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Final Report for the
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1. Introduction During the life of the $3 million, three-year project, AIDSCAP/Ethiopia provided training to nearly 5,000 people, reached over a million people with HIV prevention messages, distributed about 650,000 pieces of educational materials, and distributed or sold nearly 45 million condoms. These seemingly simple statistics mask the complexity of this large and complex, integrated and regionalized effort that made a major contribution to fighting HIV and AIDS in Ethiopia. This section summarizes the multiple layers of the three major strategies, describing some of the more interesting components in greater detail. Quantitative process data appear in the table at the end of this section. AIDSCAP/Ethiopia interventions were implemented by the Ministry of Health, the Ministry of Education and 16 non-governmental organizations. The program included improvement in services for 20 STI clinical sites of which four focus sites were selected for integrated activities combining BCC outreach with the STD interventions. Condom social marketing was implemented nationwide. The collaborating agencies implemented complementary activities for a variety of target populations resulting in comprehensive HIV/AIDS programming in the four focus sites: Awassa in the Southern Nations and Nationalities Peoples' Region (SNNPR), Bahirdar in Amhara Region, Mekele in Tigray Region, and Nazareth in Oromia Region. The four focus sites targeted female sex workers (referred to locally as MPSCs or multiple partner sexual contacts), factory and government workers, in- and out-of-school youth, and the general population with IEC/BCC messages. AIDSCAP/Ethiopia built the capacity of key players and organizations in the implementation of intervention activities through creation of innovative Focus Site Intervention Teams (FSITs) in the four targeted regions, training health care providers, peer educators, and other stakeholders, supplying drugs and equipment for STI clinics, and supplying educational equipment to support BCC programming. The names of the health centers in the four focus sites take the names of the towns of Mekele, Bahirdar and Awassa while in the Nazareth focus site, Haile Mariam Mamo Hospital served as the STI clinical site since the Nazareth Health Center was under the EEC support at that time. The towns are also the regional capitals except Nazareth which is one of the biggest towns in Oromia, located along a major highway route to the Port of Assab and four other regions. In these four focus sites, organizations involved in the HIV/AIDS prevention projects under USAID's assistance included the Regional Health Bureaus (Zonal Health Department in Nazareth), Regional Education Bureaus, the branch offices of FGAE in Bahirdar, Awassa in the SNNPRG and Nazareth in Oromia Region, the Tigray Development Association in Mekele, and Goal/Ethiopia in Metehara, 100 km from Nazareth on the way to the Assab and Sugar Plantation areas. The other 16 STI clinical sites are located in different geographic areas including: Axum Hospital and Maichew Health Center in Tigray; Debre Tabor Hospital, Debre Marcos, Woldia, and Gonder Health Centers in the Amhara Region; Abomssa , Robe, Buno Bedele, and Ijaji Health Centers and Negele Borena Hospital in Oromia; and Hosana and Dilla Hospitals, Yirgalem, Arbaminch and Jinka Health Centers in the SNNPR. Focus Site Intervention Teams In collaboration with Regional Health Bureaus, AIDSCAP/Ethiopia developed the concept of Focus Site Intervention Teams so that HIV/AIDS prevention interventions could be implemented in a more coordinated fashion at the regional level. The members were drawn from the regional and zonal health and education sectors, NGOs, government offices such as the municipalities, regional agricultural offices, factories, religious organizations, local health centers, and regional DKT/PSI representatives. Their activities involved convening monthly meetings to discuss achievements and challenges and to plan complementary or joint activities among members. They also shared a wide range of innovative educational materials, and tapped into each others' training resources. A closer working relationship exists among REBs and other USAID financed implementing agencies in Mekele, Bahirdar, Nazareth, and Awassa because of the existence of the Focus Site Intervention Teams. The FSITs have enabled implementing agencies within specific geographic areas to maximize the types of interventions being implemented and the types of populations being reached, and have continued to operate beyond the end of AIDSCAP's activities. 2. Behavior Change Communication Strategy The hub of AIDSCAP/Ethiopia's program was its behavior change interventions focusing on promoting options and choices to people making decisions that might put them at sexual risk. These strong behavior change communication activities complemented STI service upgrading and condom promotion and distribution in the four focus sites and Addis Ababa. Public and private implementing agencies reached a wide variety of gatekeepers with sensitization and awareness seminars and workshops, and multiple categories of people were trained to disseminate information and recommend strategies for risk reduction. Ultimately, more than a million people were educated through a well-integrated network of Focus Site Intervention Teams directing regional coalitions of NGOs and government agencies. Some of the details are presented below. The subproject highlights section includes more detailed descriptions of the individual collaborating agency activities. Ministry of Health Activities The MOH subproject targeted males and females with multiple partners sexual contacts (MPSC) by providing training and refresher programs for peer educators and gatekeepers in the four focus sites and Addis Ababa. Peer educators and gatekeepers included MPSC group leaders, AIDS Communicators, Community Health Agents, bar owners and factory and government officials. The MOH's MPSC outreach program helped in bringing together female sex workers and their clients and potential clients, along with community gatekeepers to share experiences and develop strategies for decreasing risk in the regional capitals. Other groups reached through various seminars, trainings, and workshops included Red Cross youth (in Awassa), core trainers, lab workers, sanitarians, media people, health care providers, IEC coordinators, secondary school teachers, MCH nurses, midwives, pharmacists, private drug vendors, traditional birth attendants (TBAs, in Mekele, Bahirdar, Awassa), and male traditional healers (in Bahirdar) AIDSCAP support to IEC materials development, printing and distribution has made a significant contribution to the availability of information on HIV/AIDS/STIs prevention. Based on STI Targeted Intervention Research results (described in the STD section below), educational materials were developed and distributed by all the focus sites, addressing common misconceptions such as STIs are contracted by "urinating facing the moon or by sitting on hot rock". HIV/AIDS/STI prevention messages were also disseminated through short dramas and role-plays during the refresher courses organized for MPSCs females and community health agents. Youth and MPSCs watched HIV prevention videos in the health centers, combining education with entertainment. Red Cross Youth in Awassa, who were used as Community Health Agents in the MPSC program, formed a drama group and performed a drama entitled "Fleet of Life," for the Awassa Textile Factory, the nursing school and the general public. MPSC group leaders in Nazareth, with the support of the Zonal Health Department, also formed a drama group to stage short dramas for their peers during training and refresher programs. Two key models used very successfully to convey messages were the "Stages of Change Ladder" where the steps in behavior change (awareness-> knowledge & skills -> concern -> motivation trail -> sustained behavior) are illustrated so that people can assess their own personal level of risk, and Tanzania's "Fleet of Hope" illustrations involving choices between "boats" representing abstinence, being faithful to one partner, and condom use. Target groups unanimously preferred these teaching methods over repeated lecturing on HIV/AIDS. A major problem encountered during the MOH's MPSC project was the resistance of male partners to condom use resulting conflict between the MPSC females and their clients. During refresher and training programs, the MPSC group leaders suggested that men at workplaces, especially the older ones, should be targeted in a more intensive way. In addition the MPSC group leaders felt that the police force and the military should also be targeted with prevention efforts. Another problem was the inability of the drama groups to achieve any kind of sustainability since they developed towards the end of the project funding cycle and had insufficient time to secure other funding sources. Finally, high turnover of staff and mobility of MPSCs affected the quality of the intervention, and implies the need for continuous refresher and retraining of MPSC group leaders. Ministry of Education Activities The focus site Regional Education Bureaus and the Region 14 EB reached secondary school students with HIV prevention information through extra- curricular and curricular activities. The interventions strengthened the existing system of Anti-AIDS Clubs through development of additional materials including teachers' and students' guides, supplementary reading materials, and a training workshop for school administrators, teachers, guidance counselors and student peer educators. The 36 participating senior secondary schools with 100,000 students are located around the 20 STI clinical sites upgraded under AIDSCAP support. A materials development workshop was held in November 1993 for curriculum developers and Regional Education Bureau curriculum experts. A booklet entitled " Know and Act " about AIDS was developed by MOE central and printed twice. Ten TV sets with VCRs were distributed to schools in the four focus sites to be used by the Anti-AIDS Clubs. A students' activity guide was also developed and distributed. In the individual regions, the Oromia Education Bureau developed a booklet entitled "AIDS facts for High School Teachers and Students" and a leaflet in Oromigna language entitled "Tokkoff Tokkotti Maratta ' uun Eedsi of Irraa Haa Eegnn." The Amhara Regional Education Bureau developed an eight page flip chart in cooperation with the focus site intervention team. The Tigray Education Bureau developed and distributed 4,000 paper caps with HIV/AIDS prevention messages. The SNNPR Education Bureau also reprinted a flip chart produced by Region 3 Health Bureau to be used in project schools. Region 14 (Addis Ababa) Education Bureau also developed a 14 page flip chart. Major problems encountered during project implementation include delay of project commencement due to the time taken to open a bank account, complicated bureaucratic procedures of FHI/AIDSCAP, lack of funds for monitoring and evaluation, difficulty in collecting monthly PIF reports from schools, high mobility and turnover of staff at REB, and bypassing of school level and zonal education offices in training and orientation programs. Non-Governmental Organization (NGO) Activities With their strong grassroots connections to urban and rural populations in Ethiopia, NGOs played a major role in AIDSCAP/Ethiopia and STAC activities under competitive, noncompetitive, and rapid response funding mechanisms. In May 1993, over 90 NGOs were approached directly and an open advertisement was placed in a local newspaper inviting NGOs for a Competitive Grants Program. Twenty-three proposals were received and reviewed locally and by AIDSCAP HQ and RO staff. Five NGOs received funding through competitive grants, and started activities in January 1994. Other NGOs received funding via noncompetitive grants at different times during the life of the project with Letters of Agreement. Several small indigenous NGOs received Rapid Response Funding (RRF) for one-time activities. Altogether, five NGOs under competitive grants, six under noncompetitive grants, and five under RRFs participated in HIV/AIDS interventions targeting various risk groups including out of school youth, female MPSCs and their potential clients, peasants and demobilized soldiers, youth with hearing problems, and the general population. Most of the NGOs involved in the project worked in Addis Ababa, although six worked in the focus sites outside the capital. Most of them focused on IEC via Peer Health Educators (PHEs) and condom promotion while only two included STI treatment in the intervention. All others strengthened STI referrals to nearby health centers in the focus sites where STI services had been upgraded. Most of the NGOs also conducted their own baseline KABP surveys with their target groups. Follow-up surveys were coordinated across NGO intervention sites through the country office in late 1996. NGOs developed innovative materials and strategies to reach target groups including, but not limited to, the pocket risk assessment calendar, traditional street theater with prevention messages, and an adaptation of the Fleet of Hope imagery originally developed in Tanzania. Key messages focused on sustaining adoption of risk-reduction behavior, including promotion of delayed sexual initiation for young adults, fidelity for couples, partner reduction, condom use, and prompt and effective treatment for STIs. Interventions included multiple, reinforcing communication channels and IEC activities, emphasizing drama, puppetry, sports events, and numerous other types of materials shared widely among implementing agencies. For example, efforts were made to reach target populations during football matches organized during vacations for in and out of school youth through four RRFs implemented by SYGA. In addition to the youth, the AIDS-related entertainment during the public football matches also reached younger children, kebele dwellers, and parents who were watching their youngsters play. MSIE also used this approach successfully to reach a variety of populations in the kebele. SYGA also organized street education for street children and youth in the evenings. As the out of school youth are among the hardest groups to reach, FGAE of Awassa devised strategies to reach them where they tended to congregate, such as on the street, at shoe shining spots, at work sites like in the fisheries, and around small kiosks. CCF in Addis Ababa found that street education on condom use by MPSC females was popular among passersby. Beza Lewegn, an indigenous NGO, used an RRF to target 1,000 youth with hearing problems through training peer educators in sign language. Under a second RRF, they targeted 3,000 youth with hearing problems to reach them through drama developed in sign language, the first time this approach had been tried in Ethiopia. The drama was staged for 800 students among the target population and for invited guests from relevant organizations to introduce the new venture in Addis Ababa. Materials developed by one NGO were often reprinted by another NGO and distributed to their target groups. For example, the pocket calendar with personal risk assessment developed by MSIE with their own budget and with technical assistance from AIDSCAP/Ethiopia was reprinted by CCF sponsored by AIDSCAP and by IHAUDP using its own funds. This has been found to be very popular among readers because it addresses personal issues and is easy to handle.
Other popular IEC approaches included dramas either staged or video taped. A video drama entitled "Testament of the Dying" funded by USAID and produced by DAY was very popular among youth. The story is based on youth engaged in risk behavior ending up in contracting HIV. Another drama entitled "Frash Meda" (Mattress Field) was produced by a drama group sponsored by MSIE and financed by FHI/AIDSCAP. It has been staged in Addis Ababa City Hall for the general public. Later the group was sponsored by OSSA and funded by USAID /AIDSCAP to perform the drama in the focus sites and in nearby towns. The NGO interventions were particularly successful due to the strong peer education programs. Despite the difficulties encountered due to lack of incentives for most (although not all) of the peer educators, the PHEs reached large numbers of people with repeated messages in short periods of time and with relatively small amounts of funding. With more time and more resources, the potential for much larger reach is great.
A major constraint to implementation was the long process of subagreement development. The short duration of projects under Letters of Agreement did not allow sufficient time to develop projects that could have achieved more reach. Another constraint concerned the fact that projects were prepared in anticipation of voluntary service by PHEs. However, among people who have no other income, such as out of school youth, lack of incentives greatly reduces the possibility of sustained participation. Some of the important lessons learned as a result of AIDSCAP/Ethiopia's experiences implementing BCC interventions include:
Section I.D.3., Other AIDSCAP Studies, describes findings from qualitative research on lessons learned from implementing BCC interventions in Ethiopia. 3. Sexually Transmitted Infection Control Strategy The major STD-related activities implemented by the Ministry of Health were refurbishment of the 20 STI clinical sites, provision of the essential STI drugs, laboratory equipment and protective supplies procured through WHO in 1993, disbursement of funds to Regional Health Bureaus for IEC activities, and provision of training for health care providers in collaboration with the AIDSCAP Country Office. Condoms were made available, accessible and affordable in the focus sites through the MOH to complement the STI service upgrading and behavior change communication activities. The program sponsored formative research (the TIR) to elicit community concepts about STDs, and a GC resistance study. Although the STAC-1 project was agreed upon on September 28,1992, it took a long time to procure the STI drugs, to refurbish the STI clinical sites, and to provide the procured drugs. In order to assess the status of STI health care services at the upgraded sites and to develop recommendations for future efforts, an assessment of the 20 clinical sites was carried out from September 1996 to March 1997. The assessment used in-depth structured interviews with regional AIDS/STD coordinators and health facility directors, as well as observation of health care providers while managing STIs cases. Laboratory and pharmacy personnel, sanitarians, and MCH/FP staff were interviewed about their involvement in STI prevention and control activities. STI patients attending the health care units were interviewed to determine their health seeking behavior and client satisfaction on health care provision. Observations included assessment of examination rooms for equipment and privacy, availability of flowcharts and management protocol, supplies, lab equipment, and up to date inventory of STI drugs and proper storage, availability of up to date information on STI drugs, and assessment of biohazard waste disposal at each level. Review of records and registration forms were done to collect accurate data on the number of cases treated at each site. Based on the data collected at the 20 clinical sites (including the four focus sites) 35,971 STI cases (21,621 males , 14,352 females) were treated. Of all cases reported, vaginal discharge accounted for 33 percent, urethral discharge for 51 percent, genital ulcer for 10 percent, inguinal bubo for 3 percent, lower abdominal pain for 2.5 percent, and conjunctivitis of the new born for 0.2 percent. In all four focus sites and in 97 percent of the STI clinical sites, health care providers have accepted syndromic management as an essential approach for managing STI cases. At all clinical sites, health education on AIDS/STI is given twice a month. A total of 2,480 health education sessions were conducted during the project period, and more frequent sessions were conducted at the focus sites. All STI clinical sites visited had been refurbished. Refurbishment included mainly painting the rooms, providing shelves and chairs, and installing water and electricity in laboratory rooms. It was generally agreed by health care providers and health facility directors that refurbishment has contributed to improved attendance at STI clinical sites. In all focus sites and in 80 percent of the STI clinical sites, STI services are integrated into MCH/FP services. Integration took place following the on-site training conducted for MCH/FP workers. Major activities accomplished include screening of FP attendants for STIs and screening of pregnant women for syphilis. Even in places where there was no RPR reagent, clients were referred to nearby laboratories and treated along with their partners based on laboratory results. In eight STI clinical sites, CSWs are screened for STIs. Services available to CSWs include health education on the transmission and prevention of STIs, laboratory services for the diagnosis of STIs, preventive counseling, and condom provision. During the assessment, health care providers were observed while taking histories and doing physical examination: 97 percent were found to have the skills and knowledge required for appropriate STI case management (P6 and P7 protocols of the WHO/GPA Prevention Indicators Manual were used for this part of the assessment). Sanitarians who were trained on proper disposal of biohazard wastes were observed to have started activities related to biohazard waste disposal such as providing wells and orientation to health workers on proper waste disposal. In order to make appropriate use of the laboratory in the diagnosis of STIs, 28 laboratory technicians were trained and 1542 STI specimens were processed (gram stain 1237, wet mount 305). Since rational use of STI drugs is of vital importance in STI control, the assessment also focused on utilization and storage of STI drugs. In all STI clinical sites, STI drugs are strictly used for STIs and are stored properly on shelves labeled "AIDSCAP." Stock cards are well kept and information easily accessible. Improvement in drug utilization and storage is considered to be due to the training of pharmacy staff on drug supply management. During the assessment, 48 STI patients(16 male, 12 females) were interviewed; 78 percent stated a preference for the STI clinical sites rather than private clinics, drug vendor shops, pharmacies, and traditional healers. Reasons given for their preference included provision of better services, specifically, laboratory support, a good approach by health care providers, free supply of drugs, and less waiting time. Some of the major constraints encountered included high turnover of trained health care workers. Out of 55 HCPs trained, only 16 were available at the time of the assessment. Shortage of laboratory reagents and consumables (shortage of RPR has weakened integration of STI services with MCH), lack of supervision and feed back (left to the MOH Central Office but not materialized due to shortage of manpower), supply of inappropriate laboratory equipment (e.g. incubators supplied to Mekele and Bahirdar HCs, and lack of built-in sustainability mechanisms. STI Guideline Development There were no national STI management guidelines until 1987 when the first guidelines were prepared by the Venereal Disease Control Division under the Department of Epidemiology of the MOH. A few copies of the guidelines were distributed to regional health departments, however, due to lack of orientation of the health personnel, they were not used. In 1990, a revised treatment protocol recommended by the STD Technical Advisory Committee was distributed to 40 health units located in 13 administrative regions, assisted by the EEC. However, the recommendations were not supported by research on sensitivity of N. gonorrhoea. The same management protocol together with WHO's recommended algorithms were also used for the USAID-assisted 20 STI clinical sites. According to research reports and monitoring findings the treatment regimen recommended for treating uncomplicated gonococcal infections is no more effective. In order to select the right regimen for treating gonorrhea, a sensitivity study was carried out in Awassa and Gondar. Results of the sensitivity study clearly show that all the drugs recommended for treating gonorrhea are no more effective and drugs that could be of use are expensive and difficult to recommend for all levels. The new STI management guidelines were prepared based on the results of the sensitivity study and on technical input from the health care providers managing STI cases at clinical sites. Additional information used in formulating the guidelines included review of research findings on the sensitivity studies conducted by different institutions in the country in the last 20 years. Management guidelines from countries like Kenya, Tanzania and Zimbabwe were also used as references. The draft guideline awaits final input from STI experts. Targeted Intervention Research The Targeted Intervention Research (TIR) on community perceptions of sexually transmitted illnesses was conducted in the four focus sites to improve STI treatment and prevention services by addressing specific issues raised by the respondents. Using the TIR manual developed by AIDSCAP and researchers from Johns Hopkins and the University of Washington, the Ethiopian researchers conducted the rapid ethnographic research using semi-structured individual interviews and guided by a Technical Advisory Group (TAG). The TAG was composed of the National STD program manager, behavioral researchers, and communication experts. The nine research guides were translated into the local languages used in the four focus sites, and administered by one male and one female interviewer in each site. Recommendations emerging from the research included: 1) Provide information to community members on the improvements that have occurred in the clinics (availability of drugs and laboratory facilities); 2) Train health care providers in provider-client communication; 3) Improve the atmosphere at the clinics so that patients feel their visits are confidential; 3) Include messages focusing on the need to seek timely and appropriate care; and 4) Train health care providers working in private pharmacies and clinics, and traditional healers to ensure provision of appropriate care, referral of complicated cases, and reporting of STI patients. TIR findings were presented to 21 health care professionals from four regions at a six-day workshop on developing STI prevention materials suitable for the language and culture of each region. Prior to the presentation of findings, the workshop participants had assumed they would immediately begin working on materials that would describe the dangers of STIs, remind people of the symptoms, and urge people to seek professional medical care. But before beginning the materials production process, the workshop facilitators arranged for the presentation of TIR findings. In presenting the findings to the workshop participants, the researchers spoke about people's perceptions of inadequate diagnostic facilities and rude health workers at government facilities; they mentioned that women disliked the lack of privacy in examination rooms; they noted that people often do not return for follow up. They also described findings on self-medication (asking a pharmacist for a medication based on the recommendations of a friend), stigma (men call STIs "women's illness" and women call them "men's illness"), and culture-specific beliefs about causation (urinating where a chicken has urinated can cause STIs). Other beliefs presented included that STIs could be avoided by washing the genitals after sexual intercourse or by taking ampicillin before. The researchers also mentioned that sex workers said they disliked condoms because "it takes a man longer to ejaculate." The workshop participants recognized and agreed with the study's findings. Based on the data presented, the health care professionals listed 33 topics that needed to be addressed in the STI prevention materials including that STIs do not cure themselves; that government clinics are now efficient, private, and free; that patients should not sell half their drugs but take the entire treatment; and that even though discussing sexual matters with a partner may be difficult, it may save your life. Topics that did not make the list included STI dangers and symptoms, but rather addressed the reasons why patients do not use health services. After hearing what their prospective patients thought about STIs and STI services, the participants changed their minds about what their materials should say. One brochure developed featured a "cool" guy from the city advising his friend from the village that you cannot get an STI by sitting on a hot rock -- one of the beliefs revealed in the research -- and urges him to seek treatment at the local clinic, where he could get a correct diagnosis and free, effective treatment. Because of time and budget constraints, the materials developed in the workshop and pre-tested and adapted in the regions reflect only a small portion of the 33 messages the participants recognized as important. Nevertheless, future educational materials and patient contacts by these professionals are likely to reflect the wider and more targeted issues that came to their attention through the TIR. Gonococcal Resistance Study Previous studies on G.C. sensitivity patterns indicate that resistance to commonly used antibiotics is common. Most of the studies lack representativeness because they were confined to Addis Ababa. In order to recommend effective antibiotic (s) for the treatment of gonococcal infection nationwide, a chemosensitivity study was conducted in Awassa and Gondar. Awassa represented the south and southwestern part of the country and Gondar, the northern part of the country. The methodology involved selecting consecutive male patients with acute uncomplicated urethritis and/or urethral discharge who gave informed consent, and culture and susceptibility testing with the E-test in Ethiopia and the agar dilution technique at the Institute of Tropical Medicine in Antwerp, Belgium, following the recommendations of the NCCLS. In Awassa, analysis of isolates found that the antibiotics most widely used for self-medication are no longer efficacious. Conversely, the remaining antibiotics have maintained their efficacy since they are rarely or not, used in the public health sector. The recommendation was to use Kanamycin (2 gm IM Stat) as the first line drug for the treatment of uncomplicated gonorrhea, while spectimomycin (2gm IM Stat) was recommended for pregnant women and referred patients. In Gondar, the study found that, except for trimethoprim sulfameroxazole for which testing was not done, the other commonly-used antibiotics are no more efficacious. The same antibiotics recommended in Awassa should be used for treatment of STI cases as first and second line drugs for the treatment of gonorrhea. 4. Condom Promotion and Distribution Strategy To implement this key strategic approach to HIV/AIDS/STI prevention in the focus sites of Mekele, Bahirdar, Nazareth, Awassa, and Addis Ababa, DKT International in collaboration with Population Services International (PSI) took responsibility for condom social marketing (CSM) while just over a million free condoms were distributed from the health centers through the Ministry of Health under the STAC project agreement. The Ethiopia Social Marketing Project (ESMP), implemented by DKT/PSI, has emerged as one of the most successful social marketing projects in Africa since it began in August 1990. Condom social marketing in Ethiopia overcame serious constraints to implementation including the lack of a developed commercial marketing and distribution system, the expanding civil war, and relative unfamiliarity with condoms on the part of target populations. Under AIDSCAP support, the size of the ESMP grew dramatically to meet the increasing demands of the expanding sales, marketing and distribution operations. Part of this expansion involved the strategic subdivision of the country into smaller and more manageable geographic sales regions, resulting in 9 sales districts, each with a supervisor and several sales distributors. The accommodate the logistic needs, the ESMP opened 14 field offices throughout the country. By the end of the task order, the sales manager oversaw 9 district supervisors, 12 bicycle agents, and 34 sales representatives, while the IEC manager oversaw 14 staff. During the 33 months of collaboration with AIDSCAP, the ESMP sold over 42 million condoms through more than 10,000 outlets in 533 different cities, towns and villages. In the last full year of project activities, the ESMP sold over 15 million condoms, averaging 1.25 million per month, 25 percent more than the monthly target of one million. In 1995, HIWOT Trust sold at nearly three times the rate it did in 1992, the year before AIDSCAP assistance began. Over 85% of sales were through "nontraditional" outlets -- those which historically have not been involved in the sale of condoms. Nearly 25 percent were sold through hotels and bars, venues closely associated with high risk sexual behaviors. At the same time, kiosks are by far the more numerous type of outlet throughout the country, accounting for 63 percent of sales. Sales through traditional outlets (pharmacies and clinics) accounted for only 8 percent of sales. Significant resources and effort were put into expanding the ESMP's communications activities, using a full range of communication media and techniques to educate the population about AIDS and to promote and advertise the use of condoms. Radio messages advertising condoms and condom use and educating about AIDS averaged over three messages per day over the period of AIDSCAP assistance, broadcast in Amharic, Oromigna, and Tigrigna, the three major languages in Ethiopia. The effectiveness of the mass media efforts was reinforced and enhanced by interpersonal communication via the project's IEC Unit. IEC activities reached 144,794 individuals through seminars, workshops, lectures, and training programs for a broad range of audiences throughout Ethiopia. The ESMP's management information system (MIS) revealed the range of types of people reached through IEC efforts: bar and hotel workers and owners, FSWs, teachers, farmers, government employees, health workers, refugees, laborers, military, NGO workers, police, prisoners, vocational students, transport workers, and youth. AIDSCAP support assisted DKT/PSI to secure longer term funding from USAID and the Dutch Government for the continued operation and expansion of social marketing in Ethiopia through 1999, and to introduce oral contraceptives for family planning as well. Sales in early 1995 were severely constrained by a shortage of condom supplies. This was mainly due to the unannounced rescheduling of a major condom shipment at the end of 1994. The short inventory position forced ESMP management to ration supplies of condoms to the market for the first four months of the year. Even after sufficient supplies were received, it took the better part of seven months before sales recovered to their pre-rationing levels of over 2 million per month. The ESMP also experienced other less serious problems with supply lines from Nairobi for packaging and promotional materials. However, these problems did not have a major effect on sales performance or overall project implementation. Three important points can be made about condom social marketing in Ethiopia, based on the past few years' experiences:
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