Sierra Leone is so staggeringly poor that HIV/AIDS is not at the top of people's concerns. After decades of poor governance and ten years of civil war, its economy and social infrastructure are in tatters. Sierra Leone is rated last on the UNDP 2002 Global Human Development Index (HDI). In post-war Sierra Leone concern about the potential for the rapid spread of HIV and AIDS is high. Although official HIV prevalence rates have been estimated to be relatively low among the general population (in the range from 0.2% to 4%) there is concern that these numbers may rise dramatically as large numbers of IDPs, returnees and ex-combatants return home.
CARE, the International Rescue Committee (IRC) and the American Refugee Committee (ARC) are among the NGOs engaged in prevention of sexually transmitted illnesses (STIs) in Sierra Leone. While their programmes are in different parts of the country and use different methods, one message is clear: when working in conflict situations HIV/AIDS prevention messages must compete with other more imminent survival issues. Sierra Leoneans are dealing with the daily realities of unstable housing, inadequate nutrition and major threats to personal safety. It is difficult to make the risk of dying from HIV/AIDS at some future point as great as the risk of dying from diarroheal diseases or conflict-related violence.
Auntie Stella gets kids talking
Youth stand out as perhaps the most tragic victims of Sierra Leonean conflict. Young people were abducted to serve as armed combatants and sexual slaves. Children experienced torture, mutilation, rape and separation from families. An entire generation of young people in a country with a young population (44% are estimated to be below the age of 14) have been deprived of a basic education, livelihood skills, nutrition and health.
CARE has promoted 'Auntie Stella', a participatory RH training activity for 13-17 year olds developed by Zimbabwe's Training and Research Support Centre. It engages youth in discussion and problem solving on issues related to their reproductive health (RH). 'Auntie Stella' stresses that young people should learn about RH and life skills through discussion rather than didactic instruction from teachers. Small groups of students of the same age and gender are given cards with real-life questions about sex, relationships and HIV. For example:
Dear Auntie Stella,
I'm very worried because I know so many girls who have been forced to have sex against their will. Sometimes they know the boy or man, but I even know one girl who was raped by a stranger. I'm so scared it's going to happen to me. What can I do?
With the role of teacher confined to that of facilitator and resource person, students are given an hour to discuss questions and answers among themselves. Facilitators were surprised at the willingness of the students to openly discuss sex. Students were so interested in discussing the topic that some teams had to spend the first hour of their time with the students simply answering their questions about HIV before the exercises could begin.
When asked to give feedback, the students requested that additional information be included on how poverty influences sexual relationships in Sierra Leone. CARE staff have used their comments to adapt the Auntie Stella materials for the Sierra Leone context. Rebranded as 'Sisi Aminata' - a more common name in Sierra Leone - materials are being printed and will be incorporated into Sierre Leone's school curriculum.
Sisi Aminata must be part of a broader development agenda, and cannot be a 'stand-alone' in a context were so many lack so much. Talking about sex alone is not going to work. CARE will continue to address the needs and rights of the most marginalised within a livelihoods framework - RH, sex and HIV will closely link with other sector specific projects in an effort to ensure continued dialogue on sensitive topics.
Community sensitisation in Kenema District
IRC is working to support primary health care units in this war-affected eastern region. IRC's strategy to prevent and reduce HIV-related morbidity and mortality focuses on disease transmission. Using a rights-based framework, planning is based on local surveillance data and documented research. IRC has been implementing an RH monitoring and evaluation project aiming to reach 70-80% of the reproductive age population in Kenema District. Community sensitisation activities have been developed with existing Village Development Committees (VDCs). Training workshops for VDCs have discussed HIV/AIDS, STIs, family planning and condom promotion. Communities have been targetted through video presentations, drama, group meetings, promotional lectures and distribution of information materials focusing on modes of HIV/AIDS transmission and safe sex behaviours. With the support of VDCs and high-risk individuals such as commercial sex workers new condom outlets have been developed.
Eighteen months after a baseline survey of RH knowledge, attitudes and behaviours, IRC conducted a follow-up study. It found that:
- While 89% of women and 82% of men could correctly identify three modes of transmission of HIV/AIDS at baseline, by the time of the follow-up survey 95% of women and 97% of men could do so.
- Knowledge of HIV transmission and prevention is higher for those who have attended school, grown up in towns or identify themselves as Christian.
- While the first survey found that 55% of men and a third of female respondents spontaneously stated that condom use during sex prevents HIV transmission, this increased to 65% of men and 49% of women.
- Although condom demand has increased, condom use patterns have remain substantially unchanged - men reporting having used condoms at last sexual intercourse rose from 18 to only 21%.
- The educated, urbanites and Christians reporting usage of condoms at last sex was double the rate for the non-schooled and Muslims.
It is not surprising, given the short amount of time the programme has been operating, that survey results reveal so little behavioural change. The findings do, however, indicate that it is vital to continue STI and HIV/AIDS education and to target community groups as on-going sources of education and awareness. A sustained effort to work with the VDCs and peer groups and to strengthen linkages with communities is required if sustained behaviour change is to be achieved.
Targeting high-risk groups
ARC has focused its HIV/AIDS prevention efforts in the Port Loko district, working with such core transmitters as commercial sex workers, military personnel, youth, ex-combatants and transport workers. ARC has aimed to have skilled community health promoters convey information, increase knowledge of the availability of condoms and STI treatment and increase the number of core transmitters using condoms.
Among the methods ARC has used to disseminate STIs/HIV/AIDS prevention are: Information-Education-Communication (IEC) and Behaviour Change Communication (BCC) campaigns, condom distribution and STI treatment. Posters, billboards, newsletters, tabloids and radio jingles were used to deliver HIV/AIDS and STI prevention messages. Educational workshops were conducted on condom use and negotiation, HIV/AIDS transmission and prevention, and STI prevention and treatment. With support from the Ministry of Health, ARC's Health Team has distributed free condoms and condom distributors have been set up to reach target populations in Port Loko.
AIDS prevention efforts are not complete without the means to establish one's personal HIV status and receive appropriate counselling. 'Voluntary Counselling and Testing' (VCT) allows individuals to access the information needed to live as healthily as possible, regardless of test results. HIV testing is currently available in Port Loko for a fee but no counselling is offered. National and local government efforts are working towards the implementation of VCT.
ARC has noticed that:
- Levels of STIs/HIV/AIDS knowledge and condom use behaviour increased dramatically across all groups surveyed - half of all respondents reporting use of a condom at last sexual intercourse.
- Degrees of personal concern about AIDS among high-risk groups have stayed relatively low - half of the commercial sex workers surveyed are not concerned about contracting HIV.
- Young people, especially girls, demonstrate the lowest levels of knowledge of those surveyed. Lack of provision of formal education is another barrier to increasing knowledge and safer sex behaviours.
- Knowledge of adequate sources of STI care is still very low.
The way forward
Key recommendations arising from NGO experience in Sierra Leone are:
- efforts to increase knowledge and condom use are not sufficient in themselves
- with so many young people prevented by poverty or lack of facilities from attending school methodologies must be adapted to meet the needs of out-of-school youth
- behaviour change takes time: STI and HIV/AIDS sensitisation and education must be on-going in targeted communities
- as resettlement continues and more people move back into abandoned villages, it is essential that prevention activities are not urban-focused and do not ignore outlying areas
- youth-focused micro-finance activities and life-skills training centres could promote healthier lifestyles
- the need to decrease reliance on NGOs for condoms and to increase support for small-scale commercial condom distributors
- greater attention to encouraging partner notification of STIs
- follow-up training for health workers on the syndromic management of STIs, and a consistent supply of drugs
- the importance of recognising that AIDS prevention efforts are incomplete without providing the means to determine one's HIV status and receive appropriate counselling
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