Report for Total Control of

Epidemic Gaza - Zambezia

For the period January to December 2014

Submitted to:

U-landshjelp fra Folk til Folk, Norge

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Name of the project: TCE Gaza - Zambezia

Organization: ADPP - Mozambique

Period Report: January – December 2014

1. Presentation of the Project

ADPP Mozambique is a Mozambican organization with 32 years of experience in

the implementation and development of projects all over the country. Among the

key projects in the area of health is the TCE – Total Control of the Epidemic, an

intensive HIV/AIDS prevention and care, community mobilization and behaviour

change program designed by the Federation Humana People to People to fight the

HIV/AIDS epidemic. The TCE model is based on door-to-door campaigning, free

and voluntary HIV-testing and interpersonal counseling given by specially trained

TCE Field Officers.

The first phase (Phase I) of the TCE Gaza project was initiated on the 1st of July

2011 and was implemented in the districts of Mandlakazi, Chibuto, Chokwe and

Bilene in Gaza Province. Gaza is the province with the highest HIV prevalence rate

in the country (25%). This is due to a wide range of factors, including social,

cultural and economic, as well as institutional structures, which all contribute to

the high number of infections in the country.

The second phase (Phase II) of the project began in May 2014 by adding two new

provinces and giving a special focus to high-risk groups, namely

1. Girls between 15 and 24 years of age;

2. Women between 25 and 49 years of age;

3. Truck drivers

4. Sex workers

5. Miners.

The Project is now implemented in the 14 selected districts of Bilene, Chokwé,

Chibuto, Guijá, Manjacaze and Xai-Xai in Gaza Province, Marracuene, Moamba and

Magude in Maputo Province and Quelimane, Nicoadala, Mopeia, Namacurra and

Mocuba in Zambezia Province. Altogether 711 Field Officers were recruited locally

and trained by health professionals form the Provincial Departments of Health.

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The Project is part of a wider 5-year Program funded by the Global Fund (Phase II,

Round 9) to fight HIV/AIDS, Tuberculosis and Malaria in Mozambique, and

reaches ADPP through the primary recipient FDC (Fundação para o

Desenvolvimento da Comunidade – Foundation for the Development of

Communities). ADPP Mozambique participates in the project by implementing a

component on community-based door-to-door prevention and care services.

2. Project Activities

2.1 Recruitment of Field Officers

The expansion of the project into two new provinces in 2014 made it necessary to

recruit a considerable number of new Field Officers in each Province. A total of

1,245 applications were submitted and 869 candidates selected for the initial

training. Of these, 711 were selected as Field Officers and sent to their respective

areas with each of them covering a geographical area of 2,000 people.

2.2 Initial training

An initial five-day training, given by the leadership of the TCE project, was

organized in order to train the Field Officers in mobilizing local communities and

in carrying out interpersonal counselling and awareness raising and door-to-door

campaigns. Various officers from Ministry of Health (MISAU) were invited to

discuss issues related to HIV/AIDS, Tuberculosis, STDs, among others.

2.3 Behaviour change through one-to-one intervention addressed to

target population

The main strategy chosen for the implementation of the second phase of the

project was the elaboration of individual Risk Reduction Plans (RRP) during one-

to-one counselling sessions. The objective was to meet with each member of the

target group for at least 3 times. Concluding the 3-session package also qualified

the person to be considered as “reached”. At the end of the sessions, the Field

Officer reported on the results of the elaboration and implementation of the

individual RRPs.

The targets and results for each of the 5 groups were as follows:

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65,419 girls aged 15-24 reached – Achieved: 64,027

45,625 women aged 24-49 reached – Achieved: 61,681

3,597 sex workers reached – Achieved: 2,766

3,319 truck drivers reached – Achieved: 2,764

1,244 miners reached – Achieved: 612.

The strategy to reach each the 5 target groups was different and chosen according

to the typical behaviour patterns: girls, women and minors were found at their

homes through the door-to-door campaigns. Sex workers and truck drivers were

found in areas identified by the Field Officers as locations of leisure, transit and

rest. Special night campaigns were also organized to reach this segment of the

target group as both were likely to be found in the same place.

Another strategy used among sex workers has been to invite them to work as

Field Officers, thereby facilitating the identification of other sex workers. This has

resulted in two positive outcomes: 1) being approached by a peer has shown to

be an effective way of reaching sex workers and 2) changing the risky behaviour

(selling sexual services) was made easier by offering alternative means to earning

a salary.

2.4 HIV-testing

One of the main project objectives is to have the target population tested for HIV

and become aware of their status so that necessary means can be taken to prevent

the spread of the virus and ensure that those diagnosed HIV-positive can start

treatment. To this end, the Field Officers have to be trained in counselling and

testing.

A 5-day training on pre- and post-testing counselling was therefore given by

officials from the Ministry of Health (MISAU) to a total of 532 Field Officers in

Gaza, Maputo and Zambezia Provinces in 2014. Given that the training was

considered short, the Field Officers have continued familiarising themselves with

the matter in the local health centres.

The initiation of the daily testing services are also pending the testing kits. The

Project leadership is currently negotiating the issue with the Provincial

Directorates for Health in order to ensure a sufficient amount of kits for all Field

Officers.

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Focusing the testing services to the high risk groups only has also proven to be a

challenge as the people pertaining to these groups has at times been difficult to

identify.

2.5 Distribution of condoms

Having access to and skills in the correct use of condoms is key in facilitating

behaviour change and in particular in adopting safe sexual practices. Given that

condoms are the main tools in implementing the individual Risk Reduction Plans,

proper knowledge on their use and their constant availability and accessibility

(including price), are crucial in terms of reaching the objectives of the project.

Thus, the focus given to the distribution of condoms and training in their use

during the one-to-one sessions and during community mobilization campaigns.

The condoms are offered by the Ministry of Health through local health centres,

hospitals and other organizations, including PSI (a global health organization

providing technical assistance to the MISAU). Altogether 4,778,420 condoms were

distributed during 2014.

2.6 Positive Living Clubs and TRIOS (Community-Based Support and

Adhesion Groups,)

One of the objectives of the TCE Project is to mobilize people infected and affected

by the HIV virus in community groups that offer peer support, training in positive

living and promote adherence to ARV treatment. These community-based support

and adhesion groups are also used to help HIV-positive people obtain their

monthly medication by organizing their members in rotational shifts of fetching

the medication from the health centres and/or hospital for the whole group. This

not only reduces transport costs but improves adherence to treatment as well.

The strategy used to join these people was through meetings at local health

facilities. The TCE Field Officers are invited to attend these meetings and often use

the opportunity to introduce the idea of establishing TRIOs and Positive Living

Clubs(groups of people living with AIDS and supporting each other). Each support

group is formed by two to six members. The TRIO consists of a PATIENT with HIV

on treatment and two people who care for her/him yet they are of her/his choice

and entire trust.

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2.7 Partnership with EGPAF (Elisabeth Glaser Pediatric AIDS Foundation)

As part of the partnership with EGPAF (Elisabeth Glaser Pediatric AIDS

Foundation) aiming at strengthening the TCE interventions in the communities

and better reaching people infected by HIV/AIDS in the target areas, altogether

180 Field Officers from the districts of Massingir, Guijá, Bilene, Xai-Xai, Chibuto

and Mandlakazi were identified and given special training in the following topics:

Family-Centered approach to Index Case (Mobilizing the family members of

a person infected by HIV for counselling and testing);

HIV and TB screening, Gender Based Violence, and HIV-counselling and

testing.

As a result of the training, 192 Index Cases and altogether 670 people related to

and/or living with them were contacted, tested and given counselling. The people

reached in this way are also screened for other diseases as particular tuberculosis.

Of the altogether 670 people tested (family member to the already tested HIV

positive), 57 were found HIV-positive and referred to the local health facilities.

Among the greatest advantages of this approach is that by relying on the already

identified HIV-positive people it offers an easy access to other possibly infected

people at their homes. This, in turn, has resulted in increasing the detection of

HIV-positive cases and their adherence to treatment.

3. Effects of the project

The TCE Project hired and trained altogether 711 local Field Officers from the communities in the three focus provinces in basics in HIV/AIDS and in counseling and HIV-testing.

As a result of the one-to-one consultations and community campaigns, more and more people are taking responsibility over their health and over the prevention of contracting and/or spreading the HIV-virus. Altogether 131,850 people were reached through the behaviour change sessions in 2014.

Establishing the Positive Living Clubs and the TRIOs and organizing the

obtaining of the monthly ARV treatment through rotational shifts has resulted in reducing the related transport costs (travel to health units) and

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improved adherence to treatment among HIV-positive people.

According to the review made by the health authorities in Mocuba district, the strategy selected by the TCE Project of sending only one person from each support group to fetch the monthly medication has been successful in organizing the HIV-positive people on treatment and reducing queues at the health centers, thereby facilitating the work of their staff.

Altogether 29 Support Groups for HIV-positive people were created in

2014 in collaboration with the district health centres. A total of 132 members benefit from the groups.

The distribution of and training in the correct use of condoms has resulted

in increasing the acceptance and constant use of condoms within the target communities, thereby demonstrating a rapid change in behaviour. Altogether 4,778,420 condoms were distributed during 2014.

The effect of the door-to-door campaign and community debates has influenced a reduction of stigma and discrimination, which has led to increased demand for HIV/AIDS services and an openness about HIV serological status.

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Attachment 1: The Project in Numbers

Number TCE Mozambique

Goals and Achievements

Goal of the

year Achieved Difference

1

Number of people covered by the

activities of TCE for the prevention

of HIV

800,000

131.632

- 668,368

2 Number of interactions door-to-

door to inform, mobilize, advise girls 116.463 64.027 - 52.438

3

Number of interactions door-to-

door to inform, mobilize, advise

women

73.213 61.681 - 11.532

4

Number of interactions door-to-

door to inform, mobilize, advise

lorry drivers

3.939 2764 - 1175

5

Number of interactions door-to-

door to inform, mobilize, advise

miners

1.112 612 - 500

6

Number of interactions door-to-

door to inform, mobilize, advise sex

workers

4.450 2766 - 1.684

7 Number of condoms distributed in

the communities 12,600,000 4.778.420 - 7,821,580

8

Number of people in supporting

groups

41.123 132 - 40.991

9 Number of People tested

300,000 2.126 - ,874

COMMENTS:

The program was initiated in May 2014 after the signing of the agreement. This is also when the recruitment process of the Field Officers begun. Although the project goals were defined in June, the Field Officers only started working in July. About the numbers achieved, as illustrated in the table above, they are far from reaching the targets, still they are beyond our expectations (80%) due to the late start of the activities in Maputo and Zambézia Provinces.

Another factor to highlight is the challenges in the appropriation of the new approach (giving a focus on a specific target population of high-risk individuals) by the new Field Officers. The short duration (5 days) of the initial training has resulted in the Field Officers considering the approach as a major challenge.

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Among the factors leading to not being able to reach the targets is that the condoms are purchased from health facilities, but only in small quantities. The challenge has been addressed through discussing the difficulties faced when acquiring, storing and distributing the condoms. The functioning of the community-based support and adhesion groups relies on people being open about their HIV-status. The establishment and functioning of the groups would therefore be facilitated if the Field Officers worked in closer cooperation with the health centres in order to have the lists of people infected by HIV/AIDS. As to the HIV-testing, there was a delay in training the Field Officers (November 2014), leading to not reaching the targets in this area. An issue to consider in the future is ensuring a sufficient supply of testing kits. Various advocacy meetings to obtain these kits are currently taking place. The project is facing challenges in reaching the planned goals and therefore is working

on strategies for 2015.

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Attachment 2: Photos from the Project

TCE Field Officer upgrading the community playground to benefit local children during

a community action

Monitoring and evaluation visit of TCE activities implemented in Nicoadala, Zambezia

province

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Administrator of Chokwe district visiting the TCE project

TCE Field Officer mobilizing a long distance truck driver

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TCE Field Officers celebrating the positive results achieved during the week

TCE Field Officer Ismael distributing Condoms

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TCE Special Force giving an explanation of the TCE program activities

.

TCE Field Officer counselling a girl about HIV/AIDS.

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TCE Field Officer mobilizing an adult woman, referring her to a health unit for testing

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Attachment 3: Relevant Documentation from the

Project.

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Field Story

“During the course of the working week I went to one of the family’s homes, on the

door-to-door approach sessions with the population, aged between 15 and 49 years.

On entering the house I asked to speak with the owner. When we started the dialog,

after introducing myself and talk about the initial information about HIV/AIDS, she

told me she is also an activist in the school where she works and asked me to talk

with her daughter. I had no reason to deny, because she was informed on those

matters, so I asked to speak with her daughter. The lady called her daughter and I

continued the same approach. We talked about testing and she told me she did not

need to take the test because they already knew their HIV status which was positive.

I asked for how long she knew her HIV status and she told me since she was born. I

realized she did not understand the issues with HIV and AIDS so I explained the

differences between being HIV positive and having AIDS and gave her a lot more

information.

Then, after realizing that, she asked me to refer her to a clinic to get tested.

A week later, I visited the house again and she had already done the test and was

happy to know the results. She really thanked for my presence on that day.”

ADPP-TCE Zambézia

Division 2

Nicoadala Patrol

Q.C: Alverinda Lacerda