Introduction

The World Health Organisation (WHO) reported in 2016 that more than one million sexually transmitted infections (STIs) are contracted worldwide every day. STIs, have a profound impact on sexual and reproductive health worldwide. Despite considerable efforts to identify simple interventions that can reduce risk sexual behaviour, behaviour change remains a complex challenge. Research has demonstrated the need to focus on carefully defined populations, to consult extensively with the identified target populations, and to involve them in the design, implementation and evaluation of planned interventions.

The impact of sexually transmitted infections came to the forefront with the outbreak of the HIV/AIDS pandemic. The severity of HIV/AIDS in Africa is clearly illustrated by statistics reported by UNAIDS in 2017. These reveal that Sub-Saharan Africa accounts for 69% of all people living with HIV/AIDS, of which 59% are women and girls in southern and eastern Africa and 56% in western and central Africa. Sub-Saharan Africa further registered 74% of all HIV/AIDS deaths in the world in 2016. On the other hand, there is cause for optimism. UNAIDS report reveals that the number of new HIV infections is declining and between 2010 and 2016, the number of AIDS-related deaths fell by 42% in eastern and southern Africa and by 21% in western and central Africa.

Although HIV/AIDS can affect anyone, it has become clear that it is spreading faster among people who live in poverty and lack access to education, basic health services, nutrition and clean water. Young people and women are the most vulnerable and, because women are often powerless to insist on safe sexual relations, they are vulnerable to infection by HIV-positive partners. When people have other diseases like sexually transmitted diseases, TB or malaria they are also more likely to contract and die from HIV/AIDS.

There was, therefore, a clear imperative for the NEPAD Spanish Fund for African Women Empowerment to channel a significant proportion of all disbursements towards projects that addressed sexual and reproductive health and HIV/AIDS prevention services in Africa. These projects, consequently, directly benefitted over 73,000 women in Africa. These interventions included, inter alia, workshops on contraceptive use and other safe sex initiatives; facilitating HIV/AIDS testing; providing financial and psycho-social support to women infected with HIV/AIDS; initiatives centred around generating awareness about women’s sexual and reproductive rights; facilitating the creation of employment opportunities  (and therefore income generation) for women infected with HIV/AIDS; training women in midwifery; the provision of specialist equipment and facilities for surgery on obstetric fistula.

Success Stories and Case Studies

The following two projects outline the success that was achieved in promoting sexual and reproductive health and HIV/AIDS prevention services.

SADEV (Health and Development): Youth, Gender and HIV/AIDS

SADEV is a non-governmental organisation working in the Republic of Niger which specialises in healthcare. SADEV specifically focuses on the fight against sexually transmitted infections (STI’s) and HIV/AIDS. SADEV used the disbursement from the NEPAD Spanish Fund for African Women Empowerment to carry out several awareness-raising activities reaching 12,390 young people from selected schools in the town of Fada and in Niamey, the capital of Niger.

Prevention activities included educational lectures, cultural evenings for young girls and boys, as well as debates and screenings of HIV/AIDS films. Additionally, the project included a training element covering gender and HIV/AIDS aspects, communication skills for behaviour change, hairdressing, and computer skills. SADEV facilitated the distribution of a wide range of informational materials on STIs

Two hundred gender and HIV/AIDS sensitization sessions were conducted in the Niamey region. These educational talks were attended by 6,524 young people, including 4,320 girls. To stimulate cascade training, 9 training sessions on gender and HIV/AIDS for young people were organized in the Niamey region. These training sessions helped train 90 girls and 90 boys. As soon as they were trained, these young people began to raise awareness in five communes of the Niamey region. Six cultural evenings were held for the benefit of young people in the region of Niamey. These were attended by 5,616 participants including more than 2,690 girls.

The project was successful in achieving its main objectives. The success can be attributed, amongst others, to the innovative way in which the messages were conveyed. For example, the youth were engaged by hosting evening activities in secondary schools on sexually transmitted infections and HIV/AIDS. They found that by using a variety of delivery methods, the pupils more readily absorbed and integrated the message conveyed. The evening performance activities, therefore, attracted many young girls and boys from the Niamey region.

The project further established partnerships with regional authorities in charge of education, HIV positive women groups, people working at the psychiatric hospital of Niamey, girls working in hair salons and others. The beneficiaries received several training sessions on gender equality, HIV /Aids prevention and people stigmatization, thus building capacity. In addition, information on human rights and the promotion of positive social norms was widely distributed in the Niamey region.

The young people that were targeted were very willing to assist with the work of the organisation as well as the training sessions and quickly assimilated the HIV/AIDS prevention messages.  Moreover, the stigmatization from which HIV/AIDS positive people had been suffering was reduced because of the greater understanding of the mechanisms of contamination or transmission.

The taboo related to sexuality initially constituted an obstacle that had to be overcome by SADEV in their interventions. In Niger, discussion about sexuality could not be freely conducted in public because it is a matter of embarrassment and disgrace in the view of older people. This lack of dialogue between parents and their children, the elders and young people, men and women, about sexuality and healthy reproduction made effective behavioural change very difficult. Erroneous information that is disseminated about sexually transmitted infections and HIV/AIDS further exacerbated the situation and required SADEV to be innovative.

Women for Women Foundation Incorporated (Trampled Rose Incorporated)

Trampled Rose, Inc. is an NGO that was established in Ethiopia to improve the general health and living conditions of women who suffer from Obstetric Fistula. These women were shunned by their families and communities and many were living alone and destitute. The source of this condition stems from a lack of medical attention or complications during childbirth or becoming pregnant at a young age due to the harmful cultural practice of early marriage. The project’s purpose was to rehabilitate 30 women annually, over a 3-year period and provide them with the necessary care, skills and knowledge to generate their own income and reintegrate into society.

Trampled Rose Inc. provided shelter, three meals a day, clothing and care to 87 women who suffered from Fistula. The women were from the Amhara region of Ethiopia and were cared for at the St. George Church in Addis Ababa.  They all received counselling from a medical professional who helped the women to understand that Fistula is a medical condition and not some form of divine punishment of which to be ashamed.

A challenge that Trampled Rose encountered and which they had to overcome was that the incidence of fistula in women is more wide-spread and complicated than they initially realised. The found that to overcome this problem they had to learn more about the disease by working and communicating with the women who have fistula and to research other known cases of and solutions to it.

A further challenge they had to overcome was that the success rate for curing fistula via surgery was much lower than originally expected. Trampled Rose, therefore, realised that more direct psychological help and intensive trauma counselling was required to counteract the psychological damage that the women suffered.

However, it was observed that the women were very eager to learn and most of the women put in extra effort and time into helping each other and working in the classrooms beyond normal class hours to improve their knowledge and skills.

One of the lessons learned during the project was that it is important to work with other NGOs.  However, this was not always easy to achieve, and they found that it was therefore important to network and find those individuals and organisations that were willing and excited to partner with them to help more women.    

The following story pays tribute to the success of the Trampled Rose Inc. project:

These are the grateful words of Maeza herself “This is the best time of my life!  I started to be human again.  I know how to write and calculate money.  I am happy.  I never imagined getting such a chance in my life.”  Her husband said “I am so happy and thankful!  The trampled Rose helped us financially because my wife knows how to get additional income to change our lives.  Thank you!”

But Maeza   Miskir’s life has not always been so happy.   She was born to a subsistence farming family. When she was young there was no school in her area and her parents didn’t consider education important for a girl. They wanted her to get married and be safe instead.

Although Maeza was only seven years old and had no desire to get married she was given to her husband to begin the duties of a wife.  This was a terrifying experience for her so as soon as she had the chance she ran away from the man she hardly knew.  Because of her illiteracy life was difficult and she married again.

 In her second marriage, she became pregnant with her first child.  In the area where she lived medical services were scarce and most of the women gave birth in their own homes or the home of their in-laws with a traditional birth attendant.  These birth attendants have limited knowledge about difficult childbirth deliveries.  Maeza was in labor for five full days.  At the end of her labor the baby was stillborn. 

The pressure on her birth canal had caused a lack of blood flow to her bladder and she developed vesico-vaginal fistula.  She began to leak urine uncontrollably.  Her husband was offended by her condition.  He asked her to leave so he could marry another woman who could have children and he wanted to be free of Maeza. 

She returned her to her family home.  She lived with them for two years when she heard about surgery at a Fistula Hospital near her region. But her depression and bad luck increased when she underwent her surgery only to discover that she seemed to be incurable. She lived for one more year in hopelessness until she met a new educated man.  He loved her and told her that he was willing to marry her because you never know what can happen in the future. 

One day she was approached by the Amhara Development Association who was contacting women in their area with fistula on behalf of Trampled Rose, Inc.  Maeza and her husband jumped at the opportunity offered by Trampled Rose. Maeza was frightened, hungry, tired and dirty when she arrived at the gates of the Trampled Rose.  During her orientation, she was taught about the causes and cures for fistula.  She was especially relieved to learn that fistula is not a curse from God but only a medical condition caused by her prolonged labor.  As part of her orientation, she was taken to a hospital to be checked for other diseases that could make her studies difficult.  She was also examined by an expert fistula surgeon to make sure that her fistula was indeed curable.  Her pleasure was immeasurable when she discovered that she did indeed have a chance to be cured by surgery.

Maeza began her literacy class during her first week.  She was taught the alphabet by using small stones and sticks to make letters.  She could read 180 words in her first week.  This quick process gave her the courage to try more. In fact, Maeza was the outstanding student in her graduation from the Trampled Rose. She also enjoyed the social atmosphere of being with twenty-seven other women with her same problems.  After Maeza could read and write she began her business training of Sambusa making, ironing, traditional bread baking, and jewellery making. She also learned how to manage money and how to make a business plan.  She even enjoyed a field trip to a bank to learn how to open her own account.  She was surprised because she thought that banks were only for rich people.

Maeza’s surgery was indeed successful and she returned to her happy husband to open her own small shop selling Sambusa, traditional beer, tea, and taking in ironing with the startup capital she received from the Trampled Rose.

Key Lessons Learned from the Sexual and Reproductive Health and HIV/AIDS Prevention Services Projects

Utilise communication and training as essential tools in the fight against HIV/AIDS

The worldwide stigma and sensitivity that is associated with HIV/AIDS provides a clear imperative to break the silence and remove the shame that surrounds it. People who are infected, fear rejection and discrimination from those around them and try to hide their illness. Effective communication and training are therefore essential tools in the fight against HIV/AIDS. Women are the most affected and they should be informed of how to prevent infection. Social attitudes that make women vulnerable should thus be changed, specifically regarding the attitudes among many men that lead to woman abuse and sexual violence. Furthermore, projects should try to include additional considerations when targeting HIV/AIDS, as it is associated with numerous, unrelated phenomena. For instance, tuberculosis (TB) infection is often considered to be an indicator of having HIV/AIDS. This inaccurate perception, along with the stigma associated with HIV/AIDS, leads to innumerable individuals not receiving treatment for TB, due to fear of stigmatization.

One of the projects that realised the importance of effective communication and training regarding HIV/AIDS prevention and sexual reproductive health issues was implemented by the Health and Development (SADEV) NGO in Niger. SADEV conducted several awareness-raising activities covering sexually transmitted infections (STIs) and HIV/AIDS prevention in selected schools in Niger. These reached some 12,390 young people. These activities included educational lectures, cultural evenings for young girls and boys as well as debates and screenings of HIV/AIDS films. The project, additionally, included a training element covering gender and HIV/AIDS aspects, and communication skills for behaviour change.

Engage and sensitise community and religious leaders regarding HIV/AIDS

Another effective method of diminishing the taboo and social stigmas surrounding HIV/AIDS and sexually transmitted infections (STIs) and to prevent these diseases, is to actively engage with and sensitise community and religious leaders regarding these issues. These leaders set the norm and are the role models that communities follow. Both the DIMOL (Reproductive Health for Safe Motherhood) and the Health and Development (SADEV) projects in Niger realised the importance of engaging these leaders in their campaigns against the diseases.

More projects need to provide free HIV/AIDS testing, especially in rural areas

The World Health Organisation (WHO) strongly recommends the regular testing for HIV and other STIs. Most often these tests provide same-day test results, which are essential for swift diagnosis and early treatment and care. HIV can be suppressed by administering antiretroviral therapy (ART) and although ART does not cure HIV infection, it allows an individual's immune system to strengthen and regain the capacity to fight off infections. Furthermore, the Centre for Disease Control in the United States of America confirmed in 2017 that effective treatment of HIV prevents transmission of the virus to uninfected individuals. The importance to provide free HIV/AIDS testing, especially in rural areas and among the poor, surfaced in many of the NSF projects.