The Sexually Transmitted Infections Project

1. Objectives
   
   The Sexually Transmitted Infections Project (STIP) has three main objectives:
   • to prevent sexual transmission of HIV;
   • to mitigate the personal impact of AIDS; and
   • to support institutional development to manage HIV prevention and AIDS care.
2. Activities / contents
   
   
   1. Prevention of Sexual Transmission of HIV.
      Change in sexual behavior is the most important approach to preventing the spread of HIV. The STIP supports promotion of safe sexual behavior through information, education and communication (IEC); provides condoms and promotes their use; and promotes STD care seeking behavior and provision of effective STD care.
      • Information, education and communication activities
        include development, testing and airing of HIV/AIDS messages in the media in both English and local languages. A wide range of community based activities target specific social groups and occupational categories such as the youth, truck drivers, commercial sex workers, police, army and prisons (including inmates).
      • Promotion of increased use and availability of condoms.
        The project promotes condom use and supplies condoms for distribution through government agencies, NGOs and via social marketing. The female condom has been introduced as an additional protective measure for women.
      • Treatment of Sexually Transmitted Diseases (STDs).
        The project provides drugs for STDs and training of health workers (public, NGO and private practitioners) in management of STDs. The project also finances promotion of STD treatment seeking behavior. Testing for HIV and other STDs is also supported.
   2. Mitigation of Personal Impact of AIDS.
      The project supports development of treatment guidelines, training of health workers on management of people with AIDS and provides drugs for management of tuberculosis and other opportunistic infections associated with AIDS. This covers public and NGO health services. The project also supports NGOs and community based organizations activities, for community and home-based care. The aim is to reduce bed-occupancy by AIDS patients who currently account for more than 50% of inpatients in hospitals and health centers. There is a risk of them crowding out patients requiring treatment for other illnesses. The project supports NGOs activities in counseling, nutrition and income generation.
   3. Institutional Development.
      The STIP supports capacity building in planning and management of HIV/AIDS programs. At central level, it supports strengthening technical skills of staff and the management and coordination functions of the AIDS Control Program of the Ministry of Health. At the district level, the project focus is on developing a participatory planning and management process involving district and local level managers, NGOs and community based organizations. Support is also provided to monitoring and evaluation to improve the information base. A system of sentinel surveillance covering twenty sites is assisted by the project through supply of testing kits and training of staff. Regular knowledge, attitudes, practices and behavior surveys are also conducted under the project. The project also contributes funding to a number of research activities: the Rakai project research on STD-mass treatment; a Tuberculosis-Ethambutol study in Mulago; and a study of sexual behavior among young people.
3. Expected Outcomes / Impacts
   
   
   1. The project is expected to contribute to a reduction in HIV infection and mortality from AIDS. This will be achieved through adoption of safer sexual practices including fewer partners (especially non regular partners), use of condoms and improved services for treatment of STDs. The project will also contribute to improved quality of life for people with AIDS. Home-based care programs for AIDS patients will reduce pressure on the health care system. The project will also enhance local capacity for management and monitoring of HIV/AIDS programs especially by districts which are now responsible for program management under the country's decentralization policy.
   2. Uganda is one of the first countries in Africa to show a sustained decline in HIV prevalence. Evidence suggests that a major change in the HIV incidence has occurred. The prevalence of HIV has dropped significantly in both urban and rural areas with the most marked change in younger age groups. This is the result of a collaborative effort of many partners led by the Government. The STIP is one of the projects that are contributing to the progress in fighting the epidemic. Currently, there is a high level of general awareness of HIV/AIDS with urban areas registering greater depth of knowledge of the disease. There are also changes in sexual behavior. Surveys show a drop in non-regular partnership and casual sex across all age groups. Condom use has also increased. The most notable change has occurred in the sexual behavior of the 15-29 years age group normally considered to be at greatest risk. Between 1989 and 1995, survey results show a delay in sexual debut. The proportion of males in the age group 15-19 years reporting never had sex has risen from 31% to 56% while that of females has increased from 26% to 46%. Sentinel surveillance data collected between 1992 and 1996 show declines ranging between 32%-54% in HIV prevalence in young pregnant mothers aged 15-29 years in some urban areas. This group is fairly representative of the general populations. It is important to note that it is the younger population which has registered the highest positive change in sexual behavior. This has important implications for the long term reduction in HIV/AIDS as this is the most sexually active group. A reduction in HIV/AIDS in this group will contribute significantly to economic productivity and social welfare in the country as this group constitutes a large proportion of the economically productive population group. However, the positive trends observed do not mean that the epidemic has been overcome in Uganda, the current prevalence levels of HIV/AIDS still present an enormous challenge for Uganda.
4. Lessons learnt
   
   
   1. Political commitment and leadership is very critical to combating the AIDS epidemic. In Uganda, the personal and active involvement of the head of state and senior government officials has played an important role in raising general awareness of the seriousness of the epidemic and in providing official support for the AIDS Control Program.
   2. There is need to mobilize all the resources available in the country to support HIV/AIDS programs. In Uganda, a strong partnership has developed involving the Government, NGOs, the UN family coordinated by UNAIDS and other donors supporting HIV/AIDS programs. The role of NGOs in particular, has been recognized especially at community level. A number of strong local NGOs such as The AIDS Support Organization (TASO) have developed strong HIV/AIDS programs.
   3. Communities and families play a central role in preventing and managing care of people with AIDS. This has been recognized in Uganda and many programs has been designed to better equip families and communities to deal with the epidemic. The Government's policy on decentralization of management of services to the district level has contributed to this by bringing management of the programs closer to the people. In many parts of the country, NGOs and communities contribute their programs for funding through district plans for HIV/AIDS activities.
   4. There is need to use a wide range of multi-sectorial interventions to deal with the epidemic. However, for Uganda and other poor countries resources are limited and cost-effective interventions with an impact on the largest share of the population have to be selected. The Government AIDS control strategy includes a wide range of interventions: increasing knowledge of HIV/AIDS; promotion of condoms; treatment of sexually transmitted diseases and reproductive tract infections; testing and counseling.
   5. As capacity for dealing with the HIV/AIDS epidemics often a key constraint in developing countries, capacity building in technical and management skills is an integral part of the AIDS control programs in Uganda; capacity building is provided for both government agencies and NGOs.
   6. Information is important for monitoring the epidemic and adapting programs to meet the most critical needs. Uganda is strengthening and expanding its sentinel surveillance system. In addition regular knowledge, attitudes, behavior and practices surveys are conducted. Research is also being undertaken.
5. Features in line with the Agenda for Action
   
   
   1. Health, Population and Poverty.
      The overall objective of the STIP is in line with the Agenda for Action to reduce infectious and parasitic diseases. The project is addressing the reduction of HIV/AIDS that is contributing to the diseases burden in Africa and reversing gains achieved over the years in improving health status. This is evident in the reduced life expectancy and increase in infant mortality observed in many countries. Improvement in the health and survival of people has direct consequences for improved productivity and reduction in poverty.
   2. Local Ownership.
      The Ugandan Government has shown commitment in the fight against AIDS with the President of the country spearheading the effort. The AIDS Control Program was set up in the Ministry of Health in 1986. Recognizing that AIDS is more than a health problem, a multi-sectoral approach was adopted and the Uganda AIDS Commission was established as an intersectoral coordinating agency. A multi-sectoral National Operational Plan (NOP) for prevention of HIV infection and mitigation of health and socioeconomic impact of HIV/AIDS was adopted in 1993. The STIP is the largest project in the plan.
   3. Local capacity building.
      An important feature of the STIP is building technical and managerial capacity for management of HIV/AIDS programs. Training is provided for the public sector (central and local departments) as well as non-governmental and community-based organizations. Capacity building encompasses activities that aim to strengthen institutions and enhance skills of health workers and families in providing AIDS care.
   4. Gender Issues.
      The STIP project has mainstreamed gender in its activities. This is important as the HIV/AIDS epidemic disproportionately affects women, especially young girls. Project activities are required to take into consideration differences between men and women in health care seeking behavior.
   5. Global partnerships.
      The project exemplifies coordination and collaboration of different partners in the fight against the spread of HIV/AIDS. The project was designed to cover gaps taking into account existing commitments by other donors and the Government. Coordination is carried out through the national and district level planning process.

World Bank

Dr. Debrework Zewdie, Lead Population and Reproductive Health Specialist Africa Region, and HIV/AIDS Coordinator, World Bank.. Adress:1818 H Street, Washington D.C. 20433, Telephone: 202 473 9414; Facsimile: 202 473 8239

Ms. Mary Mulusa, Task Team Leader for The Sexually Transmitted Infections Project, Human Development Unit, Eastern and Southern Africa, Africa Region, World Bank, 1818 H Street, Washington D.C. 20433, Telephone: 202 473 1937; Facsimile: 202 473 8299

Uganda

Dr. Patrick Kadama, Project Coordinator for IDA Projects, Ministry of Health, P.O.Box 8, Entebbe, Uganda. Telephone/facsimile:256-41-321408.