Increasing Institutional Capacity of RH and
HIV/AIDS NGOs for Linked Response
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Tanzania

Chawakua

St. Lucia Nursing Home

HIV/AIDS epidemic in Tanzania is an epidemic for young people. There are about 1.5 million people who are infected with HIV/AIDS, 20% of this population are young people under the age of 20 years. Furthermore, 7 out of 10 STIs occur to individual of 15 to 25 years old. These infections include gonorrhea, chancroid, herpezoster, chlamydia candidiasis etc. Although HIV/AIDS knowledge is high among young people - 95% for girls and 97% for boys, still there is disparity between the levels of knowledge and corresponding behavior change towards safe sex practice.

Young people below the age of 25 account for 65% of the total 35 million populations in Tanzania. Of this, a significant number of youth are sexually active. 65% of girls start sex at the age of 17 years old and boys’ start at the age of 18. It has been observed that the sexual relations are mostly unplanned, unprotected and sometimes are pressure forced. 10% of girls and 36% of boys in the age bracket of 15-19 has never used condoms for either FP purpose or STI prevention. 22% of girls and 21% of boys do not take consideration of prevention measures on HIV/AIDS and STIs. Adolescent pregnancies are major SRH problem in Tanzania. The 1999 survey on RH and child health showed that about 20% of girls 15 – 19 years are mothers. In Tanzania studies on abortion have shown the situation is not well documented. However, available hospital based data suggest that young women are likely to undergo unsafe abortion.

1. Chawakua (Chama Cha Wanawake Kupambana Na Ukimwi Arusha)

Organizational Profile

Chawakua promotes positive attitudes and safer sexual practices by providing information on adolescent sexual and reproductive health (ASRH) and life planning skills to out-of-school youth and community members in Arusha Municipality.

In recognition of the widespread and deep-rooted effect of repressive cultural taboos concerning sex education in Arusha, Chawakua uses a broad-based approach to teach healthy sexual behavior including peer educator training, vocational teacher training (VETC), youth talks, sporting events and drama performances. Chawakua recognizes the importance of involving the community decision makers in its programs to reduce HIV/AIDS infection. With the support of the African Youth Alliance (AYA), Chawakua spent the past two years sensitizing district leaders, training vocational center teachers and religious leaders, and approaching parents emphasizing the importance of open communication and SRH education. To date, 60 decision makers have been trained, and Chawakua is invited to attend the regular community meetings. It hosts sporting events and drama performances to promote healthy alternatives to street living.

On a broader scale, Chawakua is actively engaged in the struggle against sexual health ignorance with other Arusha region organizations through constant collaboration and sharing methodologies.



Youth listening attentively to ARH information

Action plan: Implementation and Achievements

CHAWAKUA began with sensitizing their Board on the linked response concept. The Board members were kept informed of the project through report and quarterly meetings and orientation. Then the program officers and 30 peer educators were trained in preparation for work with young people at the community level.

CHAWAKUA increased the young people’s access to information related to RH and HIV/AIDS through organization of site visits, youth talks, enter-educate activities, and inclusion of SRH teachings in schools.

Previously, site visits were only conducted by Chawakua staff and peer educators at the ward level. In this project, Chawakua had expanded the activities to the sub-location levels. 72 site visits were conducted, reaching 1413 youths, both in-and-out-of schools. Condoms education for dual protection was conducted. Problems encountered on SRH, including HIV/AIDS and STIs were discussed and solved. The young people were discussing openly about SRH, HIV/AIDS and their previous behaviors during the site visits.

Youth talks were also held to improve young people’s knowledge on SRH, particularly the relations between STI and HIV/AIDS. 18 sessions were held and 1780 youths were reached. At the same time, enter-educate activities were performed in different events to introduce SRH, the links between STI and HIV/AIDS, and condom use for dual protection to young people and the entire community. 1110 people were reached through drama performances and 1500 people were reached during sport events.

In order to increase gatekeepers’ participation, Chawakua disseminated information and educated teachers, ward leaders and parents on HIV/AIDS, STIs and ASRH. The 12 community mobilization meetings had reached 90 parents, religious and community leaders. Two meetings were held with 15 teachers of VET-C, secondary and primary schools to discuss linked response to RH and HIV/AIDS, STIs and referrals, and how to integrate ASRH, HIV/AIDS and STIs into the curriculum. The teacher and Chawakua’s staff then took classes on linked response for the school children. Ward leaders and sub location chairperson were involved in the planning process.

For the expansion of services, CHAWAKUA continues to collaborate and establish referral linkages with other NGOs that provide youth friendly services. 13 youths were referred to collaborating NGOs (Marie Stoppes and UMATI*) and district hospitals for VCT, FP and STI services.

Throughout the project, 30640 condoms and 3521 BCC materials (leaflets, brochures, posters, booklets) were distributed to young people to increase young people’s awareness and promote safe sex.

* Uzazi Na Malezi Bora Tanzania (UMATI), the family planning association of Tanzania


Young boys attending ARH sensitisation session

The Impact: Enhanced Capacity

‘If a 24 year old dies of HIV/AIDS, s/he was infected while in primary school. Therefore, SRH and HIV/AIDS education must be given to children early in life…’ Participant at dissemination seminar, Tanzania, 5 September 2005

Individual and community levels:

Young people, parents, teachers and community leaders became aware of the RH and HIV/AIDS issues they are facing, and the benefits of linked response to RH and HIV/AIDS. Ward leaders and parents responded positively on linked response to RH and HIV/AIDS. Chawakua staff were invited to the ward’s public meetings and ward development committee meetings (WDC) so that the concept and idea of linked response could be shared among community members. The stigma on HIV and STI was reduced.

There was increased knowledge on the links between RH and HIV/AIDS, STIs and condoms use for dual protection among youths. The topics were discussed openly among youths aged 15 to 25 years old. They brought friends to the meetings and shared their personal experiences. Even school children were aware of linked response to RH and HIV/AIDS.

Organizational and staff levels:

Board members’ awareness regarding linked response and its benefits was raised. They in turn provided support to the staff for implementation of the project. The knowledge of linked response gained by the ED, program coordinator, program officers and accountant through implementing this project helped them plan for the future.

Program and service levels:

Teachers, program staff and peer educators were able to provide information on both HIV/AIDS and RH with an emphasis on condom for dual protection. They were able to refer youth for services, as a result of a strengthened referral network between Chawakua and district hospitals and some collaborating NGOs - UMATI and Mary Stoppes.

Key Challenges

There was lack of BCC materials focused on linked response. Chawakua used IEC materials from the AYA programs for this project. RH and HIV/AIDS were covered separately, but explained to stakeholders as linked together.

Ward leaders accepted that young people should use condoms for dual protection. Relatively religious leaders and parents were less supportive on condoms dual protection. Furthermore, there was misconception about safety of condom use. Free condoms were perceived to be inferior to those sold on the market. There was also non adherence of youth for referral services.

Lessons Learned

Once community leaders are sensitized on the linked responses between HIV/AIDS and RH, they become advocates and mobilize support. There is a need to sensitize the community, including religious leaders, on the linked response, i.e. RH, HIV/AIDS, STIs and condoms for dual protection.

Capacity building of Chawakua staff and members is important to ensure efficient implementation of linked response activities.

More condoms boxes are required in youth friendly centers and public places.

The Way Forward

There is a need to establish a VCT center and an information center spanning HIV/AIDS and RH for youth in the community.

Chawakua will train more youth and peer educators between the ages of 10-25 years on linked response. It will use enter-educate activities through drama performance and sports events more extensively. It will continue mobilize the community on linked response, and undertake monitoring and evaluation to ensure performance.

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2. St. Lucia Nursing Home

Organizational Profile

St. Lucia Nursing Home was established in October 2002 by a group of women who shared a vision for caring for patients with chronic disease, including HIV/AIDS. These are women who had seen the suffering and pain that patients undergo and who volunteered to care for patients at home. A nursing home was thought to be the best way to complement home based care activities and also to serve as a referral center. The mission of St Lucia is to improve health and quality of life for patients with chronic disease, including HIV/AIDS in Tanzania, by providing nutritional food and medication for opportunistic infection, as well as comprehensive nursing and health care education to family members, which will reduce the HIV/AIDS stigma among the community.

The mayor,staff and community members of the project

St. Lucia Nursing Home is under the leadership of Winfrida Mwahsala as the ED. The director chairs a committee, which includes nurses, volunteers, counselors (spiritual, legal, and palliative) and part-time medical officers. It provides comprehensive nursing care such as bathing, massaging, and medication for patient with opportunistic infection. Nutritional supplements, foods and fruits are also provided to help patient recover. The trained volunteers and nurses visit homebound client, and also provide one or more follow-up visits for patients who have recovered and left the clinic. They help and train the family members care for the patients. They also offer spiritual counseling as appropriate. People Living with HIV/AIDS (PLWHA) who volunteer with St Lucia sensitize the community on Voluntary Counseling and Testing (VCT), so that people are aware of their HIV status and be able to seek help in order to stay healthier and do not pass the HIV to others. St Lucia also provides inpatient orphans care.

Action plan: Implementation and Achievements

The organization works in the Ward of Baraa in Arusha Region of Tanzania. There are four sub divisions with a population of 6,073 of which 2,998 are female and 3,075 are male. The populations are largely Masai who practice polygamy and among whom alcoholism is a problem. Cultural beliefs are strong with a strong gender bias in favor of men. Although some information is available on HIV/AIDS, information, services and supplies for RH, including FP are scarce.

St. Lucia Nursing Home first arranged training for two of its nurses and 11 people selected by community leaders to be health workers. The 5-day training encompassed knowledge of both HIV/AIDS and RH issues with an emphasis on making linked responses between the two. That was the first formal training on RH and HIV/AIDS and the links between them. The Community Health Workers, including the two nurses then went into the community to educate people on HIV/AIDS and RH.

In addition to its regular center-based care of the terminally ill and orphans, St. Lucia undertook the following activities under the umbrella of the linked responses project, from April to June (See Table 1 and 2) :

• 36 outreach meetings were held in the community, reaching 655 people in total

• 2800 condoms for dual protection were distributed

• 1700 IEC/BCC materials were developed and distributed

• Referrals for family planning, ART, tuberculosis testing, support, PMTCT, STIs and VCT were made

More then 20 community leaders, including ward development committee members and officers, and 3 local preachers were sensitized to linked response. St. Lucia were asked by the Church leaders to sensitize the community on Sunday Church. Condoms were distributed in the process. On 14 April 2005, there was a joint meeting of community leaders and the community health workers for coordination of efforts. The 10 CHWs trained were selected by the community leader to attach to St. Lucia. They report to both the leader and St. Lucia. St. Lucia also visited the Mayor of Arusha Municipality to discuss about the linked response of HIV/AIDS and RH, and the outcome of this project. The Mayer also attended the dissemination seminar organized by ICOMP on 5 September.

The Impact: Enhanced Capacity

‘As you can see we have made huge progress since the ICOMP project. As a result of this IN and OUT patient numbers have increased significantly. Thus increasing financial and administration needs. Therefore we are setting up an open day for potential donors, the Mayor of Arusha has agreed to attend and invite the local press.’

An email by Winfrida Mwahsala to ICOMP
29 April 2005

Organizational and staff levels:

Before this project, the focus of St. Lucia’s work was on in-patient care and home based care for PLWHA and sensitization and education for their immediate family. Now, this has changed. St. Lucia is now focusing on education and condom promotion for protection against HIV/AIDS, STI and unwanted pregnancy in the general population, regardless of HIV status. It has realized that linked response is an important component for all groups, not just those affected.

The ED, nurses and CHWs are better equipped to provide care and support to the Baraa Ward population spanning both HIV/AIDS and reproductive health needs. Board members awareness was raised regarding the linked responses between HIV/AIDS and RH and the benefits. They in turn provided support to the staff for implementation of this project.

Program and service levels:

At both the center and in the community, the nurses and CHWs were able to provide comprehensive information, services and referrals for HIV/AIDS and RH. Before this, information provided to clients on where to seek ART, FP and STI services were patchy. To overcome this, St. Lucia undertook a mapping exercise of services available in the area, and provided the information to the nurses and CHWs during the training course. As a result, there was increased in demand and access to the referral services, particularly on VCT, FP and STI, as indicated in Table 2. Over three month’s period, the demand for condoms had also increased tremendously (See Table 1). The mapping exercise also improved the relationship between St Lucia and the collaborating organizations.

In addition, after the training on linked response, St. Lucia nurses and the CHWs were making home visits in a more organized manner and better record keeping. They linked FP and HIV/AIDS when providing counseling. Previously, these were done on an ad-hoc basis, with weak connections made between FP, STDs and HIV/AIDS. St. Lucia now also visits non-HIV positive families.

Previously St Lucia only promoted condoms for HIV prevention, and it was not done regularly. But now, it has become a strong advocate and promoter of condoms for dual protection. Condoms were procured in larger quantities from the regional government hospital, and distributed at the nursing home, during home visits, and public meetings with the message that condoms prevent both pregnancy, STIs including HIV/AIDS. BCC materials on condoms were produced and distributed.

Individual and community levels:

PLWHA benefited from information on and supply of condoms for prevention of unwanted pregnancies, other FP information and benefits of delayed sexual activity (among youth). Other individuals awareness were raised about the modes of HIV/AIDS transmission, prevention methods, importance of VCT, management and care of PLWHA, STI and its proper management, FP issues, stigma of HIV/AIDS, MTCT, etc.

Whole communities, including leaders, became aware of HIV/AIDS and reproductive health issues. The stigma of HIV and STI was reduced.

Key Challenges

St. Lucia perceives several challenges in making linked responses between HIV/AIDS and RH. These encompass:

• The low level of community knowledge on prevention of HIV/AIDS and STIs

• The reluctance of men to use condoms

• Poverty, stigma of HIV/AIDS and STIs, cultural beliefs and taboos are major challenges in reducing infection rates

Lessons Learned and Recommendations

Linked response is an important component for all groups, not just those affected, but then poverty eradication is essential for people to be enabled to make RH and HIV/AIDS choices. Therefore, government, donors and individuals should work towards bringing people out of poverty.

Tanzanians at all levels should join hands in the war against HIV/AIDS. St Lucia has learnt that RH and HIV/AIDS information, services and referrals when linked, increases awareness and reduces stigma of HIV/AIDS and STIs. The stigma can also be reduced by providing opportunities for youth to interact with PLWHA.

Youth should be sensitized at an early age regarding VCT. There should be increased youth sensitization and education on linked response at all levels. Parents could also be sensitized on linked response in meetings at schools.

The head of St.Lucia Nursing
Home and orphans

Relationships must be maintained and developed to ensure an effective referral system.

Community leaders and health care workers can sustain linked response programs by working together. There should be more HIV/AIDS and RH education for the community, and continue condom promotion for dual protection at the community level and increase availability through pharmacies and shops. There should also be ongoing advocacy with community leaders, church pastors, regional medical officers and other NGOs and CBOs.

Health care providers should be given refresher courses on LR. Nurses and CHWS should increase the number of households visits, and then they are more effective if they work in designated geographical areas instead of being widely dispersed.

The Way Forward

St. Lucia still continues the linked response activities using its own resources. Four out of ten CHWs selected by the ward leaders will still attach to St Lucia, work on regular basis and receive small payments when funds are available. However, the other six CHWs still come to St Lucia for condoms as people approach them for supplies. They also refer people for FP, STI and HIV/AIDS services. Therefore, a link still remains with the organization.