Family Health International:
A Leader in the Fight Against HIV/AIDS

Virtually every organization striving to improve public health has had to come to grips with the HIV pandemic. International organizations working on HIV/AIDS issues face the triple challenge of dealing with the multiple causes and repercussions of the pandemic; strengthening the links among HIV/AIDS prevention, care, and support; and forging partnerships with governments and nongovernmental organizations (NGOs) to implement effective responses.

"HIV/AIDS is truly unique in its potential to undermine societies," says Tony Bennett, associate director of Field Programs for Family Health International (FHI), a non-profit organization founded in 1971 to improve global public health. "HIV continues to spread rapidly in many parts of the world, requiring a forceful, comprehensive, and long-term response from the international community."

FHI, a U.S.-based organization, has been a leader in the fight against HIV/AIDS for 15 years. The organization, with more than 500 employees in over 25 countries, has worked to curb the epidemic and mitigate its impact in every region of the developing world. FHI's ability to manage complex programs, its early leadership addressing HIV/AIDS as a major threat to health and development, and its network of international partners convinced the U.S. Agency for International Development (USAID) to entrust the organization with its flagship HIV/AIDS projects.

FHI's first USAID-sponsored project was the AIDS Technical Support Project (AIDSTECH), which operated from 1987 to 1992 with a budget of $40 million. Under AIDSTECH, FHI managed 185 subprojects in more than 35 countries. In 1991, USAID selected FHI to operate the AIDS Control and Prevention (AIDSCAP) Project, a six-year, $200 million program that would become the largest international HIV prevention effort to date. Under AIDSCAP, FHI worked closely with a wide range of partners to design, implement, and evaluate more than 800 HIV/AIDS and sexually transmitted infection (STI) interventions in 50 countries. Since 1997, FHI has conducted USAID's Implementing AIDS Prevention and Care (IMPACT) Project, a five-year, $150 million program with more than 680 subprojects in 40 countries. FHI will also manage the $200 million IMPACT II project planned for 2002-2007.

When FHI began working on HIV/AIDS there were few precedents. By developing innovative approaches to prevention, care, and support, FHI has identified valuable lessons. For example, FHI has learned that messages compelling people to use condoms and avoid risky sexual behavior are not enough to halt the spread of HIV. It is also critical to understand the determinants facilitating transmission, identify the motivations behind risky behavior, provide strategies and build skills to reduce risks, and ensure that support services are in place for people infected and affected by HIV.

The crucial link between prevention and care merits particular emphasis. For many years, governments and donor agencies believed that concentrating on prevention would avert the need for care and support services. Yet recent studies show that care and support for people living with or affected by HIV/AIDS are requisite components in stemming further spread of the virus. For example, voluntary counseling and testing (VCT) -- the mainstay of psychological support -- is an important element in promoting safer sexual behavior which in turn prevents HIV infection. The prevention-to-care continuum also includes provision of antiretroviral drugs for people living with HIV/AIDS; management and prevention of STIs, tuberculosis, and other opportunistic infections; prevention of mother-to-child transmission of HIV; and programs for orphans and other children vulnerable to HIV infection.

One of the most important lessons learned by FHI is that partnerships with governments and local organizations are essential in developing HIV/AIDS programs that continue beyond the period of donor funding. FHI works with a broad range of partners to increase local governmental and NGO capacity to carry out prevention, care, and support projects in Africa, Asia, Eastern Europe, Latin America, and the Caribbean. A review of three country projects demonstrates how FHI and its partners have translated goals and objectives into actions and results.

Lesedi: STI Services for Women in a South African Mining Community

South Africa is home to one of the fastest-spreading HIV epidemics in the world. Rural poverty, job-related migration, and high STI rates fueled an increase in HIV prevalence among pregnant women (a group epidemiologically representative of the general population) from less than 1 percent in 1990 to more than 20 percent in 1999. Commercial sex workers near South African mines cater to thousands of male migrant workers living in single-sex hostels, leading to high STI rates among miners and their female partners. The presence of other STIs increases the risk of acquiring HIV.

In 1996, with USAID funding, FHI and Harmony Mine Hospital launched the Lesedi Project in South Africa. The project established mobile clinic services and a peer educator network to reach women at risk in the vicinity of the Harmony Mines. The women helped to design the services, and peer educators were selected from among the population being served. Local researchers determined the ideal sites for mobile services. Further research, in partnership with area residents, suggested that periodic screening for STIs and treatment of all women regardless of STI symptoms -- an approach known as presumptive treatment -- would ensure coverage for most at-risk women. All women referred to the clinic by peer educators were encouraged to return monthly for prevention counseling and presumptive treatment with a single dose of an antibiotic to treat chancroid, gonorrhea, chlamydia, and incubating syphilis.

During the first nine months of the project, more than 400 women attended the clinic at least once for examination, counseling, and treatment. During this same period, STI prevalence among these women fell by 70-85 percent; rates of gonorrhea/chlamydial infection among local miners dropped by 43 percent; and reported incidence of ulcers decreased by 78 percent. Self-reported condom use rose from nearly zero to 20-30 percent of commercial sex encounters. A cost-benefit study concluded that the project, which cost $53,760 per year to operate, was generating annual medical savings of $539,430 due to lower levels of STIs to be treated. At the end of the project's first year, Harmony Mines, with support from the South African Department of Health, assumed the management and implementation costs of the project, and expanded its geographical and demographic coverage. The Lesedi Project is being replicated in several South African mining regions.

Pantè: Condom Social Marketing and Community-Based Distribution in Haiti

Haiti has the highest adult HIV prevalence rate in the world outside of Africa. Extreme poverty and high unemployment -- at least 50 percent -- have hastened the spread of the virus, as have political and economic instability and severe environmental degradation. Commercial sex, displacement of the population from rural to urban areas, the separation of families, and a rising sense of desperation among unemployed, out-of-school youth have all increased, fueling an HIV prevalence rate of 10 percent in urban centers and 4 percent in rural areas by 1999.

From 1991 to 1996, FHI and Population Services International (PSI), an NGO promoting greater access to health care and services, collaborated on a condom social marketing project implemented by Haitian NGOs at the community level. Before the project, condoms were commercially available for approximately 25 U.S. cents , a prohibitive price in Haiti, where average annual per capita income was only $400. Condoms were generally available in cities and towns but not in most villages or rural areas. Condom sales averaged about 30,000 per year in 1990. By 1996, when the project ended, annual sales had increased to over 540,000.

Two factors help to explain the project's success. First, PSI launched "Pantè" (Creole for panther), Haiti's first socially marketed condom. USAID ensured that this brand would be available for three U.S. cents each. Second, the project partnered with four NGOs already involved in HIV/AIDS prevention and trained 175 staff to serve as both wholesale distributors and retail sales agents. These community-based distributors, who received a percentage of condom revenues, were able to access areas out of reach of FHI and PSI and established points of sale in nightclubs, beauty salons, small shops, and other outlets.

The Pantè social marketing project -- later partnered with nine local NGOs --ultimately helped to create 3,000 new points of sale, spread throughout Haiti's administrative départements and 95 percent of its administrative communes.

Voluntary Counseling and Testing in Kenya

Under the IMPACT Project, FHI is working with such partners as the Government of Kenya, the University of Nairobi, the University of Ghent, the Liverpool School of Tropical Medicine, the U. S. Centers for Disease Control (CDC), PSI, and local NGOs to expand voluntary counseling and testing services in Kenya. Quality counseling, immediately before and after HIV testing for both negative and positive clients, in addition to follow-up counseling in the weeks after testing, is essential to behavior change and helping clients live positively with HIV. VCT services in Kenya officially began in March 2001 with the launch of rapid HIV testing. The project is implementing two models of service: integrated VCT services for women and men who attend government and NGO health facilities; and "stand-alone" services mainly for young people, men, and healthy people who do not visit government or NGO facilities. Together with the Kenya Ministry of Health and National AIDS Control Council, FHI is also helping to develop policies, standards, and guidelines for VCT services, as well as related curricula and testing protocols.

Since services were initiated, the project has provided VCT services to nearly 10,000 clients at 32 sites in 10 districts. All sites provide same-day counseling and testing with rapid-test kits, and a network for referrals to all clinical and social service agencies and NGOs that assist HIV-positive clients. Some sites also refer clients to services for prevention of mother-to-child transmission of HIV and the provision of tuberculosis prophylaxis. The CDC plans to extend VCT services through support for 20 additional stand-alone sites, and the Government of Kenya is expanding services to more than 200 sites throughout the country, with the assistance of the World Bank-financed DARE project, a large-scale HIV/AIDS program also underway in Kenya.

Conclusion

FHI's long-running partnership with USAID has resulted in extensive HIV/AIDS prevention and care programming in the developing world. FHI and its collaborators have demonstrated the value of partnership, capacity building, and linking prevention and care efforts in responding to HIV/AIDS and strengthening local health-care delivery. HIV/AIDS program managers have learned which approaches are most effective and how to achieve results. The global leadership of the U.S. government has enabled organizations such as FHI to have an impact on HIV/AIDS and health care at the community level. Maintaining and increasing funding levels for international HIV/AIDS programming will help FHI and its partners to scale up these efforts and achieve results at the national level.

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