PPSAC - HIV/AIDS Prevention in Central Africa, Phase V

Background
HIV/AIDS remains a major public health threat in the Central African Region. Given that condom use is a highly cost-effective intervention, the phase V of the HIV/AIDS prevention program ("Projet Prévention du VIH/SIDA en Afrique Central", PPSAC) assists the social marketing of condoms to combat the disease, namely at the level  of adolescents, young adults and other vulnerable groups.

Objectives and Aims
The aim of the project is to increase the use of condoms as well as the acceptance of people living with HIV/AIDS in five Central African countries namely Cameroon, Central African Republic, Chad, Republic of the Congo and Gabon.

The phase V has 3 objectives:
1) Increase the use of condoms in five countries of the Central African Region
2) Increase the knowledge and HIV/AIDS awareness among adolescents, young adults and other vulnerable groups
3) Reduce the stigmatisation of persons living with HIV/AIDS

Methods / Approaches
The project is funded with an amount of 20 million Euros by the German Kreditanstalt für Wiederaufbau (KfW). The project beneficiary is the "Organisation de Coordination pour la lutte contre les Endémies en Afrique Centrale, OCEAC". Swiss TPH acts as regional coordination and operates within OCEAC.

At country level national social marketing organisations, typically ONGs, are contracted for the execution of activities. They are:
Cameroun: Association Camerounaise de Marketing Social (ACMS) and DKT
Central African Republic: Association Centrafricaine de Marketing Social (ACAMS)
Chad: Association pour le Marketing Social au Tchad (AMASOT)
Republic of the Congo: Association pour l’Appui aux Initiatives de Santé Communautaires et pour le Marketing Social au Congo (AAISC/AMSCO)

Results
In 2016 around 42 million of condoms were sold by the national social marketing organisation. Over phase 5 of PPSAC this number shall be doubled so to stand by around 80 million of condoms by 2021. These numbers do correspond to 350'000 couple years of protection ("couples année protection“) in 2016 respectively 690'000 by the end of the phase.
The share of adolescents and young adults knowing the double function of condoms as prevention tool shall increase substantially for example in Cameroon from 71% in 2015 to 82% in 2020
Mass media campaigns are being conducted to substantially reduce the stigmatisation of persons living with HIV/AIDS

Target Groups
Along the three objectives the target groups are:
- Adult population
- Adolescents, young adults and other vulnerable groups as female sex workers
- People living with HIV/AIDS

Other important information
The project started in 2005 and Swiss TPH acts since then as regional consultant in charge of implementing activities at regional level and within OCEAC. Phase V of PPSAC is implemented over a three years period from October 2017 to 2021.

Evaluation of Project Phase II - IV

Impact

The objective of the projects at impact level was to reduce the spread of the HIV/AIDS epidemic and the social exclusion of those affected in the CEMAC region and thus contribute to improving the sexual and reproductive health of the population. The indicators were specified in more detail or supplemented for the ex post evaluation. Over the course of the projects, the incidence of HIV has declined significantly in all participating coun-tries. Since German FC was one of the most important donors in the area of HIV prevention, it can be as-sumed that the projects made a positive contribution to this development. In order to assess the overarch-ing developmental impact with regard to the target group of 15 to 24-year-olds who were specifically addressed, the development of HIV prevalence in this age cohort is used, since there is no comparable data available on the incidence in this group. Here, too, a positive trend is evident in all participating coun-tries. However, the significance of the prevalence rate, which measures the ratio of HIV-infected people in an age group, is limited because it is influenced by a number of factors: in particular, the prevalence rate no longer decreases when the successful treatment of HIV-infected people extends their life span. At the same time, it increases due to the early detection of the HIV virus through higher test numbers, which the project aimed to achieve through the awareness-raising measures.

In Phase III/IV, in line with general developments in the work on sexual health, even greater attention was paid to ensuring the acceptance of people with HIV in the social and professional environment. Special programme activities with a pilot character were only implemented from 2016 onwards. However, more comprehensive measures, repeated over a long period of time, are needed to change public opinion, and these have been stipulated accordingly in the subsequent phase. It is not yet possible to make reliable statements about stigmatisation. Even though this is the first time that a “stigma index” was compiled un-der the project, it is difficult to interpret because of the wide range of stigma: between 19% and 80% of those surveyed feel accepted in the workplace and between 4% and 73% feel excluded from religious ceremonies. A second round of the survey planned in the next phase will provide more information on the development of this indicator. Data collected as part of the Demographic and Health Surveys on attitudes towards people with HIV also paint a very heterogeneous picture for Cameroon, Congo and Chad (see Figure 4): in 2011, for example, 32.2% of men in southern Cameroon had a positive attitude towards peo-ple with HIV, compared with a national average of only 18.4%. Congo (Lékomou 38.1% compared to 18.7% national average in 2011/12) and Chad (Wadi Fera 35.7% compared to 21.8% national average in 2014/15) showed similar variations. In subsequent phases or similar projects, it is important to use re-spective analyses to focus programme activities precisely.

The contribution to the reproductive health of the population as a whole is expected to be indirect and over a longer period. The focus was clearly on the sub-sector of sexual health, which is why no overarch-ing indicators for reproductive health were included and evaluated.
It can be assumed from the positive trends across all indicators and the plausible impact chain that the project made a positive contribution to achieving the developmental impact. However, the treatment of HIV with antiretroviral drugs, which is primarily financed by the GFATM, is certainly also of great im-portance.

Sustainability

The sustainability of the projects must be seen from a political, financial and institutional perspective. The national HIV/AIDS strategies of the CEMAC member states continue to attach great importance to HIV prevention as recommended by UNAIDS. In practice, however, there is considerable competition with the government-financed treatment of HIV with antiretroviral drugs. In 2014, for example, the Congo gov-ernment spent around USD 19 million (2016: USD 14 million) of its own funds on HIV treatment, but only USD 1 million (2016: no expenditure from own funds) on the provision of contraceptives (WHO Global Health Expenditure Database - no validated data is available for the other countries). Moreover, the fragile security situation in the region poses a perpetual risk to the sustainable implementation of prevention ap-proaches.

The sustainability of the project is also at risk due to institutional weaknesses of the project executing agency and the SMA. However, project management by the project executing agency OCEAC has be-come increasingly professional. The professionalisation is supported in part by an ongoing FC comple-mentary measure. The social marketing agencies, on the other hand, still suffer from a low level of qualifi-cation with regard to financial-administrative processes, which can only be compensated for by support from long-term consultants. In view of the significant donor financing in the region, it can be assumed that this would still be guaranteed even if German support were to end, which is not least indicative of an emerging donor diversification of the SMAs that is already well advanced, particularly in Cameroon. Overall, the sustainability of the projects can therefore be rated as (still) satisfactory.

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