’s Rapid-Re­

sponse Program funded

workers and volunteers.

more than 230 such activi­

ARLS (the Senegalese Asso­

ties from 1993 to 1997.

ciation Rurale de Lutte

With modest amounts of

Centre le SI DA), a group of

money, organizations such

mostly women farmers,

as Health Matters, ARLS,

used an AIDSCAP grant to

Beza Lewegen and the

build a rural network of

Media Foundation were

volunteer HIV/AIDS educa­

able to reach more than a

tors that works with

million people worldwide

marabouts (Islamic teachers)

with life-saving information

and other community insti­

about preventing

tutions. In Ethiopia, the

HIV/AIDS. ■

NGO Beza Lewegen trained

percent of country programs were directed by resi­
dent advisors from the host country or neighboring
countries and almost all other field staff were host­
country nationals. Their contacts and understand­
ing of the local situation made it possible to begin
programs more rapidly, resulted in stronger rela­
tionships and better communication with
AIDSCAP’s partners in each country, and enhanced
local ownership of the programs.
Recognizing that the skills and experience of the
staff of these field offices represented a valuable
resource in each of the host countries, AIDSCAP
launched an NGO Partnership Initiative in 1996 to
help this newly developed capacity continue beyond
the AIDSCAP Project. Through this initiative,
AIDSCAP and FBI assisted seven of its offices in
establishing indigenous NGOs and provided train­
ing in business planning, fund raising, proposal
writing and financial management. These skills have
enabled the new NGOs in Brazil, Cameroon, the
Dominican Republic, Ethiopia, Haiti, Honduras and
Zimbabwe to raise funds from a variety of sources
so that they can continue to provide technical and
financial support to other local organizations work­
ing to prevent the spread of HIV/AIDS.

• A systematic planning process articulates a clear
vision for a program, provides a framework for
implementation and makes it easier to assess
program progress.

In each of its 19 major country programs,
AIDSCAP worked with representatives of the
host-country government, USAID Mission,
NGOs, community leaders, potential target audi­
ences, influential stakeholders, other donors and
technical experts to conduct needs assessment and
develop detailed, multiyear strategic and imple­
mentation plans. This process ensured that pro­
grams were responsive to local needs, gave long­
term direction to program efforts and enhanced
donor coordination.
• Joint planning by all of the organizations that
will be involved in implementing a country pro­
gram results in stronger individual projects and
encourages valuable collaboration among the
organizations.

93

8.3
Collaborative Design Process
Creates Integrated Prevention
Programs
When representatives

at the end of the two

one of the facilitators

ciated the opportunity

often Honduran

weeks, 10 projects

at the Tanzania work­

to learn from each

organizations met in

had been created, the

shop. “They really had

other. “The interaction

Tegucigalpa in July

contracts between

a chance to put it into

among all the institu­

1995 to design a na­

AIDSCAP and the

immediate practice.”

tions involved gener­

tional HIV/AIDS pre­

participating organiza­

The workshops

vention project, many

tions had been signed,

were also a “very

better responses and

of them had never

and those organiza­

effective team-building

strategies,” said Juan

worked together

tions had received the

tool,” Goodridge said.

Ramon Gradelhy of

before.

initial funding for

Designing their

Comunicacion y Vida,

project implementa­

projects together gave

a Honduran HIV/AIDS

tion.

“It’s the first time

that a project of this

participants a clear

prevention project

magnitude has been

AIDSCAP used a

understanding of each

sponsored by the

developed where the

similar process for its

organization’s role in

municipality of San

MOH (Ministry of

programs in Tanzania

the comprehensive

Pedro Sula.“All of

Health) and local

and Indonesia, holding

program and of how

those involved in this

organizations have

project development

they could collaborate

common effort shared

worked together to

workshops after initial

to achieve the overall

experiences and

define strategies for

assessments con­

objectives of the pro­

helped each other.”

intervention,” ex­

ducted with the indi­

gram.

plained Maria Luisa

vidual organizations

Gonzales of the

and training sessions

workshop, for ex­

nizations well as they

Centro de Orienta-

in project design.This

ample, the Ministry of

carried out the

process gave partici­

Health designed a

projects they had

cion y Capacitacion en

94

ated a search for

At the Honduras

This collaborative
spirit served the orga­

SIDA, a participant in

pants an opportunity

subproject to

designed. In Indonesia,

the planning process.

to receive technical

strengthen its STD

Tanzania and Hondu­

AIDSCAP brought

assistance in project

services. Other par­

ras, participants said

the ten public and

design, proposal devel­

ticipating organiza­

that it strengthened

their ability to coordi­

private organizations

opment, financial plan­

tions then added an

together for two

ning and computer

STD referral compo­

nate their activities

weeks shortly after an

technology as they

nent to their projects

and to work together

intensive one-week

applied these new

to ensure that project

to achieve common

course in project

skills.

staff and volunteers

goals. ■

would encourage

planning.The goal was

“Participants didn’t

to use these new skills

just learn the theory

to develop a compre­

of effective AIDS pro­

audiences to use

hensive HIV/AIDS

gram design,” said Gail

these improved ser­
vices.

members of the target

prevention program

Goodridge, AIDSCAP

consisting of comple­

associate director for

Participants in all

mentary projects. And

country programs and

three countries appre­

AIDSCAP’s experience in Tanzania, Honduras
and Indonesia provides a model for such team
building, with an intensive design process that
brings together all the implementing agencies in
a country to develop complementary projects
(Box 8.3).
• Effective project monitoring requires intensive
on-site support but can be facilitated with appro­
priate, easy-to-understand tools.
Frequent site visits by program managers pro­
vide the best vehicle for monitoring activities in
the field; however, such visits are not always pos­
sible given staffing limitations, geographic dis­
tance, travel costs and other constraints. One
strategy is to complement visits to project sites
with the use of process indicator monitoring
forms that require implementing agencies to
report monthly progress toward achieving previ­
ously agreed-upon project targets, such as
condoms distributed, individuals reached
through interpersonal communication, materials
distributed and training sessions conducted.
Monitoring such process indicators can help
managers identify when it is necessary to modify
the project approach (and budget) to ensure
achievement of project objectives.

• Mechanisms for reviewing and revising project
objectives, strategies and activities are essential to
ensure that HIV/AIDS interventions remain
responsive to the evolving epidemiology of the
epidemic and the changing needs of target audi­
ences.

AIDSCAP found that requests by implementing
partners to modify or augment project designs
were often a demonstration of active, attentive
program management and commitment to im­
proving the effectiveness of activities.
Large national or regional programs can also
benefit from periodic internal assessment and re­
view. Reviews by senior managers of each of
AIDSCAP’s major country programs allowed pro­
gram managers to make mid-course corrections to
program strategies or management structures,
incorporate innovative technologies and strategies
from other programs, expand successful interven­
tions and boost staff morale by recognizing pro­
gram accomplishments.
In Jamaica, for example, the AIDSCAP program
was expanded to reach people in the high-prevalence areas of western Jamaica as a result of a pro-

gram review conducted in 1994. The geographic
coverage of AIDSCAP’s STD activities in Senegal
was also broadened at the recommendation of a
review team, and several full-time consultants were
hired to meet the increasing technical and manage­
ment needs of the program. The participation of
senior program managers and representatives of
the donor in these reviews allowed for rapid joint
decision making.

• Ensuring regular input from clients in project
design and implementation is essential for effec­
tive programming.

AIDSCAP maintained communication with its
target audiences through formative research and
qualitative evaluation and by encouraging their
participation as peer educators and project staff.
The project found that peer education was not
only a good way to reach target audiences, but
also provided a regular source of valuable feed­
back about clients’ needs and perceptions of
prevention activities and services.

Forging Partnerships
• Formal collaborative relationships among all
the organizations working on HIV/AIDS preven­
tion in a region can strengthen prevention efforts,
create opportunities to share resources and reduce
duplication of effort.

In Ethiopia, for example, AIDSCAP brought
together NGO, community and industry repre­
sentatives and federal and local government offi­
cials to coordinate HIV/AIDS prevention activi­
ties in four regions that were project “focus sites.”
Members of these “focus site intervention teams”
carried out their own interventions, but met
monthly to ensure that their individual projects
fit within the larger regional HIV strategy, that
the designated target groups were being reached
and that efforts were not unintentionally dupli­
cated. They also shared resources and planned
joint events. Team members said that this col­
laboration and coordination enabled their orga­
nizations to accomplish much more than they
could have done alone and built stronger, more
productive relationships between the public and
private sectors in the four regions.
Another effective mechanism for encouraging
collaborative partnerships among organizations
working in HIV/AIDS is the “cluster” approach
AIDSCAP established in Tanzania (Box 8.1).

95

• Programs can be structured to ensure collabo­
ration between governmental and nongovernmen
tai organizations.

A number of AIDSCAP country programs built
such collaboration into their program designs
and into their grant agreements with local orga­
nizations. In Honduras, for example, the project
helped four regional health administrations of
the Secretariat of Public Health strengthen STD
services and created a referral system supported
by the local NGO implementing partners. Simi­
larly, AIDSCAP strengthened STD services at
select district health clinics in Ethiopia and in­
cluded STD prevention and referral in its agree­
ments with NGOs working in those districts.

• Linkages between international and domestic
HIV/AIDS organizations can be mutually benefi­
cial, particularly when the organizations work
with similar populations.

AIDSCAP sponsored a number of exchanges
between U.S. and developing country NGOs,
including a project that paired NGOs from the
Dominican Republic with U.S. NGOs that work
with Dominican immigrants. NGOs from both
countries were able to share intervention meth­
odologies and materials developed for working
with Dominican populations. They also identi­
fied opportunities for further cross-country col­
laboration. Participants in this exchange decided
to form a coalition to work on issues of common
concern, including providing referrals to support
services for HIV-positive people who travel fre­
quently between the two countries.

Mobilizing Communities
• Working with existing organizations is gener­
ally more effective and sustainable than setting up
new ones.

AIDSCAP found that organizations with estab­
lished links to their communities—even NGOs
with no HIV/AIDS experience—were generally
better able to respond to changing community
needs for HIV/AIDS prevention and care than
new NGOs created in response to the epidemic.
These organizations can mobilize quickly, pos­
sess a ready infrastructure into which they can
incorporate HIV prevention and AIDS care,
often have a shorter learning curve and are able
to maintain their efforts with little technical

96

assistance. Organizations that have deep roots in
a community, such as the Family Guidance Asso­
ciation of Ethiopia and the Community Devel­
opment Association in Thailand, are also in a
better position to sustain recently integrated
HIV/AIDS services.
• Community-based groups with little or no
previous HIV/AIDS experience can be mobilized
to support HIV/AIDS prevention in their commu­
nities if the process is kept simple.

Donors must be careful not to overwhelm com­
munity-based groups with overly bureaucratic
application, monitoring and reporting require­
ments. AIDSCAP found that small grants with
streamlined application and reporting proce­
dures are a good way to encourage innovative
community-based approaches to prevention and
to help community-based groups develop skills
in HIV prevention and program management
(Box 8.2).

Sustainability
• The tension that often exists between achieving
direct program results and building long-term
capacity can be resolved, but only when capacity
building objectives have been clearly stated and all
the stakeholders have agreed that capacity build­
ing is a priority.
Better methods of defining needs and measuring
improvements in capacity, such as the collabora­
tive self-assessment and strategic planning pro­
cess developed by AIDSCAP, could make it easier
to strike an appropriate balance. Funding should
be allocated specifically to achieve capacity
building objectives.

• Effective management of donor-funded na­
tional or regional programs requires a critical
mass of local staff.

The initial design of the AIDSCAP Project called
for a minimal country office staff of manage­
ment (resident advisor) and administrative (fik
nance officer and secretary) personnel. Local
consultants or AIDSCAP regional and headquar­
ters staff were expected to provide additional
support. But senior managers soon recognized
that AIDSCAP resident advisors needed addi­
tional long-term, on-site capacity to help them
provide the necessary technical and program

support to local organizations implementing
AIDSCAP country programs.
All the country programs increased the size of
their program management staff and some added
full-time technical experts. Such investments made
it possible to manage programs more efficiently
and provide more responsive oversight and sup­
port. And by supporting and strengthening the
capacity of local program management and techni­
cal staff, AIDSCAP contributed to the
sustainability of HIV/AIDS prevention efforts in
the host countries.

Recommendations
• To ensure that programs are responsive to local
needs and to enhance collaboration and
sustainability, international HIV/AIDS programs
should involve government and community
leaders, influential stakeholders, other donors and
technical experts, and all implementing partners
in a systematic joint planning process.
• Periodic opportunities to review and revise
objectives, strategies and activities should be built
into programs and projects.
• International HIV/AIDS prevention programs
should seek to work with existing organizations
that already have strong links to their communi­
ties—even groups with no HIV/AIDS experi­
ence—rather than establishing new community­
based organizations.
• HIV/AIDS programs should consider creating
formal collaborative relationships among all the
organizations working on HIV/AIDS in a region
to strengthen prevention efforts and reduce
duplication of effort. Donors can use contractual
agreements with government agencies and local
organizations to encourage coordination of the
HIV/AIDS services provided by the private and
public sectors.
• Donors, contractors, implementing agencies
and beneficiaries should clearly articulate reason­
able benchmarks and schedules for achieving both
direct program results and long-term capacity
building.

Future Challenges
Maintaining Momentum
With the realization that the epidemic is not a
short-term crisis comes the challenge of main­
taining the enthusiasm, energy and commitment
that drove early HIV/AIDS prevention efforts.
Program managers need to find ways to reduce
“burnout” among staff whose work is difficult
and often discouraging and to document slow
but real progress in prevention to convince gov­
ernments and donors of the importance of con­
tinued support.

Overcoming Adversity
The constraints caused by war, civil strife and
natural disasters make it more difficult to man­
age effective programs. Yet the populations af­
fected by these calamities are particularly vulner­
able to HIV/AIDS due to displacement, disrup­
tion of families and lack of access to services.
Program managers need to identify and docu­
ment strategies for overcoming such constraints
and implementing effective prevention pro­
grams.

Linking Prevention and Development
Building stronger linkages between HIV/AIDS
programs and other development programs
would make HIV/AIDS interventions more sus­
tainable and enable them to address many of the
social, structural, environmental and economic
factors that influence sexual risk behavior. Gov­
ernments, NGO coalitions, donors and other
international organizations need to establish
formal mechanisms for encouraging collabora­
tion among people and organizations working in
various development sectors.

Sustaining Prevention and Care
Perhaps the greatest challenge facing those who
manage and support HIV/AIDS programs is
sustainability. Stronger partnerships between
donors, governments, NGOs and the private
sector are needed to help sustain HIV/AIDS
programs. Fostering greater community owner­
ship of programs would also increase their
sustainability by reducing dependence on out­
side donors.

97

Preven
an Care:
Mutually Reinforci
Approaches
With no cure or vaccine available, the global
strategy against HIV/AIDS has focused on pre­
vention. However, as the number of people be­
coming infected continues to rise at an alarming
rate and millions of HIV-positive people fall ill,
there is an increasing need for care and support
services for people living with HIV/AIDS.
In this second decade of the pandemic, there is
also a growing recognition of the contribution care
can make to prevention efforts. People living with
HIV/AIDS are valuable partners in prevention,
giving the epidemic a human face and bringing the
weight of their experience to prevention messages.
And with no vaccine on the horizon, sustained

behavior change over time remains the only way
those infected can prevent HIV infection in others.
However, if people living with HIV/AIDS feel
abandoned by care services, they are less likely to
acknowledge their status or to be motivated to
protect others.
Communities throughout the world are search­
ing for affordable models of prevention and care
that meet their needs. Providers are expanding
services from the traditional hospital crisis inter­
vention model to develop community-based strat­
egies for improving the quality of life for people
living with HIV/AIDS and supporting their fami­
lies and loved ones.

Exploring Models of Care
and Prevention

AIDSCAP successfully integrated care and pre­
vention into community-based structures and
services in a number of countries. In Kenya , MAP
International won over a skeptical clergy to the
cause of HIV/AIDS prevention and support, creat­
ing a powerful grassroots campaign based in the
churches and the communities they serve. Surveys
conducted in 1996 showed that the churches in the
MAP areas were more likely to provide home care
for people living with HIV/AIDS, develop peer
counseling programs, and counsel couples on risk
reduction. In Jamaica, the Community Outreach
Program expanded the support services provided
by both governmental and NGO organizations by
sensitizing health service providers to the needs of
people living with HIV/AIDS and developing a
referral resource manual. And in Tanzania,
strengthening NGOs and other community-based
groups to provide both prevention and care forms
the cornerstone of the country program, resulting
in integrated community-based services.
To meet the growing demand for practical tools
to help those working in prevention respond to the
increased demand for care, AIDSCAP developed a
manual on HIV/AIDS care and support projects. A

In AIDSCAP’s work with communities affected
by the epidemic, we found that it can be difficult
to separate prevention from care, and that doing
so may reduce the potential effectiveness of a
prevention program. Although AIDSCAP’s man­
date was primarily to build local capacity for
prevention, the project was able to conduct
short-term pilot interventions of community­
based HIV/AIDS care and support in a few
countries.
A small grants program for AIDS care and man­
agement enabled AIDSCAP to respond quickly to
support innovative, community-based initiatives
for the care and management of people with HIV/
AIDS. In Haiti, for example, AIDSCAP’s care and
management grants helped several hospitals to
change the focus of care from the hospital to com­
munity-based prevention and home-based man­
agement of people living with HIV/AIDS. Through
these projects, community members became di­
rectly involved in training, home care, developing
educational materials, and prevention education.

98

concise guide to designing, implementing and
evaluating such projects, the manual helps health
and development organizations integrate HIV/
AIDS care and support into their other activities in
communities. 1 Three other AIDSCAP publications,
part of the “Emma Says” comic book series, help
communities, families and individuals affected by
HIV/AIDS learn how they can come together to
end stigma and improve care (Box 2.3, page 24).2
Several studies, mainly from developed coun­
tries, suggest that care and support in the form of
counseling and testing can play an important role
in encouraging preventive behavior.3,4 AIDSCAP
counseling and testing study at centers in Kenya
and Tanzania and at a third UNAIDS-supported
site in Trinidad assessed the efficacy of this inter­
vention in developing countries (Box 5.1, page 54).
Another study sponsored by AIDSCAP in Tanzania
was one of the first to examine whether care and
support for people newly diagnosed with HIV can
encourage preventive behavior change over time
(Box 9.1).

Sean Sprague/Panos Pictures

Lessons Learned
• Providing care and support for HIV-positive
people in a community promotes acceptance of
HIV/AIDS as a community problem and reduces
stigmatization of people living with the virus.
In the isolated mountain communities served by
Hopital de Fermathe in Haiti, involvement in
care and support helped community members
understand that HIV/AIDS is not the result of a
supernatural curse. Acceptance of HIV/AIDS as
an illness led to less stigmatization of people
with HIV/AIDS and greater willingness to speak
openly about preventing its transmission. An­
other AIDSCAP-supported project in Haiti re­
sulted in a dramatic shift in the attitudes of staff
at the Grace Children’s Hospital, who had been
reluctant to care for people with HIV/AIDS. At
the request of hospital staff and other caregivers,
the hospital expanded a support group for
people living with HIV/AIDS to include family
members, other community members, and hos­
pital staff and patients, fostering a sense of soli­
darity among all these groups.

• Care and prevention efforts are more likely to
be sustained if they are integrated into existing
community-based structures and services.

The USAID-funded Tanzania AIDS Project man­
aged by AIDSCAP, which brought together
NGOs working on HIV/AIDS in a region to
strengthen prevention and care, illustrates the
benefits of building on community resources.
Ownership and control of these programs,
implemented by a “cluster” of NGOs in each of
nine regions, remain in the hands of the commu­
nity institutions.
The Tanga AIDS Working Group, for example, is
an association of physicians, nurses and public
health workers who coordinate cluster activities in
and around the Tanzanian town of Tanga. Their
involvement has made care an integral part of pre­
vention activities in the cluster and has encouraged
greater public sector support for HIV/AIDS pro­
grams. Government support for cluster activities,
which includes providing office space, furniture
and some transport costs and paying the salaries of

-A young patient fights tuberculosis and HIV/AIDS in a

hospital in Leogane, Haiti.

99

9.1
Study Explores Link Between
Prevention and Care
Passersby barely notice

ences like those of the

people who received

counselor talked to family

the large shipping con­

Tanga AIDS Working

enhanced support and

members about what it

tainer that stands at the

Group suggest that HIV/

those who received post­

means to be HIV-positive

test counseling only.

and how they could work

together.”

edge of the hospital

AIDS care and prevention

grounds in a small Tanza­

are complementary, but

Members of the experi­

nian market town. But

only a handful of stud­

mental group participated

others—mostly young

ies—mainly in developed

in regular counseling

Dr. Gad Kilonzo started

men and women—stop

countries—have exam­

sessions and some re­

recruiting participants at

ined the role of care and

quested home visits.

three sites in the Tanga

support in reducing risk

These home visits

and go inside.
Some enter hesitantly,

dreading the news that

behavior.

may await them. Others

AIDSCAP’s study in

Principal investigator

district in November

were for support rather

1996. People were asked

than medical care, ex­

to enroll voluntarily in the

hurry inside, seeking reas­

the Tanga district was

plained Dr.Joan MacNeil,

study after the second of

surance. For the container

designed to detect differ­

AIDSCAP’s associate

two post-test counseling

serves as the Muheza

ences in risk reduction

director of behavioral

sessions. A total of 157

office of the Tanga Al DS

among HIV-positive

research.“During a visit, a

people, ages 22 to 35,

Working Group, a com­
munity-based association

of health workers that
provides HIV pre- and

post-test counseling, HIV/
AIDS prevention services
and continued counseling
and support for people

living with HIV/AIDS.

Joan MacNeil/AIDSCAP

. w •
£

...

The makeshift office
was also one of the sites

'■

'Si

''i

for a unique research
study, one of the first to
assess how providing such

care for people living with
HIV/AIDS affects their
sexual behavior. Experi-

Tanga AIDS Working Group staff
confer outside the converted

- -

shipping container that serves as

their office in Muheza.

100

A- -

public health workers who devote as much as 40
percent of their time to HIV/A1DS interventions,
has laid the foundation for a sustainable program.

• HIV/STD prevention programs in the work­
place lead to a more tolerant and accepting
attitude among workers toward HIV-positive
employees, resulting in a positive effect on morale
and productivity.
chose to participate.

aged those who were posi­

Members of both groups

tive and healthy to be more

were interviewed at enroll­

open about their status and

ment, after three months

led to the creation of the

and at the end of the six-

first HIV-positive support

month study period. Re­

group in Tanga. Final results

searchers collected

will be available by the end

information about illnesses,

of 1997 and will be shared

hospital and clinic visits,

with policymakers, donors,

episodes of sexually trans­

program managers and

mitted disease and, for

health care providers.

women, pregnancy.They

“The results can be

asked about risk behavior,

used to develop strategies

condom use and other

for supporting behavior

prevention strategies, dis­

change over time among

cussing HIV with partners,

people living with HIV/

and relationship histories.

AIDS,” Dr. MacNeil said.

Participants also discussed

“This is one small study,

their thoughts about their

but it will give us a better

condition, the reactions of

understanding of one of

their families and communi­

the most critical issues in

ties, and the impact of their

this second decade of the

HIV status on decisions

pandemic.” ■

about having more children.

Studies conducted by AIDSCAP on the impact of
HIV/AIDS on 17 sub-Saharan businesses found
that managers of organizations with HIV/AIDS
prevention programs believe their workplace
activities are increasing tolerance and productiv­
ity as well as reducing employee risk behavior,
health costs and other business costs. Many
noted that greater acceptance of people living
with HIV/AIDS reduces the potential for work
stoppages, which have occurred at other compa­
nies because employees were afraid to work with
HIV-positive coworkers.5
• There is a high demand for HIV counseling and
testing services in many developing countries.

HIV counseling and testing centers established in
Tanzania and Kenya as part of a study sponsored
by AIDSCAP and UNAIDS had no trouble re­
cruiting study participants. In fact, people kept
coming to the centers for counseling and testing
even after recruitment efforts ended. At the re­
quest of community members, this valued ser­
vice was continued when the study concluded.

All of this information is
expected to shed light on

how people make decisions

during the first months after
they learn that they are

HIV-positive and on the

• Provision of care can be an entry point for
discussions about behavior change and can
provide opportunities for personalized prevention
messages in traditional and nontraditional
settings.

kinds of support that en­

courage them to adopt
preventive behaviors. Pre­
liminary findings revealed

that most participants cited
abstinence as their main

prevention strategy, yet they
also said they wished to
have children or additional
children. In addition, ongoing

care and support encour­

In Haiti, for example, religious leaders trained as
community-based caregivers by Hopital de
Fermathe provided counseling to people living
with HIV/AIDS in their homes, taught their
families how to provide basic care and nutrition,
and helped them access other support services.
The caregivers also used these home visits to talk
to HIV-positive people and their families about
prevention. In Tanzania, providing care and sup­
port has enabled TAP to involve people living
with HIV/AIDS in educating their families,
neighhjMs^ij^^^^g^femtprevention.
/C^ZCPHE - SOCHAHA
I 7 (
Kora manga la
\ v^\Bangaiore - 34^

(CL1C';

101

• Peer educators and others working in commu­
nities to prevent HIV transmission are increas­
ingly called upon to provide care and support to
people living with HIV/AIDS and their families.

A study of peer education in 21 AIDSCAP
projects found that in many countries, people
are looking to community-based prevention
educators for HIV/AIDS counseling, care and
support.6 In Zimbabwe, several AIDSCAP-spon
sored projects responded to changing commu­
nity needs by teaching trainers basic home care
techniques to pass on to peer educators. And in
Nigeria, AIDSCAP expanded its peer education
training curriculum to include support for
people living with HIV/AIDS.
• An educational approach is useful for introduc­
ing the concept of peer support groups for people
living with HIV/AIDS.

Peer support groups can reduce fear, decrease
isolation and encourage HIV-positive people to
educate others about HIV/AIDS. But participat­
ing in a support group can be difficult for people
in cultures where such group processes are a new
idea. The NGO Jamaica AIDS Support found
that it was more effective to start groups with an
educational focus, inviting people to meetings to
learn about how to live with HIV/AIDS. After a
number of meetings, these gatherings often de­
veloped into true support groups.

Recommendations
Many questions remain about how to best pro­
vide care and support for people living with
HIV/AIDS and about the relationship between
care and prevention. Operations research is
needed to:

Henny Allis/Panos Pictures

A young Tanzanian AIDS patient. AIDSCAP worked with local NGOs in Tanzania to integrate HIV/AIDS care and support with
prevention efforts.

102

• Gain a better understanding of the types of
social, psychological and economic support
required to mitigate the virus’s impact on families.
In particular, studies should examine the role of
care in reducing social vulnerability to HIV in atrisk populations such as women and children.
• Identify models of care and support for people
with HIV/AIDS and their partners that can
influence HIV risk behavior.

of labor lost due to illness and absenteeism have
been documented, but increasing attention needs
to be paid to HIV and the workplace.

Future Challenges
Improving Cost Effectiveness

• Examine the effects of integrating HIV/AIDS
prevention with care at sexually transmitted
disease, family planning, tuberculosis, maternalchild health and other health clinics.

Determining how to make care and prevention
services more cost effective by improving accessi­
bility, affordability and acceptability represents
the major challenge for the future. To cope with
this challenge, health care planners must im­
prove health care delivery and develop new mod­
els of prevention and care.

• Explore the relationship between HIV and
productivity. Thus far, primarily anecdotal reports
suggest that if people with HIV are provided care
in a humane and non-discriminatory way, they are
more likely to resume a productive life. The costs

Developing new models of prevention and care
will require a shift in thinking from the notion of
individual risk to a new understanding of social
vulnerability and structural evolution. For pre-

Developing New Models

Betty Press/Panos Pictures

II
_

5)

I

An HIV-positive woman cares for her husband, who suffers from AIDS-related illnesses, in their home in Kigali, Rwanda.

103

vention, we need to explore more multidimen­
sional models of collective empowerment and
community mobilization. For care, we need to
build confidence in levels of care closer to home
and to encourage the development of alternate
providers and settings. At the same time, services
must become more responsive to the diverse
needs of people living with HIV/AIDS.

References
I.

2.

Reaching Youth
Young people under 25 now account for half of
all new HIV infections, with the most rapid
growth among women 15 to 24 years old. This
age group also has the highest rates of other
sexually transmitted diseases. To help reduce
young people’s vulnerability to infection, re­
search is needed to identify the best ways to link
STD/HIV prevention with care services for ado­
lescents and youth.

3.

4.

Adopting Long-Term Strategies
As earlier and more accessible testing and im­
proved treatments make it possible for people to
live longer with HIV/AIDS, they need support
and must engage in prevention for longer peri­
ods of time. More long-term strategies must be
developed for providing care and support and
for encouraging sustained behavior change.

104

5.

6.

HIV/AIDS Care and Support Projects (1997).
AIDSCAP BCC Handbook Series. Al DSCAPZ
Family Health International,Arlington,Virginia.
Emma Says Comic Book Series (1997).
AIDSCAP/Family Health International,Arlington,
Virginia.
Annie Learns to Help 2( I)
Emma Counsels a Family 2(2)
A Community Organizes 2(3).
Kamenga M, Ryder R, Jengi M, et al. (1991).
Evidence of marked behavior change associated
with low HIV-1 seroconversion in 149 married
couples with discordant HIV-1 serostatus:
Experience at an HIV counselling center in
Zaire.AIDS 5:61-67.
Padian N, et al. (1993). Prevention of hetero­
sexual transmission of human immunodeficiency
virus through couple counseling. Journal of
Acquired Immune Deficiency Syndromes 6:10431048.
Select Company HIV/AIDS Policies (1996). In
Rau B, Roberts M, eds. Private Sector AIDS Policy:
Businesses Managing HIV/AIDS, Module 6.
AIDSCAP/Family Health International,Arlington,
Virginia.
Flanagan D,Williams C, Mahler H (1996).Peer
Education in Projects Supported by AIDSCAP.
AIDSCAP/Family Health International,Arlington,
Virginia.

Crossing Bordlersi: Reaching Mobile
Popula
Populations
at Risk
Most HIV/AIDS prevention efforts are defined
by geography: they are designed, funded and
implemented country by country or in regions
within countries. But the epidemiologic and
behavioral factors that drive the epidemic know
no borders. In fact, mobile populations—and
those affected by transient traffic in the areas
where they live—are often at increased risk of
HIV/AIDS. These mobile populations, in turn,
can bring the epidemic from cities and towns to
more rural regions when they return to their
spouses and other sexual partners at home.
Mobile populations at risk of HIV infection
include transport workers, miners and other mi­
grant workers, military troops, refugees and
women who trade sex in tourist and transient ar­
eas. Their risk stems from the experiences they
share: separation from families and communities,

language barriers, limited entertainment options,
and easy access to alcohol, drugs and commercial
sex.
Reaching mobile populations with consistent
HIV/AIDS prevention messages and interventions
is a formidable challenge. Cross-border and tran­
sient areas tend to have less developed health care
infrastructures, including facilities for STD diag­
nosis and treatment, and mobile populations often
do not know where or how to access the services
that are available. The remote locations of most
transient towns, the cultural and language differ­
ences among the populations who pass through
them, and the generally higher crime levels and
security risks encountered in cross-border environ­
ments make it difficult to carry out successful HIV/
AIDS prevention programs.

Leading the Way

towns and port cities in Asia and the Pacific,1'6
leading to the design of some of the world’s first
cross-border prevention projects.
In Indonesia, in a pilot prevention project that
could serve as a model for other Asian port cities, a
shipping company’s management endorsed a com­
prehensive HIV/AIDS intervention, enabling out­
reach teams to work with Thai fishermen and their
Indonesian sex partners in the city of Merauke. In
the Lao People’s Democratic Republic, AIDSCAP
and CARE International used local festivals and
other innovative communication strategies to raise
awareness of HIV and increase condom use along
the border with Thailand. In the Philippines, the
Center for Multidisciplinary Studies on Health
Development reached thousands of fishermen and
their partners through interactive group sessions.
And assessments along Nepali and Indian trucking
routes led to successful collaboration between
projects on both sides of the India-Nepal border
(Box 10.1).

During the late 1980s the AIDSTECH Project
(also funded by USAID and implemented by
FHI) pioneered interventions with mobile popu­
lations in Tanzania, where it carried out a suc­
cessfill HIV/AIDS prevention project targeting
truck drivers and their assistants and sex part­
ners along the country’s major transportation
routes. AIDSCAP used the lessons from this ex­
perience in Tanzania to design interventions
with transport workers in a number of African
and Asian countries, including Zimbabwe, Ethio­
pia, India and Nepal.
Beginning in 1994, AIDSCAP expanded this
early focus on drivers and truck routes to under­
standing sexual risk behavior among other mobile
populations and developing effective interventions
for them. A series of ethnographic studies sup­
ported by USAID’s Asia and the Near East Bureau
produced a wealth of information about the fac­
tors that promote the spread of HIV in border

105

AIDSCAP interventions targeting refugees, min­
ers and military troops have also yielded useful
lessons about how to reach and influence mobile
populations and their sexual partners. In Rwandan
refugee camps in Tanzania, AIDSCAP sponsored
the first large-scale early intervention against HIV
and other STDs among refugees.7 In South Africa,
where mining companies are beginning to develop
prevention activities for employees who often
travel across the country or from neighboring
countries to work in the mines, AIDSCAP and
Population Services International built upon the
prevention efforts of the management of South
Africa’s large Welkom area mines to establish a
condom social marketing project for miners and
the community around the mines. Annual condom
sales exceeded 249,000 in 1996 and had already
reached 213,000 in the first four months of 1997.
In its work with the armed forces in Thailand,
Cameroon and Zimbabwe, AIDSCAP found that
the military hierarchy and its traditional role in
educating young men offer ideal opportunities for

HIV/AIDS prevention education. An intensive
intervention that used Thailand’s military struc­
ture and the prevailing social networks among
soldiers was so successful in reducing risk behavior
that it was adapted for use throughout the Thai
military. In Zimbabwe, a local NGO called CON­
NECT worked with the Air Force and Army to
conduct workshops on HIV/AIDS issues for com­
manding officers, train military personnel and
their spouses as peer educators, and develop ap­
propriate communication materials. And the
AIDSCAP-sponsored Civil-Military Project on
HIV/AIDS worked with civilian and military
populations worldwide through the Civil-Military
Alliance to promote collaborative HIV/AIDS pre­
vention strategies.
AIDSCAP was also able to reach the female
partners—both commercial and casual—of mobile
men. For example, a study conducted by the
African Medical Research and Education Founda­
tion identified the most acceptable and cost effec­
tive ways to provide confidential STD services

BhorukaAIDS Prevention Project

? ' .'x,

is
i
I fJH

o

I

An outreach worker discusses HIV/AIDS prevention with truck drivers at the border checkpoint in Raxaul, India.

106

to women living along the Tanzania-Zambia truck
route.8,9 In South Africa, in conjunction with the
national AIDS program, the project reached out to
the sexual partners of miners with education and a
condom social marketing project in the mining
communities. AIDSCAP also supported pilot ef­
forts to help the wives and other steady partners of
mobile men protect themselves from infection—a
difficult challenge because these women often live
far from the original intervention sites .
But perhaps AIDSCAP’s greatest contribution to
strengthening HIV/AIDS prevention for mobile
populations has been its role in raising awareness
of the magnitude of the problem and in advocating
for interventions that cross borders, particularly in
Asia. The results of AIDSCAP’s assessments of HIV
risk among mobile populations and the experi­
ences from subsequent interventions were dissemi­
nated through position papers and other publica­
tions, presentations at international and regional
meetings, and smaller workshops and meetings. As
a result of these efforts, several international orga­
nizations and donors, including UNAIDS and the
British and Australian aid agencies, have agreed to
support AIDSCAP cross-border projects once the
project ends or have used AIDSCAP findings to
design new projects. And government officials who
participated in meetings that AIDSCAP organized
to encourage support for cross-border activities are
beginning to recognize the importance of facilitat­
ing such cooperation to slow the spread of HIV/
AIDS.

Lessons Learned
Cross-Border Interventions
• Mobile populations encounter increased
opportunities for HIV-risk behavior in border
towns and port cities.
Formative research conducted by AIDSCAP in
nine countries revealed that border towns and
port cities offer individuals greater access to in­
expensive commercial sex and alcohol than other
urban and trade areas.16 The remote locations of
border towns also isolates individuals from their
regular social networks, which typically regulate
individual behavior. As a result, mobile popula­
tions in cross-border environments, where men
greatly outnumber women, have more opportu­
nities to engage in risk-taking behavior.

• Consistent and complementary prevention
strategies and messages, implemented on both
sides of a border, can greatly enhance the effective­
ness of HIV prevention programs.

AIDSCAP’s experience working with NGOs in
neighboring border towns in Nepal and India
shows that consistency and collaboration are the
keys to implementing an effective cross-border
project (Box 10.1).
Similarly, community-based organizations
implementing AIDSCAP-supported projects in
Haiti and the Dominican Republic exchanged
ideas, shared resources and established networks
with counterpart groups working with Haitians
and Dominicans in New York, Florida and Massa­
chusetts. A brochure listing referral services in both
countries is just one of the ways in which the orga­
nizations from the Dominican Republic and New
York plan to reinforce HIV prevention messages
and provide services to a mobile Dominican popu­
lation that frequently travels between the two
countries.
• Intergovernmental authorization and support
are preferable, but not required, for assessments
and HIV/AIDS prevention interventions across
borders.

Blanket authorizations from all countries in­
volved would, of course, be most desirable, but
require long-term policy dialogue. In the mean­
time, prevention activities can proceed while
program managers and sponsors simultaneously
seek broader support for cross-border action.
The AIDSCAP-sponsored cross-border activity
in Nepal and India, for example, began in 1995
through the collaborative efforts of two NGOs
(Box 10.1). In 1996, AIDSCAP convened a threeday workshop for representatives of governments,
NGOs and private industry from India, Nepal and
Bangladesh to share lessons learned from the
project and to encourage further collaboration
among prevention projects in border zones.
UNAIDS is providing funding for a series of work­
shops to continue this dialogue, as well as support
for the India-Nepal border project after the
AIDSCAP Project ends. And Family Health Inter­
national is planning additional cross-border inter­
ventions in India, Nepal and Bangladesh.

107

10.1
The India-Nepal Partnership:
A Model Cross-Border Intervention
into Nepal from India and

Dhaaley Dai, a cartoon

transient border popula­

network of 15 STD clinics

condom figure, wards off

tions.

throughout India. In 1995,

because of its proximity

to GWP’s activities in

HIV with a shield in the

This collaboration

with technical assistance

border town of Birgunj,

grew out of AIDSCAP’s

from AIDSCAP, the Trust

Birgunj. Both border

Nepal.“Wear condoms.

research on HIV risk

opened a similar clinic in

towns are located at

Drive away AIDS,” reads

behavior along trucking

Raxaul and began linking

“zero points” where a

the message on billboards

routes in India and Nepal

it to GWP’s prevention

number of major high­

and posters. Just a few

and the Transport Corpo­

activities across the bor­

ways converge. About

hundred meters away in

ration of India’s (TCI’s)

der.

Raxaul, India, another

interest in protecting its

condom figure spreads a

workers from HIV/AIDS.

the site for the cross-

often stopping to load

similar message in Hindi.

Through its Bhoruka

border intervention be­

and unload trucks and to

Public Welfare Trust,TCI

cause it is the most

rest before continuing

had already opened a

important entry point

their drive.

The use of a slightly

modified Dhaaley Dai in

2,000 truck drivers pass

Raxaul was chosen as

through these points daily,

India (pretests revealed

that members of target
audiences there did not
identify with the tradi­

tional Nepali shield and
Michael Buja/AIDSCAP

did not like the condom’s

muscular limbs) is just
one example of the close

collaboration between
two AIDSCAP-sponsored
organizations on opposite

sides of the India-Nepal
border. By adopting simi­

chUSdT ohttst

lar strategies, methods
and materials, the Nepali

NGO General Welfare
Pratisthan and the

BhorukaAIDS Prevention
(BAP) Project in India
were able to create

complementary HIV/AIDS

prevention programs for

k’Sri wnaff

108

AIDSCAP Nepal’s

The Indian version of the popular cartoon

“Dhaaley Dai” logo

character

Women
• Reaching the spouses and regular partners of
migrant workers, business travelers and military
personnel with HIV prevention activities is
possible and essential in order to slow the spread
of HIV.

At every stage of the

we are grateful to GWP,”

project, the Indian and

he said. “Our staff has gone

Nepali staff of the two

there and worked with

projects worked together

them.They have taken us

to ensure that project goals,

to the field and showed us

strategies, evaluation indica­

how to interact with sex

tors, messages and services

workers.”

were consistent on both

The two teams also

sides of the border. And

organized several joint

because the projects had

events, including a World

adopted similar approaches,

AIDS Day Rally at the bor­

outreach workers from

der. But the most impor­

India and Nepal found it

tant part of the collab­

easy to coordinate their

oration was the joint STD

activities. Staff from BAP,

referral system. Because

GWP andAIDSCAP re­

people were often reluc­

viewed communication

tant to visit the highly vis­

strategies, materials, training

ible and well-known STD

curricula and condom social

clinic in Birgunj, GWP staff

marketing strategies devel­

used bilingual referral cards

oped for the Nepal program

to direct men and women

and adapted them for the

in need of STD services to

BAP Project in Raxaul.

SAP’s general clinic just

Frequent visits and com­
munication among field staff

across the bridge.
Such visible cooperation

were also important to

helped both groups gain

successful collaboration.The

credibility and support

GWP team in Birgunj and

within their communities. It

BAP staff visited each other

also meant that the target

regularly, and BAP person­

audiences of the transport

nel participated in staff

workers and their sex

training activities at GWP’s

partners received the same

Hetauda field office, just an

messages on both sides of

hour’s drive north of the

the border—a successful

border.

way of reinforcing the idea

BAP Project Manager

that HIV knows no bound­

Atanu Majumder noted that

aries and ensuring access

his staff had learned a great

to consistent prevention

deal from GWP’s outreach

options. ■

workers.“We didn’t have

the experience of how to
work with sex workers, so

It is difficult, but not impossible, to reach the
regular partners of mobile men when they do
not live at the men’s place of employment or
along the transportation routes. For example,
AIDSCAP-supported research conducted by the
Indian Institute of Health Management Research
in the Jaipur region of India successfully engaged
truck drivers and their wives in a dialogue about
HIV/AIDS and other STDs, which resulted in a
greater awareness about the epidemic and an
increased willingness among participants to
discuss sexual matters with their spouses. The
study results will be used to design an education
and counseling intervention that will target both
groups.
In Zimbabwe, AIDSCAP’s intervention with the
National Army and Air Force trained not only the
military men but also their spouses as peer educa­
tors. Women’s involvement ensured that both
members of a relationship received the same mes­
sages and were aware of the same risks, which was
particularly important because men in the Zimba­
bwe National Army are not permitted to live with
their spouses.

Refugees
• Effective HIV/A1DS prevention interventions
are possible in refugee camps.

Refugees are vulnerable to high-risk sexual be­
havior that can lead to HIV infection because of
family disintegration, general trauma and stress,
rape and violence, lack of access to condoms, the
breakdown of HIV/AIDS prevention interven­
tions, and increased impoverishment of women,
whose only option may be to exchange sex for
money or food. But to people who have been
displaced by war, civil strife or natural disasters,
HIV/AIDS may seem a distant threat as they
struggle to survive. Therefore, when AIDSCAP
launched the first large-scale early HIV/AIDS
and STD intervention in a refugee camp, no one
knew whether project staff could engage camp
residents in efforts to protect their long-term
health.

109

The pilot project, managed for AIDSCAP by
Care International in the Benaco camp for
Rwandan refugees in Tanzania, proved that HIV/
AIDS prevention programs can be effective in a
refugee setting. Using a comprehensive strategy
that included peer education, educational enter­
tainment, condom distribution and promotion,
and STD services, the project trained thousands of
peer educators, reached hundreds of thousands of
refugees with prevention messages, motivated
thousands of them to seek counseling and STD
treatment, distributed 1.5 million condoms in less
than a year, and reduced the number of people

who reported having more than one sex partner
(Box 10.2).

• Income-generation projects can help reduce the
risk of HIV infection among women and young
girls in refugee camps.
Relief agencies usually avoid creating income­
generating activities for refugees because they
fear that such activities would encourage people
to stay in camps indefinitely. Their objective is to
provide temporary relief to displaced people
until they can be repatriated or resettled. But in

Howard Davies/Panos Pictures

1

fl
w

Rwandan refugees arrive at the Benaco camp in Tanzania, where AIDSCAP launched the first large-scale, eai
prevention program in a refugee setting.

110

refugee camps where single women and girls are
at high risk of acquiring HIV infection because
many must exchange sex for food and other ba­
sic commodities, income-generating projects are
essential for HIV/AIDS prevention, giving par­
ticipants a means of supporting themselves with­
out threatening their health. In Benaco, women
benefited from income-generating activities such
as produce-growing cooperatives sponsored by
other NGOs working in the camp.
• Structural changes in the environment of a
refugee camp can play an important role in HIV/
AIDS prevention.
Environmental changes may be easier to make in
these temporary settlements than in more settled
communities, and they can help prevent HIV
transmission as well as improve the quality of
life. For example, in the Benaco camp in Tanza­
nia, relief officials learned that rapes often oc­
curred in the large communal latrines, which
were located a short distance from the camp and
shielded with pieces of plastic. Replacing the
latrines with smaller, four-family structures close
to people’s tents helped protect women and girls
from sexual assault and HIV/AIDS. Another
environmental change—construction of a com­
munity sports complex with a soccer field and
basketball court—helped combat the boredom
that often led to high-risk behavior. It also pro­
vided a venue for creative HIV/AIDS prevention
activities (Box 10.2).

Recommendations
• HIV/AIDS prevention activities should not
only target individuals passing through border
towns and port cities, but should also address the
factors that make cross-border sites such high-risk
environments.
Examples of such interventions include policies
requiring consistent condom use in brothels,
presumptive STD treatment of key groups, pro­
vision of free condoms in hotels and brothels,
and mass media messages warning of the height
ened risk of contracting HIV in border towns
and port cities.

• Linkages need to be established between
organizations implementing HIV prevention
activities on both sides of an international border.

By agreeing on common goals, strategies and
evaluation indicators, these groups can address
cultural differences and language barriers to
provide consistent, complementary and effective
HIV prevention messages and programs to the
populations they serve.
• The lack of bilateral treaties or memoranda of
understanding between governments should not
deter projects from establishing the cross-border
linkages needed for effective HIV/AIDS preven­
tion among mobile populations. Project directors
and managers can create successful linkages on
their own while seeking wider support from
national and regional governments.
• Refugee programs should incorporate HIV
prevention activities into reproductive health
services as early as possible and should address
environmental issues as refugee settlements
emerge, such as the placement of latrines and
creation of sports fields. They should also con­
sider organizing income-generation activities to
give women alternatives to trading in sex.

Challenges for the Future
BuildingTrust
Inspiring trust in target populations is one of the
keys to convincing them to change behaviors.
But establishing such relationships takes time
and repeated contacts, which are very difficult to
achieve with mobile populations. Programs need
to use a variety of methods to convey consistent
messages to mobile populations at different des­
tinations and to design structural interventions
that make the environments mobile populations
encounter in their travels less hospitable for
high-risk sex.

Increasing Support
Many international donors and national and
regional governments do not seem to have the
flexibility to fund projects that cross borders.
The interest generated by the growing body of
knowledge about HIV/AIDS among mobile
populations needs to be converted into greater
financial support for cross-border interventions.
These interventions could also be integrated into
more established cross-border initiatives in other
sectors, such as transnational environmental
projects.

in

10.2
Rwandan Refugees Mobilize to
Prevent HIV/AIDS
In 1992, a staggering

vention for refugees in

and other organiza­

ers conveyed HIV/

30 percent or more of

August 1994, when

tions working in the

AIDS messages

Rwanda’s urban popu­

AIDSCAP and CARE

camps was the key to

through traditional

lation was infected

launched prevention

the project’s success.

dance and music, and

with the virus that

activities that were

In response to

PSI and CARE staff

causes AIDS.When

gradually expanded to

needs identified by the

distributed condoms.

genocidal civil war

three other refugee

community, the

sent hundreds of

camps. An assessment

project expanded. For

CARE project in the

thousands of people

conducted for the

example, a home­

Tanzanian camps

fleeing the country

project by John Snow,

based care compo­

proved that it is pos­

two years later, HIV

Inc., found that more

nent was added for

sible to involve refu­

gees in HIV/AIDS

inevitably followed

than half the respon­

those already sick,

them into hastily

dents perceived them­

“Adolescent Health

prevention, training

constructed refugee

selves to be at risk of

Days” were held to

2,173 peer educators

camps in neighboring

HIV infection.

Tanzania and Zaire.

With families sepa­

acquaint teens with

and reaching more

The project began

the health services

than 700,000 people.

by training about 100

available to them, and

A survey conducted

rated and communi­

volunteers as commu­

a women’s crisis team

after the first year of

ties torn apart, the

nity health educators

was created to pro­

the project found that

daily hardships con­

to teach camp resi­

vide social, legal and

the number of people

fronting refugees living

dents about HIV/AIDS

medical support to

who reported having

in overcrowded

prevention, distribute

those who experi­

more than one sex

camps often over­

condoms and encour­

enced sexual violence.

partner had dropped.

shadow the threat of

age them to seek

Empowerment—

About 80,000 people

HIV. But those same

treatment for STDs.

taking control of one’s

had sought counseling

day-to-day struggles

PSI, which managed

own health—proved a

and STD treatment as

put refugees at in­

condom distribution

powerful message in

a result of project

creased risk of con­

for the project, also

an environment

efforts. But with con­

tracting HIV/AIDS and

trained special con­

riddled with uncer­

tinuing unrest

other STDs. Commer­

dom promotion teams

tainty. Refugees also

throughout the world

cial sex is common,

and peer educators.

responded to mes­

and the growing inter­

alcohol consumption

And CARE trained

sages urging them to

national threat of the

is high, and condoms

counselors to conduct

seek STD care to

HIV/AIDS epidemic,

are rarely available.

health education ses­

ensure future fertility.

the pilot project’s

Women and youth—

sions about HIV/AIDS

particularly those

and STDs for patients

perhaps the most

may be a greater

separated from their

awaiting treatment at

effective medium for

understanding of

families—are at risk of

outpatient clinics run

reaching youth with

how to help refugees

rape, other forms of

by the African Medical

HIV/AIDS prevention

prevent HIV transmis­

violence,and HIV

Research and Educa­

messages. Weekly

sion. ■

tion Foundation.The

events at the commu­

The Benaco camp

112

The AIDSCAP/

Sports events were

in Tanzania became

remarkable degree of

nity sports complex

the site of the first

collaboration that

drew thousands. Dur­

early HIV/AIDS inter­

occurred among these

ing half-time, perform-

most valuable legacy

Reaching Women

References

Women whose husbands or boyfriends have mo­
bile lifestyles are at significantly greater risk of
HIV and other STDs than the average spouse
because their partners are more likely to acquire
HIV than a husband who returns home every
night. Reaching these women is difficult because
they do not necessarily live or congregate in one
place, and their homes are usually far from the
sites of interventions for mobile populations.
Empowering them to protect themselves from
infection is even more difficult because of cul­
tural expectations that wives submit unquestion­
ingly to their husbands and because of their eco­
nomic dependence on their male partners. More
aggressive efforts are needed to help these women
protect themselves without antagonizing their
partners. HIV/AIDS prevention programs need
to develop more realistic prevention options for
these women as well as better ways to reach
them.

l.

2

3.

4

Testing Alternative Strategies
Because many border areas lack the infrastruc­
ture needed to support traditional prevention
efforts, including health facilities for STD treat­
ment and a staff of outreach workers to edu­
cate and counsel members of the target audi­
ence, there is an urgent need to explore alterna­
tive strategies such as prevention marketing
and periodic presumptive STD treatment of
key groups. Pilot studies are needed to test
prevention marketing approaches to HIV/
AIDS among mobile populations, using exist­
ing commercial outlets to sell subsidized
condoms and prepackaged STD therapy and
employing the mass media available to target
populations to promote healthy sexual behav­
ior.

5.

6.

7.

8.

9.

Jenkins C (1994). Final Report: Behavioral
Risk Assessment for HIV/AIDS Among
Workers in the Transport Industry, Papua
New Guinea. AIDSCAP/Family Health
International, Bangkok,Thailand.
Pramualratan A, Somrongthong RJindasak
K, Saetiow S (1995). Assessment of the
Potential for Spread and Control of HIV
Among Cross-border Populations Along the
Thai-Cambodian Border. AIDSCAP/Family
Health International, Bangkok,Thailand.
Rao A, Sundararaman R, Shrestha BK
(1995). Report of the Study Team for the
Assessment of HIV/AIDS Situation on the
Trucking Routes between Nepal, India and
Bangladesh. AIDSCAP/Family Health
International, Bangkok,Thailand.
Simbulan NP, Gomez DC,TayagJG,
Imperial RH (1996). Formative Research on
the Seafaring Population: Philippines Final
Report. AIDSCAP/ Family Health Interna­
tional, Bangkok,Thailand.
CARE International/Laos (1995). Three
Provinces Focus Group Project. AIDSCAP/
Family Health International, Bangkok,
Thailand.
Program for Appropriate Technology in
Health (1995). Rapid Ethnographic
Assessment: Strategic Planning for AIDS
Prevention in Five Indonesian Cities.
AIDSCAP/Family Health International,
Bangkok,Thailand.
Benjamin JA, Engel D, DeBuysscher R
(1996). AIDS prevention amid chaos: the
case of Rwandan refugees in Tanzania. XI
International Conference on HIV/AIDS,
abstractTu.D.241. Vancouver, Canada,July
7-12.
Mbuya C (1995). STD services for women
in truck stops in Tanzania: an evaluation of
acceptable approaches.Abstract pre­
sented at the Third USAID HIV/AIDS
Prevention Conference,Washington, DC,
August 7-9.
Nyamuryekung’e K, Laukamm-Josten U,
Vuylsteke B, et al. (in press). STD services
for women in truck stops in Tanzania: an
evaluation of acceptable approaches. East
African Medical Journal.

113

Position: 1205 (4 views)