APPENDIX A
Panel Visits to Three African Countries: January 20-February 12, 1995

INTRODUCTION

During January 20-February 12, 1995, a subset of the panel visited three African countries to observe first-hand the state of the response to the HIV/AIDS epidemic. The purpose of these visits was to (1) learn more about the current prevention and mitigation efforts taking place in these sub-Saharan African countries; (2) brief key African researchers on the efforts of the National Research Council with respect to HIV/AIDS; and (3) gather information to help the panel carry out its mission of identifying the research and data priorities, particularly in the social and behavioral arena, for HIV/AIDS prevention and mitigation in sub-Saharan Africa over the next 5 to 7 years.

Given time and financial constraints, it was impossible to visit more than three countries. The countries were selected to maximize the panel's exposure to countries undergoing different stages of the epidemic, with differing responses and with differing social and behavioral research capacities, while at the same time minimizing the overlap in knowledge reflected in the panel members' considerable expertise. The countries thus selected were Zambia, Tanzania, and Cameroon.

Zambia is a country with a mature epidemic that is being countered with a coordinated response from a strong Ministry of Health, including innovative workplace and traditional healer prevention programs. In comparison with other countries in the region, relatively little HIV-related research focusing on the social and behavioral aspects of the disease is being conducted in Zambia. Tanzania is a second country with a mature epidemic, but one that is being countered



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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences APPENDIX A Panel Visits to Three African Countries: January 20-February 12, 1995 INTRODUCTION During January 20-February 12, 1995, a subset of the panel visited three African countries to observe first-hand the state of the response to the HIV/AIDS epidemic. The purpose of these visits was to (1) learn more about the current prevention and mitigation efforts taking place in these sub-Saharan African countries; (2) brief key African researchers on the efforts of the National Research Council with respect to HIV/AIDS; and (3) gather information to help the panel carry out its mission of identifying the research and data priorities, particularly in the social and behavioral arena, for HIV/AIDS prevention and mitigation in sub-Saharan Africa over the next 5 to 7 years. Given time and financial constraints, it was impossible to visit more than three countries. The countries were selected to maximize the panel's exposure to countries undergoing different stages of the epidemic, with differing responses and with differing social and behavioral research capacities, while at the same time minimizing the overlap in knowledge reflected in the panel members' considerable expertise. The countries thus selected were Zambia, Tanzania, and Cameroon. Zambia is a country with a mature epidemic that is being countered with a coordinated response from a strong Ministry of Health, including innovative workplace and traditional healer prevention programs. In comparison with other countries in the region, relatively little HIV-related research focusing on the social and behavioral aspects of the disease is being conducted in Zambia. Tanzania is a second country with a mature epidemic, but one that is being countered

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences by a fragmented response, mainly through nongovernmental organizations. On the other hand, some interesting and important social and behavioral research has been conducted in Tanzania. The AIDS epidemic in Cameroon is not as far advanced as in Zambia or Tanzania, and is characterized by a relatively low level of response. Although the country enjoys some limited social and behavioral research capacity, no prioritization of research needs has yet been conducted. The visiting team included Deborah Rugg (Centers for Disease Control and Prevention), Carl Kendall (Tulane University), and Peter Way (U.S. Bureau of the Census), together with Barney Cohen (National Research Council). A fourth member of the panel, Dr. Eustace Muhondwa, joined the team in Dar es Salaam, and Peter Way left the team there for a brief visit to learn more about the situation in Kenya. Additionally, Dr. Tom Barton (UNICEF and Makerere University) was invited to join the team for 2 days in Dar es Salaam so he could brief them on the research needs assessment he had conducted for the Uganda AIDS Commission in October 1992. The team met with the national AIDS control program managers in each of the three countries, as well as many other government officials, social and behavioral scientists, donors, university researchers, policy makers, caregivers, and employees of national and international nongovernmental organizations. This appendix presents findings from the team's visits to Zambia, Tanzania, and Cameroon.1 For each, it presents an overview of the current HIV/AIDS situation, summarizes the history of AIDS-prevention efforts, describes ongoing prevention and mitigation initiatives, and reviews the state of social and behavioral research. The final section presents overall themes emerging from the visits to the three countries. ZAMBIA JANUARY 23-27, 1995 Overview of Current HIV/AIDS Situation In Zambia, the AIDS epidemic is already at an advanced stage and has become a major health crisis for the government. The first AIDS cases in Zambia were reported in 1984 and 1985. By 1986, the disease had been recognized as a major public health problem. Over the last 10 years, the number of AIDS cases has risen dramatically. Although exact figures are unreliable, the magnitude of the problem is enormous. Data are available from selected sentinel surveillance sites around the country for 1992, and preliminary data are available for 1993. These data indicate that HIV prevalence among sexually active adults in urban areas ranges from 15 to 37 percent in urban areas, with an average figure of 1    A list of the people contacted by the team can be found at the end of this appendix.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences around 25 percent. In rural areas, where approximately 58 percent of the population resides, HIV prevalence among sexually active adults ranges from 7 to 15 percent, with an estimated average figure of 10 percent. Rural areas close to truck routes, military bases, or mines are likely to have higher rates. In sum, these data indicate that over 600,000 Zambian sexually active adults are HIV-positive and will, sometime in the future, develop AIDS. History of AIDS-Prevention Efforts Early efforts at HIV/AIDS prevention in Zambia followed quite closely the typical sub-Saharan African pattern. In 1986, the Government of Zambia set up a National AIDS Surveillance Committee and an Intersectoral AIDS Health Education Committee to coordinate all activities of AIDS prevention and control. With the assistance of WHO, the National AIDS Surveillance Committee implemented an emergency Short-Term Plan to deal with the immediate problem of ensuring a safe blood supply. Under this plan, two laboratories at the University Teaching Hospital in Lusaka and the Tropical Diseases Research Centre in Ndola were designated as national reference centers, with the task of supervising the 31 blood screening centers that were set up subsequently throughout the country. A mass media campaign was launched to create public awareness about HIV infection and AIDS. In July 1987, the Ministry of Health, recognizing the long-term implications of AIDS, formulated a 5-year Medium-Term Plan covering the period 1988 to 1992, with technical assistance from WHO. This plan identified several priority areas for interventions. It was adopted in September 1988, with a financial outlay of US $12 million over the 5-year period. At a donor meeting in Lusaka in March 1989, a total of US $4.9 million was pledged—$1.9 million more than the amount required for the first fiscal year of the plan. Over the life of the plan, seven functional units evolved: Programme Management; Information, Education, and Communication (IEC); Laboratory Support; Epidemiology and Research; Counseling; Home-Based Care; and STD and Clinical Care. A key turning point in AIDS awareness for Zambians came in 1989 with the untimely death of the former president's son as a result of AIDS. Over the period of the Medium-Term Plan, the Zambian National AIDS Programme received approximately US $10 million through the WHO Trust Fund. In addition, the Government of Zambia receives assistance for AIDS prevention and control from most of the major donor countries, including the United States, the United Kingdom, Canada, The Netherlands, France, Japan, Norway, and Sweden, in the form of bilateral agreements. Each donor organization has its own readily identifiable AIDS prevention or control activities, but these are integrated reasonably well into the overall national strategy. In addition, a large number of national and international nongovernmental organizations operate throughout the country.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences In 1992, three major external reviews were conducted—by the World Bank, WHO, and the Swedish International Development Authority (SIDA)—which revealed that, although each of the above seven functional units had achieved major success, their combined efforts had failed to slow the spread of the epidemic. In effect, increased knowledge among the general population about the dangers of HIV/AIDS and its modes of transmission had not translated into safer sexual behavior. There was a growing realization that all prevention and control efforts were too medically focused, and that there was an urgent need to develop a multisectoral response to the epidemic. At the same time, there was also the need to improve condom distribution and make STD services more accessible. In response to these reviews, the government, recognizing the need for a broad participatory approach, organized a 3-day consensus workshop in May 1993 in Livingstone as a basis for preparing the second Medium-Term Plan. To ensure the broadest possible base for consensus, the Ministry of Health invited to the workshop over 60 participants from other government ministries and departments, local and international nongovernmental organizations and parastatal organizations operating in Zambia, and representatives from bilateral and multilateral donors. The consensus workshop was followed by technical workshops in the areas of youth, women, the workplace, defense, management, and behavioral change. The planning process for the second Medium-Term Plan coincided with a change in political structure and ongoing health reform. The Ministry of Health has now moved toward a decentralized model, with responsibility for decision making transferred to the district level. In 1994, the National AIDS/STD/TB & Leprosy Programme produced its strategic plan for 1994-1998 and launched its enhanced prevention strategies and mitigation/care efforts. Currently, the National AIDS Programme is part of the National AIDS/STD/TB & Leprosy Programme. It is situated in the Ministry of Health, and the program manager reports to the Deputy Director of Medical Services (Primary Health Care). The onset of the AIDS epidemic has coincided with a period of general economic malaise in the country, so that resources for health education and prevention have become even scarcer than usual. Consequently, the National AIDS Programme has been forced to rely heavily on the generosity of the international community. Foreign donors fund virtually all of Zambia's HIV/AIDS prevention and mitigation activities. For example, a large share of prevention activities is implemented through a 3-year, US $8.24 million Morehouse University School of Medicine project funded by the U.S. Agency for International Development (USAID). At the same time, Overseas Development Aid (ODA) is developing a model of home-based care for people with AIDS, and UNICEF is working with orphans. An immediate and important constraint for the National AIDS Programme is a lack of condoms for free distribution.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences Ongoing Prevention and Mitigation Initiatives It would be impossible to review all the worthy HIV/AIDS prevention and mitigation initiatives that are currently taking place in Zambia. Three of the more innovative programs are discussed below. Workplace Peer Education and Counseling The Morehouse project, together with the Institute of African Studies of the University of Zambia, has designed and started implementing a workplace peer education and counseling model intended to reach 30,000 workers at approximately 300 sites over 3 years. The project has been designed to provide a mechanism whereby Zambian public-and private-sector employers can assume responsibility for, and institutionalize, a continuing peer education program that will increase STD/AIDS awareness, promote safer sexual behavior, and reduce STD/HIV transmission among their employees. The project includes the training of peer educators and the development of health communication activities within the work site, the provision of assistance to workplaces in designing effective prevention policies, and ultimately the use of workers and management to reach the larger communities affected by the workplace. The project has encouraged interested employers to develop their own HIV/AIDS prevention and counseling programs and has developed a workshop for training peer educators, for which it has designed accompanying manuals and materials. The project is currently working at 22 worksites in two areas: Lusaka and the Copperbelt. Among the first sites where the project was implemented were Standard Bank and Chibote Farms in Lusaka Province; the Ministries of Tourism, Information, and Agriculture and the Pamodzi Hotel in Lusaka City; and Indeni Petroleum in the Copperbelt Region. These sites represent a variety of work environments, with different kinds of staffing, and each accordingly has a specially designed program. At each site, approximately 1 of every 40 workers is nominated to serve as a peer educator. Approximately 600 workers attended workshops in 1994. The strategy for curriculum development is participatory, with workers playing an active role. Obviously, one of the goals of the project is to induce major behavioral change. Although the project has been established for only a relatively short period of time, and STD/HIV trends have not been formally tracked, recent evaluation revealed that the project may be having some impact on those trends. The Chiboti Meat Corporation reported that STD cases among its employees had declined by about one-half, and the company's drug procurement costs dropped significantly between May-June at the outset of the project and July-August 1994.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences Traditional Healer Component Traditional healers have always played a major role in the provision of health care in Zambia and have been well organized for over 30 years. Registration of traditional healers in Zambia began in the mid-1960s. A major challenge to STD/HIV prevention in Zambia is that many people seek treatment for STDs from traditional healers, rather than from doctors who use western medicine. Although healers tend to express great faith in their prescribed treatments for STDs, these treatments are usually considered nonefficacious from a biomedical perspective. There is considerable confusion among traditional healers about some of the facts pertaining to the epidemic, for example, the difference between HIV and AIDS, and many traditional healers are reluctant to tell patients that AIDS is a fatal disease. In fact, some healers identify AIDS with the symptoms of ''kalyondeonde," which is thought to be curable. Against this background, it was decided that any HIV-prevention program in Zambia should include a traditional healer component. Currently, this component is conducting workshops to prepare healers to play the role of community educators, individual counselors, and condom distributors. A series of 20 workshops trained approximately 400 traditional healers in 1994. In addition, routine monthly meetings of healers are used to review topics not well understood; cover additional topics; provide support to the healers in their communities; and identify needed changes in the materials and presentations, incorporating the healers' own suggestions. The strategy for curriculum development is also participatory, with healers playing an active role. The project is still in its initial stages. Thus it has yet to be formally evaluated, which will be a challenge. However, initial indications are very positive: healers representing the national organization appear quite willing to promote biomedical models of disease transmission, refer clients to hospitals if they suspect AIDS, and promote greater use of condoms and partner reduction among their clients. Additionally, some healers counsel patients whom they believe to be seropositive that repeated unsafe sex will make them sicker. These preliminary findings about the project encourage further exploration of the potential role of traditional healers in HIV prevention and care. Programs for Orphans Currently, there are two government initiatives to help orphans and children in need. The Ministry of Community Development and Social Welfare has introduced a Public Welfare Assistance Scheme that is accessible in all districts through the Social Welfare Department offices. It assists the poor and vulnerable by providing money for medical fees, house rentals, educational fees, and material goods. Each district has its own District Welfare Assistance Committee. The other initiative is the Child Care and Adoption Society of Zambia, which is

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences operating in Lusaka and Ndola. This society is promoting fostering (for varying lengths of time) and adoption of children. In response to the emerging orphan crisis, UNICEF, in collaboration with other nongovernmental organizations, has set up a Children in Need Secretariat, whose mandate is to strengthen family and community capacities to protect and promote the welfare of children. Note that one has to be careful in defining an "orphan" in Zambia. Because of the system of inheritance and property grabbing, the loss of one's father is much more damaging than that of one's mother. Consequently, in a recent Ministry of Health study, 24 percent of "orphans" had lost both parents, 25 percent had lost only their mothers, and 51 percent had lost only their fathers. In all, the study found that 4 out of every 10 households had one or more orphans under their care (Social Policy Research Group, 1993). The State of Social and Behavioral Research In general, AIDS-related research activities have been largely uncoordinated in Zambia. Currently, multiple research activities are being carried out, but as far as the team could ascertain, they are not being coordinated by the National AIDS/STD/TB & Leprosy Control Programme or by any other organization. Most research appears to be driven by donors rather than the government of Zambia. The government has not conducted a research-needs assessment or a prioritization exercise to develop a national plan of action for research on AIDS in Zambia. There appears to have been no effort to synthesize research findings for Zambia, and there is no readily accessible bibliography of AIDS-related research either completed or currently in progress. However, in an effort to promote information exchange, Morehouse is sponsoring a one-day research workshop to review and disseminate research findings. Despite the obvious potential for overlap and duplication of effort, the team found no evidence that a serious duplication of effort is taking place. With regard to social and behavioral research, a number of important initiatives are currently under way in Zambia. For example, research is taking place on the socioeconomic impact of AIDS. As part of the ongoing process of integrating AIDS activities into sectors of the economy outside the health sector, the government of Zambia has commissioned a series of studies to evaluate the social and economic impact of the disease. Each study will assess the impact of HIV/AIDS on one sector of the economy, including, among others, agricultural production systems, transport, mining, and hotels. Some of these reports are still in preparation, but the report on the effects of HIV/AIDS on agricultural production systems has been completed; according to its findings, most labor farming systems are not immediately vulnerable to the epidemic (Barnett, 1994). However, case studies from two rural communities, Teta and Chipese, indicate that in these two communities at least, the epidemic is already affecting quite large numbers of households. Furthermore, large-scale agricultural schemes or the "estate" sector

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences is feeling the impact of the epidemic at all levels of the workforce, particularly among migrant workers and among the more-skilled and more-educated members of the workforce, although in economic and financial terms the impact is not very serious (Barnett, 1994). UNICEF is currently sponsoring research to develop a better understanding of the trends and the magnitude of the orphan problem in Zambia. A recent Ministry of Health study found that 25 percent of urban orphans and 40 percent of rural orphans quit school because their guardians could not pay uniform and school fees. Furthermore, the majority of orphans did not go to health facilities when ill because of the expense. Given the advanced state of the epidemic, the enormous number of people suffering, and the limited financial and human resources the public sector can provide, there is an urgent need to develop appropriate models of home-based and community care. With this in mind, ODA is supporting health systems research on costing and evaluation of home-based care in Zambia. The goal of the research is to develop alternative models of home-based care to alleviate the burden of hospitals and to extend the quantity and quality of care available. Initial research on this topic was carried out by Chela et al. (1994), who found that hospital-initiated home-based care cost approximately three times more than community-initiated home care. The largest cost item in hospital-initiated home care was the cost of transportation for caregivers. There was also considerable variation found in the type of service provided, as indicated by the statistic that the average duration per visit was 30 minutes for the hospital-initiated home care, as compared with 120 minutes for the community-initiated home care. With regard to AIDS prevention, there has been little major research apart from a few studies conducted in communities restricted to urban areas and the Copperbelt. Studies on the social aspects of HIV/AIDS are being carried out by a few institutions, including the University of Zambia, the Commonwealth Youth Program, Family Health Trust, the Churches Medical Association of Zambia, and the Copperbelt Health Education Project. Under the University of Zambia, the Institute for African Studies has been particularly active. Each of these institutions has a library in which it keeps records of work done. A good number of individuals in Zambia have conducted research related to HIV/AIDS. Most have at least masters degrees in the social sciences from universities abroad, coupled with relevant experience at various levels of governmental or nongovernmental organizations. A directory of Zambian consultants working in the HIV/AIDS field was published in 1993.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences TANZANIA JANUARY 30-FEBRUARY 3, 1995 Overview of Current HIV/AIDS Situation The first three cases of AIDS in Tanzania were clinically diagnosed in Bukoba regional hospital in Kagera in 1983. From 1983 on, the number of people infected with HIV increased exponentially, mainly through heterosexual contact. AIDS cases were increasingly diagnosed throughout the country, using the Bangui criteria of two major and one minor clinical sign or symptom, and by 1986 were found throughout Tanzania. Although some seroprevalence studies have been conducted in Kagera and elsewhere, it is difficult to know precisely the seroprevalence for Tanzania. The World Bank estimates that 400,000 new infections occur in Tanzania each year and projects a cumulative total of 1.6 million cases by 2010. AIDS kills between 20,000 and 30,000 people every year in Tanzania. It is believed to be the leading cause of death among adults and is likely to be the leading cause of death among children in the very near future (World Bank, 1992). An estimated 130,000 children have lost a parent to AIDS, and by the year 2000 there could be 750,000 AIDS orphans in Tanzania. In Dar es Salaam, HIV infection levels among antenatal care attenders have almost doubled, from 8.9 percent in 1989 to 16.1 percent in 1993. The extent of the epidemic varies widely by region, with some parts of the country much more affected than others. The levels of infection are highest in Kagera, Iringa, Mwanza, and Rukwa regions, ranging from 12 to 21 percent among pregnant women attending antenatal clinics. In other regions, levels range from 2.9 to 9 percent. Whether seroprevalence levels in these latter regions will ultimately reach levels similar to those recorded in Kagera and other more heavily affected regions will depend crucially on what happens to patterns of sexual behavior. Regardless of whether behavior changes or not, however, there is no doubt that AIDS will be a major health problem in Tanzania for many years to come. History of AIDS-Prevention Efforts In 1985, the first institutionalized efforts were initiated with the formation of the AIDS Task Force, later named the Technical Advisory Committee on AIDS. Efforts to control the pandemic in Tanzania began with small-scale studies among selected population groups in 1986 and a population-based study in Kagera in 1987. In 1988, the Technical Advisory Committee assisted in the creation of the Tanzanian national AIDS control program, which is now in its second 5-year Medium-Term Plan.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences Ongoing Prevention and Mitigation Initiatives Although many HIV/AIDS prevention and mitigation activities have been undertaken in Tanzania, there is relatively little coordination through the national AIDS control program or consensus on the best approaches, nor is there much integration of the various programs. Each donor has its own interventions. For example, USAID focuses on condom social marketing, while other donors focus on STDs or family planning. Ideally, there should be more donor coordination to meet national needs and use resources optimally. Instead, donor programs are offered on a "take it or leave it" basis. Little Tanzanian national funding for HIV/AIDS prevention and mitigation has been forthcoming. The presence of international donors, especially the bilateral donors, has permitted the country to invest national financial resources in other areas; however, this has made the national AIDS control program almost completely dependent on international donors and their priorities. (See the discussion of these issues in Chapter 7.) This problem has also existed for the multilaterals, but the new reorganization of United Nations services may resolve the problem for those programs. There is a general feeling within the national AIDS control program that the choice of interventions and strategies to be adopted is imposed on the basis of international or individual nongovernmental organization agendas, rather than being based on research on what works in Tanzania. This leads to some obvious tensions and conflicts of interest. For example, the national AIDS control program would like to see a behavior-change focus and more emphasis placed on improved materials. However, donors have identified commodities, such as condoms and STD therapy, as the focus of their intervention programs. The Tanzania AIDS Project, funded by USAID, is the largest single AIDS-prevention effort in Tanzania. The main purpose of the project is to support nongovernmental organizations in complementing the government's efforts through the national AIDS control program. Components of the Tanzania AIDS Project The Tanzania AIDS Project has five main components: Social Marketing of Condoms: The project provides the national AIDS control program with technical assistance in condom logistics for the public sector, while also managing the Population Services International social marketing campaign. Last year, 3 million condoms had been sold at 20 Tanzanian schillings each. Social marketing has been so successful that people would now rather buy a condom than get one for free. Behavior-Change Communication and Information, Education, and Communication (IEC): The project has supported the presentation of AIDS-related messages in both electronic and print media. These have included radio spots,

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences since many Tanzanians listen to the radio at some point in a given day or week, even if they do not own one. The project also borrowed the idea of a newspaper for schoolchildren ("Straight Talk") that has been so successful in Uganda. Videos have been supported, as well as a film entitled "More Time." STD Control: The project is working with the private sector to facilitate training in STD diagnosis among health-care providers. Nongovernmental Organization Support: The project has facilitated the establishment of coalitions or "clusters" of nongovernmental organizations in nine regions. Operating through a designated "anchor" organization in each region, the project conducts training of nongovernmental organization staff in management skills, leadership skills, and financial management and provides technical assistance as needed. A nongovernmental organization workplace project started as a demonstration project in 1990 and supports 22 organizations. This project has yet to be formally evaluated. Peer educators have generally noted that knowledge of the modes of transmission and means to prevent AIDS has greatly increased in the last 2 years, but they are uncertain whether this has translated into behavior change. Consequently, despite the successes experienced by the nongovernmental organizations involved, this effort has not been scaled up. Workplace Education: The project supports the African Medical Research Foundation (AMREF) in its truck driver/truck stop project, which trains peer educators, distributes condoms, and now offers STD treatment near the truck stop sites. AMREF also works with the women's clubs that have sprung up along the trucking routes. The problem is that these naturally occurring community-based groups have proved difficult to sustain because the women die or move on down the truck route. The Nongovernmental Organization Strategy Tanzania is unusual among the countries visited by the team in that USAID-funded interventions are channeled exclusively through nongovernmental organizations. This strategy arose from concerns on the part of the USAID mission that there was a divergence between the mission goals and the GPA-linked national AIDS control program. There was also concern about the effectiveness of the utilization of funds in the public sector. (For example, a recent condom audit uncovered a substantial divergence between warehouse records and condoms on hand in a warehouse.) Not surprisingly, a policy of funding only nongovernmental organizations leads to obvious questions surrounding the capacity of those organizations. Although there are many excellent examples of nongovernmental organizations doing AIDS-related work in Tanzania, many require substantial technical assistance, as envisioned in the Tanzania AIDS Project. Although a nongovernmental organization strategy, at its best, promises local control and ownership, great

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences issues in Cameroon, who questioned the real commitment of donors to help African populations and cited examples of linkages between foreign aid and political decisions to illustrate this point. This perceived lack of commitment extends to donor institutions, politics, and personnel. As discussed earlier for Zambia and Tanzania, donors have their own priorities and do not fully take into account the needs of the country. In Cameroon, this is evidenced in an AIDS control program that is geographically fragmented, with donors operating programs that reflect their own priorities, each in a different geographic region of the country. If one local organization does not agree with the priorities or approach proposed by a donor, another organization is found to do the desired project. This raises the question of whether there is actually a national AIDS control program. One researcher suggested that there is not. The researchers suggested that the way to address the threat of AIDS effectively in Cameroon is to build programs from the bottom up. Programs must consider relationships as the key to understanding behavior. The interface between program administrators at the top and the community needs to be the local government officers. A program needs to get them doing useful things at the local level by empowering them (including providing technical assistance and training) and encouraging demand for such services from the community, although, unfortunately, many at the top perceive such an approach as representing a loss of power and control. At the top, donors need to do the same with African policy makers and researchers. Ongoing Prevention and Mitigation Efforts Overview AIDS control activities in Cameroon are divided among the various donors. There are four major donors currently active: USAID (AIDSCAP project), GTZ (Germany), FAC (France), and CARE. In addition, WHO/GPA provides some support. Donor activities tend to be divided either by region or by type of intervention. GTZ has a variety of programs in three of Cameroon's ten provinces—Littoral, Northwest, and Southwest provinces. It contributes about US $200,000 per year for these activities. FAC is active in three northern provinces, with an annual budget of US $1.3 million, much of which goes toward primary health-care programs. CARE is working in the eastern part of the country with a limited program. UNICEF will soon be starting a school-based HIV education program in Cameroon. As discussed below, AIDSCAP has several specific interventions with commercial sex workers and university students and has a nationwide condom social marketing program (Population Services International). WHO/GPA supports purchase of blood screening reagents and some IEC activities, but its total contribution

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences is about US $150,000 per year, which represents a significant drop in recent years. Donor meetings have been held once or twice a year, but given the above description of activities, whether Cameroon has a national program or not is a legitimate question, as discussed earlier. Virtually all of the money spent on AIDS control activities in the country comes from external sources. The Cameroon government provides the (small) staff of the l'Unité du Lutte Contre le SIDA (ULS) (the national AIDS control program) and their office facilities. The ULS has six functional areas (IEC, counseling, laboratory, research, epidemiology, and STDs), each with a chief, but the chiefs seem to be serving in a part-time capacity, and there are no staffs in those functional areas. There is no support in other ministries for AIDS control activities, and most are doing nothing. According to the director of the national AIDS control program, existing donor support funds about 50 to 60 percent of the current Medium-Term Plan, begun several years ago. The remainder of the plan is simply not being implemented. In addition, because donor funds are generally programmed, donors cannot be responsive to requests, for example from the ULS, for specific interventions or programs. The team found no evidence of a clear set of research and/or intervention priorities at the ULS that might help guide future donor activities. AIDSCAP Cameroon's AIDSCAP project, which succeeds AIDSTECH (1990-1992), began in September 1992. It includes the following five activities: Sentinel surveillance in antenatal clinics; IEC strategies with three high-risk target groups: Military and police, University students, Commercial sex workers (a peer educator approach); A small grants program, which has supported the following: Save the Children—for community-based strategies in the north, CARE—for strategies targeting out-of-school youth in the east; Social marketing of condoms (''Prudence" brand) through Population Services International; and Research/STD studies conducted with graduate students at the university. The military and university students have been targeted because they are frequent clients of commercial sex workers and because these groups are frequently single, male, and possessed of ready cash. University Students The AIDSCAP-supported intervention program involves the use of peer educators in each university. Project planning began in May 1993,

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences and the initial training of peer educators in Yaoundé was conducted in January 1994. The program has found working with students directly to be far more efficient than having to go through the major bureaucratic delays involved in contracting with the university per se for a project. Peer educators are drawn from various social groups at the university, including those involved with sports and the arts and those associated with particular ethnic groups. The peer educators have developed their own educational materials and also are engaged in condom sales and promotion. They hold monthly meetings. However, their initial enthusiasm is beginning to wear off, and motivation is increasingly a problem. The project is not able to provide them with financial support, even to cover the cost of materials and transportation. As of our visit, only about half of those trained over the past year were attending the monthly meetings. Commercial Sex Worker Project This project began as a pilot among Yaoundé commercial sex workers and their clients in 1988; STD clinic patients were also added as a target group. The project began with only 15 peer educators. As of our visit, it had 40 peer educators in Yaoundé and had expanded to other cities as well. The objectives of the project are as follows: To provide small-group and one-on-one peer education in locations that are high risk, such as bars, brothels, truckstops, hotels, and the "maisons du passage" (places where men can go for sex with a woman, not overnight accommodation). To conduct educational dramas. The purpose of the project is to increase condom use among commercial sex workers and their clients; thus both men and women are being targeted. Project activities include (1) "health talks" given in small groups by the peer educators to commercial sex workers and their clients, (2) individual educational discussions and demonstrations on how to use condoms, (3) peer educator sales of condoms, and (4) drop-in HIV counseling and testing. HIV Counseling Project In addition to the commercial sex worker project, AIDSCAP runs an HIV Counseling Center, which provides free and anonymous HIV counseling and testing and supportive counseling for those who are infected. There is also a home-visit program for people who cannot make it to the center for supportive services. About three-fourths of clients who come to the center accept testing after being counseled; approximately 50 percent come back for the results. Condom Social Marketing—Population Services International With AIDSCAP support, Population Services International runs a condom social marketing program

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences in Cameroon, marketing the "Prudence" brand. This activity was initiated under the earlier AIDSTECH project. Thus far, the program has achieved moderate success, selling about 0.6 condoms per capita in 1994. This places it about third among African condom social marketing programs. The State of Social and Behavioral Research Strengthening the capacity for social and behavioral research is a clear need in Cameroon. Not enough such research related to AIDS is being conducted, and the skills and experience of local researchers are consequently somewhat limited. In this light, the Cameroon experience with two local nongovernmental organizations composed of young social and behavioral scientists is encouraging and may serve as a model for the development of similar groups in other countries. IRESCO The Institute for Social and Behavior Research (IRESCO) is a nongovernmental organization composed of young social and behavioral scientists. Over the past several years, they have undertaken research and evaluation projects for donors such as AIDSCAP, WHO, and UNICEF. IRESCO maintains a core staff (secretariat) and can draw on other researchers in universities and elsewhere to conduct research projects. FOCAP The Cameroon Psychology Forum (FOCAP) is another local nongovernmental organization working in the area of social and behavioral research in Cameroon. Like IRESCO, FOCAP comprises an interdisciplinary team of young social and behavioral scientists. Initially begun as a professional association, over the past several years it has conducted a variety of studies in medical sociology, sociology of development, political sociology, community health, and anthropology. FOCAP has employed both qualitative (focus group) and quantitative (community-based survey) approaches in its work. OVERALL THEMES This section summarizes the main themes that arose from the panel's visits. The most significant themes (most of which are discussed in Chapter 5 of this report) were as follows: the real lack of solid evaluation research assessing behavior change due to the HIV-prevention strategies that have been tried; the lack of formative research, needs assessment, or tailoring of efforts in the development of HIV-prevention programs and a failure to utilize existing research findings; the paucity of information or strategies addressing the HIV-prevention

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences needs of women and youth; and the questionable sustainability of the national AIDS control program infrastructures and their current gaps as a result of donor financial and technical assistance reductions and withdrawals, particularly the withdrawal of WHO/GPA advisers. Other overall themes are listed below. A pervasive theme was a concern over the reduction or withdrawal of donor financial assistance and the consequent inability to sustain the HIV-prevention infrastructures that have been put in place. Some, maybe most, developing countries are going to need considerable donor assistance for HIV prevention and care for the foreseeable future. The costs of not providing this assistance in terms of both human and economic impact in Africa are staggering. Primary and secondary prevention programs are considerably more cost-effective than dealing with the costs of care and the indirect effects of the epidemic on the future of these countries. While government national AIDS control programs should be encouraged and helped to work toward sustainability, gradually reducing their dependency on foreign aid and introducing limited cost-recovery efforts, they are likely to need considerable financial and technical assistance for at least some 10-20 years. The programs we visited were trying to recover from the major withdrawal of WHO/GPA technical advisers and the concomitant reduction in funds and guidance. According to the national AIDS control program managers, this GPA withdrawal was abrupt and not done in consultation with them; thus it has been very disruptive. All the managers with whom we spoke feel that there has been a real gap left in the wake of the GPA withdrawal. All of the national AIDS control program planning areas are having a difficult time coping with these losses. Many national AIDS control program managers interviewed cited the need for change in certain social norms that are fueling the spread of HIV across Africa and the need for more sophisticated intervention strategies to address these norms (see Chapter 2). There was general agreement that what is needed is to (1) identify the specific practices that create an increased risk for spreading HIV (several of which are already well known, such as the low status of women and the general dislike of condoms); (2) identify the factors that influence or determine these practices; (3) conduct formative research to design interventions that address these determinants and specific risk behaviors, specifically targeting the social norm gatekeepers (e.g., elders, traditional healers, political and religious leaders), as well as the individuals involved in these practices; and (4) use indigenous people and strategies to implement these interventions on a large scale. The surveillance systems that have been established (typically HIV surveillance in antenatal clinics) are often very limited, incomplete, and inconsistent and rarely measure behavioral variables. Thus there is still considerable need for basic monitoring information about HIV, STDs, sexual behavior, and other risks, and the strengthening of HIV and STD surveillance systems is a priority need for

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences most national AIDS control programs. Beyond the basic monitoring of the epidemic, there also needs to be more integration of behavioral and epidemiological research (see Chapter 3). There are some good examples of national AIDS control programs using HIV behavioral research results in program planning. For example, the Zambian program used a situation analysis conducted by the Morehouse Project to inform significant policy changes concerning sexual inheritance practices. UNICEF's participatory model of program planning and qualitative assessment has been instrumental in evaluating Uganda's national AIDS control effort at the district level and has improved district-level program planning (UNICEF, 1993). Behavioral research is needed on the types, frequency, and meaning of sexual practices that generate most individual risk of HIV infection (see Chapter 4). Information on practices such as the types and numbers of partners and condom use is seriously lacking. For example, social marketing data show that condoms are being sold in larger numbers than ever (in the millions); however, there are no good data showing that they are being used effectively, leaving everyone to rely on the implicit assumption that condom purchase equals effective condom use. It also appears that once social marketing of condoms takes hold, free distribution of condoms by the public sector subsides. The reasons for this need to be investigated further, since certain segments of African society will always require the availability of free condoms. Programs and research projects are often launched without a sufficient period of formative research and pilot testing (see Chapter 5). These developmental activities are often not conducted because they are not funded. This is a short-sighted strategy: it may save funds in the short run, but will ultimately be costly because programs are less likely to be effective if they are not appropriately designed and tailored to local circumstances. In the worst case, untested strategies can waste time, money, and good will and possibly even do harm, as has been seen in a variety of misguided IEC campaigns. In general, few rigorous impact evaluations of behavior change have been done in Africa (see Chapter 5). Evaluations that have been done often lack precision in their measurement of risk behaviors and thus are not very informative. As a result, few strategies have any real evidence of effectiveness. Consequently, even if program managers were to turn to the research literature for guidance, there would be little solid evidence of what works best or which strategies would be most appropriate for specific populations or conditions. There is also a general absence of information about the costs of various interventions. Thus it is impossible to analyze the cost-effectiveness of various programs—one of the criteria that can be used to judge the usefulness of AIDS-prevention programs. Given the extreme scarcity of resources faced by most countries, implicit cost-effectiveness decisions are having to be made on a day-to-day basis. Consequently, there is a need to provide information that will allow countries to make more informed choices about where to spend their money.

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences There are many similar interventions being implemented across Africa—mostly information-based health education campaigns providing generic messages that are not personalized and do not address specific risk behaviors. Few if any intervention strategies are based on theory. Innovative approaches are few and far between. Some innovative strategies are being tried, but they are very small scale and difficult to find. Examples are Saturday AIDS classes; youth-run health clubs and campaigns; and workshops for potential initiators of change, such as traditional healers. These strategies need to be evaluated to determine their effectiveness, and if they are found effective, operational research is needed to determine how to scale them up. Reinterpretation of HIV-prevention messages is common as people seek to understand HIV in their own terms. The understanding of the epidemic is dynamic and evolving. Economic, social, and political empowerment of women and youth, especially adolescent girls, was among the most frequently discussed issues and stated needs by the HIV professionals and policy makers interviewed (see Chapter 5). These are crucial HIV-prevention areas about which we know very little. There is an urgent need for substantial research that goes beyond traditional health education for commercial sex workers and creatively reaches women and youth in a variety of venues. There was also a call for policy research to explore strategies for changing/developing policies so that they are more conducive to large-scale HIV-prevention efforts, condom promotion, and social norm change. Research on the social and economic impact of the epidemic is also needed (see Chapter 6). Models of cost-effective strategies for the delivery of home-based care are needed. There are many issues uncovered in assessing the epidemic's impact that are now in need of operational research. Examples are issues surrounding care for AIDS orphans, inheritance and support for widows, and the increasingly compromised ability of kin-based groups to care for people with AIDS, as well as legal rights and antidiscrimination policy research. In general, AIDS-prevention programs do not use research findings/data to target and design their efforts. Thus there is a great need to increase capacity to both conduct research and use research results in designing programs (see Chapter 7). The USAID missions visited in Zambia, Tanzania, and Cameroon appear to have limited inclination to conduct research and limited capacity to synthesize or translate research findings. Capacity for outcome research is limited in terms of human resources, expertise, fiscal resources, and equipment. Until this lack of resources for research is addressed, research studies cannot be expected to produce meaningful findings for program design and evaluation. However, basic program evaluation and some operational research should be feasible even in low-resource situations

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences and should be encouraged more by the donors as a requirement for any program implementation award. Typically, donors develop HIV-prevention strategies on the basis of fundamental universal health principles and then dictate which interventions are implemented in particular settings. There is little community or stakeholder participation in program development and evaluation activities, with the exception of Uganda. Stakeholder and community participation in program design, implementation, and evaluation is essential to mounting an effective and sustainable HIV-prevention program in Africa (see Chapter 7). Donor funding agendas and priorities often provide little opportunity to explore local needs. This means donor priorities may not match the priorities of national AIDS control programs. There is a need to consider introducing more flexibility into the process for directing funds to national AIDS control programs. There is also a need to shorten the bureaucratic delays in funding that can sometimes undermine effective strategies. As a result of such delays, it may be 2 or 3 years before a program approved for funding actually receives the funds and can be launched. Additionally, research funding decisions seem to be made on an ad hoc basis, with little attention paid to developing a thoughtful research agenda, building a portfolio that sets sound research priorities, and funding research based on these priorities. In Africa, there is a serious lack of information sharing among AIDS professionals both within each country and among countries. Thus there are frequently duplication of effort and "reinventing-the-wheel" activities that waste time and limited resources (see Chapter 7). This lack of information sharing could be redressed if donors sponsored innovative information exchange activities both within and among countries. Examples are newsletters; electronic bulletin boards; national or regional clearinghouses for materials, articles, and relevant questionnaires; smaller local, national, or regional HIV-prevention conferences and training workshops; and traveling "road shows" that showcase model programs and experienced program managers, encouraging them to act as consultants to other HIV-prevention programs. Sometimes information is not shared until it has been presented at an international conference. This practice ensures that timely information is not received by those who need it most—those fighting AIDS on the front lines who never go to international conferences. Incentives to share research findings in a timely and effective manner with those who can most use the results must be developed and encouraged by donors. A serious look at how best to synthesize research results and disseminate them to African HIV-prevention professionals is greatly needed. The development of a variety of dissemination systems, networks, and strategies would represent a meaningful contribution to HIV-prevention efforts in Africa. There is a growing reliance on nongovernmental organizations to deliver HIV prevention and care services, rather than on the government. However, many of the small nongovernmental organizations depend totally on donor assistance

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences and appear to be unsustainable otherwise. Furthermore, exclusive reliance on such organizations by donors and government often leads to duplicate and uncoordinated efforts that frequently leave major geographical or substantive areas untouched. There are certainly examples of excellent nongovernmental organizations that are doing good work, but not all these organizations are local or effective, and many have a need for technical training and assistance from the government national AIDS control programs. The optimal roles of government, nongovernmental organizations, and donors in HIV prevention need further study. REFERENCES Barnett, T. 1994 The Effects of HIV/AIDS on Farming Systems and Rural Livelihoods in Uganda, Tanzania, and Zambia. Unpublished report prepared for the Food and Agriculture Organization. Overseas Development Group, University of East Anglia, Norwich, U.K. Chela, C.M., R. Malska, T. Chava, A. Martin, A. Mwanza, B. Yamba, and E. van Prang 1994 Costing and evaluating home based care in Zambia. Abstract No. 099B/D, Volume 10(1):31. IXth International Conference on AIDS, August 7-12, Yokohama, Japan. Social Policy Research Group 1993 Orphans, Widows, and Widowers in Zambia: A Situation Analysis and Options for HIV/AIDS Survival Assistance. Lusaka, Zambia: Institute for African Studies, University of Zambia. UNICEF 1993 Districts Speak Out: A Participatory Program Planning Workshop . Kampala, Uganda: UNICEF. World Bank 1992 Tanzania: AIDS Assessment and Planning Study. Washington, D.C.: The World Bank. PEOPLE CONTACTED Zambia Dr. Stella Anyangwe, Morehouse School of Medicine Dr. Mazuwa Banda, Churches Medical Association of Zambia Ms. Heather Benoy, Private Consultant Mrs. Given Daka, ZAMCOM Dr. Knutt Flykesnes, World Health Organization Mr. Paul H. Hartenberger, U.S. Agency for International Development Professor Alan Haworth, University of Zambia Father Michael T. Kelly, Director, Kara Counselling Mr. Bradford Lucas, Population Service International Dr. Roland Msiska, National AIDS Control Programme Mr. Vincent Musowe, Chief Health Planner, Ministry of Health Mr. Eli Nangawe, PHC Advisor, Ministry of Health Dr. Masauso M. Nzima, Morehouse School of Medicine

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences Mr. Michael O'Dwyer, Overseas Development Administration Mr. Leo O'Keeffe, UNICEF Mr. Johnathon Phiri, Project Officer, UNICEF Dr. Karen Romano, Morehouse School of Medicine Ms. Birgitta Soccorsi, NORAD Ms. Inger Teit, NORAD Ms. Margareta Tullberg, Swedish Embassy Mr. Joe Wiseman, Morehouse School of Medicine Tanzania Dr. B. Fimbo, IEC Director, National AIDS Control Programme Mr. Khalid Hassan, Laboratory, National AIDS Control Programme Dr. Susan Hunter, U.S. Agency for International Development Dr. Saidi H. Kapiga, Muhimbili Medical Center Theofrida A. Kapinga, Tanzanian Council for Social Development (TACOSODE) Professor W.L. Kilama, National Institute for Medical Research Dr. Japhet Z. J. Killewo, Muhimbili Medical Center Kajab Kondo, TACOSODE Dr. M.T. Leshabari Muhimbili Medical Center Dr. George Lwihula, Muhimbili Medical Center Tim Manchester, Population Services International Immaculate Manyanda, Organization of Tanzanian Trade Unions (OTTU) G. Mbonea, VIJANA Professor Fred Mhalu, Muhimbili Medical Center Siami Mohamed, Tanzania Girl Guide Association Nuru S. Msangi, Tanzania Society for the Deaf H. Mussa, VIJANA Janeth Mziray, Tanzania Parents Association Dr. E.F. Ndyetabura, clinical AIDS/STDs, National AIDS Control Programme Justin Nguma, Tanzania AIDS Project I.S. Ngunga, Tanzania Scouts Association Penina Ochola, Tanzania AIDS Project Dr. F. Owenya, Danish Red Cross Abdul I.W. Pagali, Tanzania National Freedom From Hunger Campaign Dr. R.O. Swai, Director, National AIDS Control Programme Ms. Angela Trenton-Mbonde, World Health Organization Technical Advisor Cameroon Ms. Claude Cheta, Institut de Recherche et des Etudes de Comportements Hortense M. Deffo, Institut de Recherche et des Etudes de Comportements Jean Pierre Edjoa, Institut de Recherche et des Etudes de Comportements

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Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences Dr. Eleonare Seumo Fosso, CARE Mr. P.L. Hougnoutou, Chief, IEC Section, Ministry of Health Tchudjo Kamdem, Cameroon Psychology Forum Charles Kamta, Cameroon Psychology Forum Joseph Kemmegne, Cameroon Psychology Forum Emmanuel Kiawi, Cameroon Psychology Forum Mr. Alexis Boupda Kuate, AIDSCAP Jean-Christophe Messina, Cameroon Psychology Forum Dr. Ngole Eitel Mpoudi, Director, National AIDS Control Programme Mr. Jopesh Betima Ndongo, Manager, CSWs project, Ministry of Health Dr. Peter Ndumbe, Chief, Research Section, National AIDS Control Programme Marc Ngwambe, Cameroon Psychology Forum Zakariaou Njoumeni, Institut de Recherche et des Etudes de Comportements Adonis Touko, Cameroon Psychology Forum