A Presentation at the 131 st Annual Meeting of the American Public Health Association San Francisco, California Novembe

1. AIDS Action Clubs: Improving Adolescent Reproductive Health in ZimbabweBy Clarence S. Hall, DrPH, Dorothy E. Nairne, PhD, Gift Malunga, MS, and William O. Fleming, MSPH A Presentation at the 131st Annual Meeting of the American Public Health Association San Francisco, California November 18, 2003 Africare Africare House 440 R Street, NW Washington, DC 20001 202-462-3614, chall@africare.org

2. The Context • Population: 11,900,000 44% under 15 years of age 36% between the ages of 10 and 24 years 68% live in rural areas • Economy: Per Capita GNP: $520 (Malawi--$190; South Africa--$1360; Zambia $320 Inflation: Over 100% Increasing Poverty Poor Micro-economic Performance • Food shortages, malnutrition and hunger • Teens: Very High Unemployment Lack of Recreational Outlets Vulnerable to Risky Behavior and Crime

3. The Problem • HIV/AIDS Prevalence: 33% • Deaths Per Week: Nearly 2000 • PLWAs: 2 million Women: 1.2 million Children: 240,000 • Surge in STD & TB Infections • Life expectancy decrease from 60 to 40 years—35 years by 2020 if trend continues • Adolescents: 35% of youth will be orphans by 2010 Higher Infection rate among females than males Increasing number of youth “heads of households” High rate of teenage pregnancies

4. Government’s Response •   5-Year HIV/AIDS Strategy targeting adolescents • Multisectoral approach including civil society • Life skills and HIV/AIDS Action Program (1992) • In-school AIDS Action Clubs

5. Baseline Survey • Target Area: Mashonaland Central Province Two of Seven Districts (Bindura & Mt. Darwin) Total Population: 856,736 47% under 15 35.5% between 10-24 years • Methodology: KAPC Individual Interviews and Focus Groups In and out-of-school youth Teachers Parents • Sampling and Size: Multi-stage cluster sampling procedure used to select wards, enumerating areas and individuals 209/230 adolescents and young adults

6. Selected Findings • First sexual encounter occurred between 9 and 15 years. • Sexual experience most common among men (82%) than women (18%). • Young adults aged 20-24 were more likely than younger ones aged 15-19 to have had sexual experience (89 percent vs. 11 percent respectively). • Primary school adolescents who had friends with boy/girl friends as well as friends who have had sexual intercourse were 26% and 37% respectively. • Seventy percent of secondary students who had sex stated that experimentation was the main reason. • Parents were very suspicious of HIV/AIDS school programs. Most believed their children were being taught how to have sex and the syllabus encourageschildren to experiment.

7. Adolescent Reproductive Health Initiative (ARHI) • Purpose: To effectively reach adolescents (10-24 years) with reproductive health information and promote positive attitudes and behaviour. • Objectives: • Provide relevant adolescent reproductive health information and/or technical assistance to all participating community-based initiatives (CBIs); • Provide reproductive health messages to 100,000 adolescents and young people; • Disseminate CBI best practices to at least 30 community groups and indigenous non-governmental organizations (NGOs); • Increase planning and management skills of 25 CBIs; and • Prepare a minimum of 10 participating CBIs to be self-sustaining through income generating and other fundraising activities. • Countries: Malawi, South Africa, Zambia & Zimbabwe • Sponsors: Bill & Melinda Gates Foundation

8. AIDS Action Clubs • Goal: To effectively reach adolescents (10 – 25 years) and teachers with reproductive health information and promote positive attitudes and behavior change through the establishment of AIDS Action Clubs. • Objectives: • Instill in-depth knowledge, promote effective communication, positive attitudes and behaviors related to HIV/AIDS and STD; • Equip adolescents with life skills to enable them to make informed choices; • Facilitate accessibility to reproductive health services; • Empower adolescents with self-reliant skills through income generating activities (IGAs); and • Establish and strengthen links with relevant organizations, ministries and other stakeholders.

9. Major Components • Formation of AIDS Action Clubs led by teacher (30-80 students) • Training of adolescents, CBI leaders, school administrators, teachers, parents and health providers. • Production of IEC materials (pamphlets, songs, drama, t-shirts, and caps). • Introduction and Support for IGAs (15% invested in club and HIV/AIDS activities). • Youth Friendly Corners. • National Media Events. • National Competitions (theater groups, music groups, and essays) • Volunteer activities in the community to support orphans and people living with AIDS. • Establish linkages to networks and social services that support AIDS Action Clubs activities.  

10. ARHI Evaluation • Independent Consultant • Objectives: • Determine whether or not Africare met program objectives; • Measure the impact of key outcomes; and • Document improvements in health outcomes. • Review of periodic reports, project documents, health facilities records. • Individual interviews (Action Club members, staff, school administrators, stakeholders and implementing partners). • Focus group discussions (teachers, community leaders, parents, health providers, in-and out-of-school youth).

11. AIDS Action Clubs Results • Behavior and Health Impact • Increasing openness to talking about HIV/AIDS. • Increasing numbers of youth accessing services through the youth-friendly services. • Reduction in sexual partners among both male and females. • Self-reported abstinence and delay of onset of sexual activity. • More compassionate treatment of PLWAs. • Increased support of clubs and HIV/AIDS programs by school administrators. • Increasing parental involvement in AIDS Action Clubs. • Less students hanging around rural shopping centers.

12. AIDS Action Clubs Results Con’t • Other Effects of ARHI • Over 2 million youth reached in the four participating countries. • One hundred forty-four (144) CBIs participated. • Youth involved in ARHI more confident and assertive as their knowledge of reproductive health and interaction with communities increased. • Increased retention of girls after the first 2 years of secondary school. • Youth friendly training of health providers instituted through ARHI. • Communities that have participated in the training are more engaged and taking more interest in HIV/AIDS awareness.

13. Lessons Learned • Successful AIDS Action Clubs must have the full support and encouragement of the school administration. • The viability of income generating activities questionable due to the very poor state of the economy---frequent price changes and short supply of inputs. • Out-of-school youth are very much in need of sources of income. Most are unemployed and engage in deviant behavior. • Out-of-school youth should be given the option of remaining as members of the AIDS Action Clubs after leaving secondary school. They are a great source of leadership and a resource for training activities.

14. Conclusions/Recommendations • AIDS Action Clubs and their combination of strategies are effective approaches to reaching adolescents and youth at risk for HIV and other sexually transmitted diseases. • Scaling up of this best practice should be considered by other countries in the region with similar challenges and issues among adolescents. • Theatre groups are highly effective HIV/AIDS outreach activities in rural and peri-urban areas where radio, print or television coverage is limited. • More attention should be given to making condoms accessible to sexually active adolescents. • Indicators for adolescents in the Demographic Health Surveys (DHS) should be revised to include age at first intercourse, number of sexual partners, increased condom use, rate of unwanted pregnancies, HIV and STD infection rates.