"Three years ago, people didn't seem to care. When we talked to them about AIDS they would laugh and say 'give us a condom.' Now they are interested to hear about prevention. They are seeing people getting sick and dying. They cry about it. They have changed...People ask us 'how can we get married when we don't know who's infected?' Now clients go home earlier if they go to the bars at all. The bar ladies say that business is down because of the epidemic. Everyone now knows someone who has died... People are changing because of fear... Behavior change is a long term thing. If you have a meeting with 400 participants, that may yield 10 people changing their behavior. So each time you do that, you get more and more people to change." [Nazareth Zonal Health Dept. project manager, 1996]
"We definitely say that youth have revealed behavior changes. Primarily they buy condoms from us. Secondly, when they contract STDs, they come to us and discuss their problems. Thirdly, they ask questions about HIV to which we give answers." [male youth peer educator, Awassa, 1996).
"...One of the indicators is this: why would they look for condoms if they have not changed their behavior? Why should they go with one girl only, when they used to have five or six? This is a very important indicator of behavior change." [NGO project manager, Addis, 1996]
This section reports outcomes from primary evaluation research undertaken through the AIDSCAP/Ethiopia country program, as well as secondary research conducted by other individuals and organizations which helps to illuminate some of the behavioral trends observed among target groups reached by AIDSCAP interventions.
1. Biologic/Impact
To date, there have been no reported declines in HIV prevalence in any population groups in Ethiopia. However, assessment of HIV seroprevalence has not been systematic and comprehensive to allow changes to be tracked over time. At the beginning of AIDSCAP's involvement with STAC, it was proposed to repeat the GPA protocols for assessing effectiveness of prevention programming in the same areas where they were originally conducted, but this activity has not happened as of the time this report is being written.
During the past few years, among international HIV prevention specialists, it has become increasingly evident that not only are reliable and representative measures of HIV prevalence difficult to obtain, but interpretation is so problematic that their usefulness for evaluating HIV prevention programs and projects is of limited value. Changes in HIV prevalence may be indicative of the long term impact of multiple AIDS prevention efforts, but it is difficult to prove that observed decreases in prevalence are the result of HIV prevention programs. Other factors such as mortality, migration and saturation of the population at risk can also account for such changes. In addition, even if decreases in prevalence do result from successful prevention programming, the decreases cannot be attributed to any single intervention. Trends are difficult to interpret without sufficient knowledge of the dynamics of the epidemic in a defined setting and/or control groups for comparative purposes. Nevertheless, tracking prevalence among key target groups will likely remain a priority as the international community continues to monitor the epidemic's progress in each country. Surveillance systems for tracking rates in key target groups in Ethiopia need to be considered in future programming efforts.
2. Behavioral/Outcome
Multiple behavioral data points are available for MPSCs and out of school youth in Ethiopia, as they represent the priority target groups for the past three years of programming. These groups have demonstrated improvements in behavioral indicators in catchment areas of AIDSCAP's implementing agencies. Data points were also established for other target populations during AIDSCAP programming which will provide benchmarks for organizations undertaking future HIV/AIDS prevention activities.
Interventions with MPSCs through the MOH used as their baseline benchmark the WHO's final evaluation study with the Department of AIDS Control for a five-year intervention with MPSCs in 26 cities, although the sites in their study did not include AIDSCAP's four focus sites. The intervention began in 1989/90, and the final evaluation was conducted in 1994. The NGO implementing agencies, with AIDSCAP funding, also conducted baseline KABPs in the four focus sites and in Addis Ababa. FGAE/Bahirdar, CCF/Addis, and GOAL/Metahara conducted surveys among MPSC females in 1994. The FGAE branch offices in Bahirdar, Awassa and Nazareth, TDA in Mekele, MSIE, IHAUDP, and SYGA in Addis conducted surveys among out of school youth in 1994/95 early in project implementation. TDA in Mekele also conducted FGDs at the time of their survey. The MOE conducted a self-administered baseline KABP with secondary school students in seven schools in AIDSCAP/Ethiopia focus sites in April 1995.
As a follow-up for two key target groups, AIDSCAP/E conducted a KABP complemented by FGDs in late 1996 among 886 MPSC females in three intervention sites (Addis, Metahara and Bahirdar) and 681 female and 473 male out of school youth in five intervention sites (Addis, Bahirdar, Awassa, Mekele and Nazareth). This strategy of combining intervention sites and standardizing questionnaires and sampling frames represents a marked improvement in evaluation strategy. Data quality is much improved and the model can be used in the future for additional data points for these target groups in the same regions.
Secondary sources of behavioral data include the 1993 WHO/GPA field-test of prevention indicators (general population data), and the 1993 DKT/PSI KABP in three urban sites.
Table 3: Behavioral Data Points for Target Populations Reached Under AIDSCAP/Ethiopia
| Target group |
1990 |
1993 |
1994 |
1995 |
1996 |
| General population |
– |
WHO/GPA (KABP) |
– |
– |
– |
| MPSCs |
DAC/WHO (KABP/FGDs) |
– |
FGAE/Bahirdar (KABP, FGDs), CCF/Addis (KABP), GOAL/Metahara (KABP), DAC/WHO (KABP/FGDs) |
– |
AIDSCAP/E (KABP/FDGs) |
| Out of school youth |
– |
– |
FGAE/Bahirdar (KABPs/FGDs), MSIE/Addis, SYGA/Addis, CCF/Addis (KABPs) |
FGAE/Awassa (KABPs/FGDs), TDA/Mekele (KABPs/FGDs), FGAE/Nazareth (KABPs) |
AIDSCAP/E (KABP/FDGs) |
| High school students |
– |
– |
Mulatu (KABP) |
MOE (self-administered KABP) (FGDs) |
– |
| Youth aged 15-30 |
– |
– |
– |
IHAUDP (KABP) |
– |
| Truck drivers and assistants |
– |
– |
GOAL/Metahara (KABP) |
– |
– |
| Peasants and ex-servicemen |
– |
– |
NACID (FGDs) |
– |
– |
| Multiple target groups |
– |
DKT/PSI (KABP) |
– |
– |
BCC LL (FGDs/KIIs) |
Note: Studies not funded through AIDSCAP include the WHO/GPA field-test, DKT/PSI KABP, Mulatu (data collected 1994, abstracted 1996), and DAC/WHO studies of the MPSC program on which AIDSCAP's intervention was based. All other studies were funded through AIDSCAP/Ethiopia and implemented via the subproject implementing agencies or local contractors. The BCC Lessons Learned study included open-ended questions about project managers' and peer educators' perceptions of behavior change in their communities and among their target populations.
Knowledge and risk perception
"I do not think that there is anyone who does not know about AIDS...I can say everybody is knowledgeable. Even the nomads. One day I went out with the MCH program for the nomads, and actually [they] interpreted for me since I do not know the language. They were demonstrating about family planning. One of the nomad women said, 'oh, this condom also protects our husbands from AIDS.' It was interesting to hear." [NGO project manager, Addis, 1996]
Probably as a result of the government's early attention to the HIV/AIDS crisis, levels of knowledge about transmission and prevention have been consistently high among both the general population and key target groups, although misconceptions and misinformation are common. Condom use is mentioned more frequently than most other preventive methods, and a majority understand that a healthy-looking person can still be infected with HIV. Variations in rates remain among regions and different age groups and sometimes between genders.
Awareness
Baseline studies with MPSCs showed universal awareness of AIDS. Out of school youth also showed high levels of awareness. In DKT/PSI's 1993 study sampling adult males, adolescent males, adult females and CSWs, having heard of AIDS was mentioned by over 95 percent of all respondents across target groups (sampled from Addis Ababa, Axum and Assela). However, in one 1995 study among out of school youth in Addis, 14 percent claimed not to know how AIDS is transmitted. In the same study, 19 percent thought mosquitoes can transmit HIV, and 12 percent thought that sharing eating and drinking utensils can transmit the virus. Among high school students in 1995, 83 percent had heard of AIDS, but only 76 percent knew that AIDS was preventable (non-response to that question was 15 percent). Females were less well-informed than males. About two thirds reported hearing about AIDS from school and health workers. In 1996, among out of school youth, 21 percent still believed that avoiding insect bites could prevent transmission of AIDS and 11 percent did not know.
FGDs with peasants and ex-servicemen in Nazareth (NACID 1994) revealed that most participants perceive AIDS as a killer disease, and that sexual intercourse with many partners and sharing of blades were most frequently mentioned as common modes of transmission. Qualitative research in 1996 in AIDSCAP intervention areas supports the conclusion that basic information about the disease is fairly well disseminated although some misconceptions remain.
Knowledge that condoms can prevent AIDS
Among MPSCs, rates among most samples have been over 90 percent since before AIDSCAP began. In 1993, condom use as a prevention method was cited (unprompted) by 82 percent of adult men, 66 percent of adult women, 90 percent of adolescent men, and 96 percent of MPSCs (DKT/PSI). In 1994, among out of school youth, mention of condoms as a prevention method (prompted) was reported by 51 to 95 percent of sampled respondents (varying by NGO catchment area); 95 percent in 1995; and 93 percent in 1996 (sampled across catchment areas). In 1995, 77 percent of high school students believed that condoms can prevent AIDS.
Ability to mention 2 correct ways to prevent HIV infection
WHO/GPA's PI field-test in 1993 revealed knowledge of two or more methods of prevention to be 94 percent for males and 84 percent for females in the urban general population. Among adult males in DKT/PSI's 1993 study, 78 percent were able to cite condom use and at least one other method. The indicator for MPSC females varied among NGO catchment areas from 62 to 95 percent in 1994 and measured 94 percent in 1996 across the three sex worker intervention areas. Among out of school youth, the same indicator increased from 78 percent at the beginning of 1995 to 99 percent in October 1996 (in the follow-up study, there were no gender differences). 82 percent of high school students mentioned 2 correct prevention methods in 1995 (prompted). Among truck drivers and their assistants in 1994, 82 percent could name 2 correct methods.
Knowledge that a person can look healthy and still be infected
Rates for this indicator varied widely across target groups and locations: in 1993, 86 percent of adult males, 61 percent of adolescent males, 49 percent of adult females, and about 66 percent of MPSCs ; 76 percent of truck drivers and their assistants (Metahara in 1994), 40 percent of out of school youth (Addis in 1994), and 68 to 72 percent of youth (several locations in 1995), and about 69 percent of MPSCs in 1994/95. In 1996, 76 percent of out of school youth across catchment areas agreed that an infected person might look healthy, while 10 percent said they didn't know. Females were somewhat less likely than males to understand asymptomatic transmission. Among MPSCs, 55 percent said HIV carriers can look healthy, 33 percent said they always show symptoms, and 13 percent said they didn't know. This indicator remains a key knowledge indicator. Future IEC programming efforts will need to try to reduce the percentage of respondents who don't know and increase the percentage who understand asymptomatic transmission.
Seen an AIDS patient/knew someone who had died of AIDS
Among DKT/PSI's 1993 sample, about a third of each target group knew someone personally who had died of AIDS. Among a group of MPSCs in Addis in 1995, 27 percent knew someone who had died of AIDS, but the question was not asked the following year. Among several studies with out of school youth in 1995, 18 to 33 percent said they knew or had seen someone who had AIDS; and 41 to 47 percent said they knew someone who had died of AIDS. Among high school students in 1995, 49 percent had seen an AIDS patient. Personal exposure to an AIDS sufferer has been shown in other countries to correlate with higher rates of behavior change. Future studies in Ethiopia should include this question and should also look for correlation with risk assessment and rates of behavior change. In 1993, the DKT/PSI study found that "those individuals who knew someone personally with AIDS were significantly more likely to consider themselves at risk for the disease than those who did not. However, having heard or talked about AIDS/HIV in the past month did not seem to have any effect on risk perception."
Risk perception
Among MPSCs, in DKT/PSI's 1993 study, 57 percent "felt themselves at risk for HIV/AIDS." In AIDSCAP's three intervention sites in 1996, 19 percent of MPSCs thought they had a moderate or good chance of "catching HIV/AIDS" while 44 percent remained unable to state their risk, perhaps because they did not know their HIV status and thought that their past behavior could have put them at risk of infection. Of the 36 percent who said they had no chance, the most frequently mentioned reason (88 percent) was condom use, while among those who said they had a moderate chance, 46 percent blamed clients' refusal to use condoms, and 33 percent mentioned multiple partners.
Among out of school youth in 1995, 15 percent were unable to state their risk, while 82 percent said it was likely they were not infected, and only 3 percent thought they might be infected. In 1996, 65 percent of males and 74 percent of females said they had no chance of contracting HIV, although the analysis included all those who were not sexually active. Main reasons for perceived low risk for males were condom use, sleeping with only one partner, no injections, no sex with CSWs, and no sexual intercourse. For females, the most frequently mentioned reasons were no sexual intercourse, sleep only with one partner, no injections, and condom use. Further analysis of the sexually active sub-sample, cross-tabulated with various behavioral indicators, would provide additional insight into the intersection of the domains of risk assessment, condom use and multiple partner sexual networking.
Among high school students in 1995, 45 percent said they had no chance of catching AIDS, 15 percent did not know, and 30 percent did not respond to the question. Using as the denominator only those who did respond to the question (n=1781), 63 percent thought they had no chance of becoming infected. Only 8 percent felt they had a moderate or high chance of becoming infected. Most commonly mentioned reasons were: had an injection, sexual contact with multiple partners, and failure to use condoms. Among truck drivers and their assistants in 1994, 72 percent did not perceive themselves to be at risk of AIDS, despite the fact that they told interviewers that the occupations perceived to be at highest risk of AIDS were male truck drivers and bar girls. Among adult females in 1993, 32 percent considered themselves to be at risk for HIV/AIDS (DKT/PSI).
Measuring self-risk assessment is difficult, especially in areas where HIV counseling and testing services are not available, as is the case in Ethiopia. In general, program managers would want to see decreasing rates of inability to state risk. Risk assessment would vary by the degree to which safe sex is practiced either in the past or currently, and also according to cultural and linguistic interpretation of the concept of probability. Translating words like "risk" and "likelihood" has proven quite problematic in many cultural settings. Risk assessment questions also need to be analyzed by actual reported behaviors in order to determine some degree of "appropriateness" of assessment.
Sexual partners
Quantitative data suggest that out of school youth have become more sexually active in recent years. The percentage of out of school youth in the NGO's catchment areas that reported being sexually active increased during the project period. Between 1993 and late 1996, the percentage of samples of respondents who were sexually active ranged from 23 percent of adolescent males (DKT/PSI in 1993), 39 to 72 percent for out of school youth in the NGO's catchment areas, and 26 to 29 percent among high school students (in 1994 and 1995). In 1996, the study across five intervention sites found that 83 percent of male youth and 63 percent of female youth reported having ever been sexually active. Reports of permanent or regular partners ranged from 53-76 percent among youth, including a study in Addis showing that 57 percent of males and 64 percent of females reported a regular partner.
Data on percentages reporting more than one partner present a confusing picture. The 1993 WHO/GPA field-test of the PIs with an urban general population sample stated that 22 percent of males and 8 percent of females reported non-regular sexual partners. The same indicator among various AIDSCAP target groups varied: 30-69 percent for males and 12 to 23 percent for females (Addis out of school youth) and 23 percent for truck drivers in Metahara in 1994; 44 percent of high school students in 1995; and 29 percent of out of school youth in Mekele in 1995 (not gender disaggregated). Mulatu's study of 1,616 high school students from 10 towns in Ethiopia (data collected in 1994) found that 44% of the sexually active sample reported "casual" partners, and 68% reported "multiple partner" sex. By 1996, percentages of samples reporting more than one partner included 34 percent for females and 50 percent for males (across NGO catchment areas reaching out of school youth). In addition, 45 percent of male youth and 33 percent of female youth believed in 1996 that their partner has sexual contact with other partners, a question that was not asked on other surveys.
Table 4: Sexual partner data for male and female out of school youth Ethiopia 1994-96
| Partner/Location |
Sexually active population |
Reporting >1 partner in past 12 months |
| 1994 |
| FGAE/Bahirdar |
m/f 59% (n=1115) |
– |
| MSIE/Addis |
m 69%; f 43% (n=406/488) |
m 30%; f 12% n=(279/210) |
| 1995 |
| FGAE/Awassa |
m 59%; f 39% (n=190/185) |
– |
| TDA/Mekele |
m 89%; f 65% (n=87/200) |
m 74%; f 18% (n=87/200) |
| FGAE/Nazareth |
m/f 52% (n=300) |
– |
| 1996 |
AIDSCAP/E
Includes: TDA/Mekele, FGAE/Bahirdar, FGAE/Nazareth, FGAE/Awassa, MSIE/Addis |
m 83%; f 63% (n= 445/647) |
m 50%; f 34% (n=357/394) |
FGDs with out of school youth in 1996 revealed that males, in particular, "like to have more than one partner...[because of]...getting fed-up soon with each other, falling in love with new ones soon and shifting to new partners." Some youth participants felt that having many partners was an adventure. "Sexual intercourse may not be satisfying with his permanent girlfriend. So, he tries secret sexual relations." [Male out of school youth, Nazareth 1996] They said that young women just starting sex "usually change partners frequently and don't care about the use of condoms." A male youth in Addis (1996) said, "One-to-one does not work among young people, because this is a difficult age to control ourselves. Thus, condom use is the priority."
Commonly, relationships between young people do not last very long, according to most participants in the 1996 FGDs. "Sight love, greediness of some youths to have everybody as his partner, and alcoholic drinks [are] driving forces to change sexual partners frequently." Many participants stated that one-to-one relationships between young people "were not sustainable... Youth are not usually stable in their relationships." They change partners frequently, in effect, practicing serial monogamy. External conditions tend to support the inherent instability of youthful relationships. "Money, alcoholic drinks, hashish will create or lead to multipartner relations." (Female out of school youth, Nazareth 1996) The 1996 survey with out of school youth in five intervention areas revealed that 53 percent of male youth and 32 percent of female youth report alcohol consumption. Daily consumption was reported by 14 percent of males and 7 percent of females.
Some young women practice sex for economic reasons, particularly with older partners. If their permanent partner, who they love, is unable to provide material benefits to the relationship, then the girl might decide to have other partners who have more economic resources:
"Economic reasons are one of the biggest problems that lead a girl to infidelity. If one [man] could support me economically and my friend [permanent boyfriend] does not, I will go out secretly." [Female out of school youth, Nazareth 1996].
The FGDs with female youth suggest there remains an underlying desire for fidelity in relationships for some of the young women, for example, "I believe in faithfulness. Being faithful to each other will lead to future marital relationships. Marriage, having children, and lifelong friendship are the result of being faithful to each other." [Female out of school youth, Bahirdar 1996] But the realities of everyday life in urban Ethiopia don't seem likely to support long-term one-to-one relationships between out of school youth. As one male youth put it,
"The youth, though they preach about one to one relationships, are vulnerable to separation and their relations usually do not last long. This is happening because the young people do not one hundred percent believe that AIDS is existing. They also get drunk and forget about everything and are pushed to make sex without condoms." [Bahirdar 1996]
Nevertheless, there is some qualitative data suggesting that some people feel their peers are reducing partners, especially when exposed to extensive interventions. FGDs with peasants and ex-servicemen in Nazareth in 1994 revealed that most participants preferred abstinence as the best means of prevention and using condoms if one is doubtful about the other partner.
"I feel that people are reducing partners. You see, one way of learning is by seeing. They see their friends dying. These days especially these long distance drivers used to have many mistresses everywhere, on the road to Assab...Before the AIDS era, they wanted to taste everybody. So [now] people are reducing their partners." [DKT/PSI IEC manager, Addis, 1996]
"Definitely, friends and the peer educators, most of them have changed. For example, many of them have their own girlfriends and even though they have a single girl friend they have started using condoms because they start feeling responsible." [SYGA/Addis project manager, 1996]
Sex workers, on the other hand, reported having an average of five to nine casual sexual partners per week during the 1996 survey. This figure did not change, and was not expected to change, over the course of the intervention.
The apparent increases in multiple partner sexual networking have yet to be adequately explained. However, lack of comparability of data due to different sampling plans and geographic locations may also explain some of the inconclusive results. Future data points, using consistent probability sampling methods, can begin to provide data for trend analysis that will better explore these apparent increases in sexual activity among out of school youth. Continued monitoring of this indicator and further investigations into the meaning of the data will be critical in future programming efforts.
Condom use
Condom use data has been collected in a variety of ways by different survey instruments over the past few years. At the same time that number of partners appears to be going up among out of school youth, condom use also seems to be increasing despite certain constraints. Condom availability and accessibility are generally quite good in urban Ethiopia, as described above.
Access
Because of DKT/PSI's extremely successful condom promotion program, in place since 1990, availability of condoms is not really an issue. In their 1993 study, 92 percent of adult males, 89 percent of adolescent males, 71 percent of adult females, and 89 percent of CSWs reported being able to obtain a condom if they needed one. Among out of school youth, in 1995, for example, 78 percent reported ability to get a condom if they needed one. By 1996, 91 percent reported access to condoms (male 94 percent and female 87 percent). And among MPSCs in 1996, 95 percent knew where to get condoms. However, access for youth remains somewhat problematic. Qualitative research suggests that young people have problems with access despite easy availability due to embarrassment when asking for condoms in shops and kiosks.
"...Through the agents of the Anti-AIDS Clubs, condoms were distributed. They do not want to buy from the pharmacy but they do [buy] from their friends...They do not want to be seen. When he is seen, people may say, 'oh, he is out of our culture.'" [MOE project manager, Bahirdar, 1996]
"Anybody can get condoms from anywhere...The most important thing is we give skills during the training period. They acquired negotiating skills, even purchasing or buying condoms. And at the end of the training program, we let both boys and girls go and buy condoms from the kiosks... The young people did this for fun at the end of our training...whenever these young people ask for condoms, especially the girls, the shopkeepers were amazed by the action of the girls and ask a lot of personal questions. Yes, [we tell them what kind of answers they should give], but you know, it is a kind of acting so I am not quite sure whether they practice it or not. But at the end of the workshop, they did it very well, and they gave answers to every questions." [NGO project manager, Addis, 1996]
Societal prohibitions against sex before marriage interfere with youth's public purchase of condoms:
"A youth who goes to a shop to buy condoms may be embarrassed to ask for condom if there is someone in the shop, particularly if there are people just standing in the shop who suspect that he is practicing sex." [Male out of school youth, Bahirdar 1996]
"If a young person is found using condoms, he will be humiliated [because people will think] he is going to bar girls. So, some youths do not use condoms because of this." [Male out of school youth, Addis 1996]
Girls report similar reactions to questions about access to condoms:
"For girls, I think it is very shameful to go and buy or ask from shops or any place. But, we know the MSIE youths and it is easier and not shameful to get condoms from them." [Female out of school youth, Addis 1996]
"I will not go and buy condoms from shops since there could be people [there] who know my family. If someone sees someone from the neighborhood, he or she will go and tell my parents who will then think that I am not decent. Those who reported to my family would not also want to see me with their children." [Female out of school youth, Nazareth 1996]
Two FGD participants mentioned using code words for requesting condoms in shops:
"Some youths are shy to ask or name condoms; for this reason, instead of asking for a condom, they ask for plastic bags or festal. The shop keeper also understands the code... and provides the client with a condom instead of festal [plastic bag]." [Female out of school youth, Nazareth 1996]
"I am not ashamed to buy condoms. I ask the shopkeeper for metekemia ['something for use' in Amharic]. Hotel key men also call it metekemia and they ask everybody who goes to the hotel room if they need metekemia." [Female out of school youth, Nazareth 1996]
FGD participants had varying opinions on the subject of buying condoms. Other comments included:
"As for me, I am not afraid to buy condoms, because it is my life. If I am shy and refrain from buying condoms and by chance, get the disease, who is going to suffer for me? As long as I believe that condoms could save my life, I will not be bothered about [what people think of me]." [Male out of school youth, Nazareth 1996]
"If I believe that condoms prevent me from catching AIDS, I would not be afraid of people who by chance may see me buying condoms. Whether they point their fingers at me or laugh at me, I don't care, and it's their own headache." [Male out of school youth, Nazareth 1996]
"It is those who do not want to use condoms who report that they feel shy to buy condoms. Otherwise, there is no reason why one should feel frightened to purchase condoms." [Female out of school youth, Addis 1996]
Ever-use of condoms among MPSCs (bar ladies) has varied widely as measured by various KABP surveys since 1990. DAC/WHO measured ever-use at 91 percent in 1990 and 96 percent in 1994 in a sample of their intervention areas, although DKT/PSI found only 69 percent ever-use in their small sample in three cities. AIDSCAP's 1994 surveys showed a range from 50 percent in Bahirdar to 97 percent in Metahara, a town along a major transportation route. By 1996, AIDSCAP's three-site survey measured ever-use at 97 percent. There is variation by age and location in the 1996 data with ever-use of condoms highest among FSWs aged 20-24, followed by ages 15-16. Ever-use rates were highest in Bahirdar (99.8 percent), followed by Metahara (89.9 percent) and Addis (88.7 percent); differences were statistically significant. CCF/Addis reported in 1996 that:
"Most of the MPSC females, being convinced after these education, tell us that they openly negotiate with their male sexual partners about practicing safe sex and that they reject to have sex with those men who do not agree to use condom regardless of their regularity and the amount of money they give them. According to these women, the number of men that carry condoms with them when they go to MPSC females has increased and only very few men resist to use condoms." (CCF final subproject report, 1996)
Sex workers in FGDs were more positive about condom use, although they also described instances of clients' reluctance to use condoms. Although one women in Addis said, "I have children to feed; I have to eat. If he gives me more money than other clients, I will do sex without condoms," most of the sex workers made statements similar to:
"I will never do sex without condoms unless it is beyond any control like being broken in the middle of sex or sometimes the man removes it without my knowledge... Nowadays, it is only a few men who refuse to use condoms. They have a better understanding of condom use."
Ever-use rates for other target groups are lower: in 1993, 56 percent of adult and adolescent males, and 20 percent of adult females (DKT/PSI); among bar customers, 54 percent in 1990 and 60 percent in 1994 (WHO/DAC).; among truck drivers and their assistants, 60 percent in 1994; among out of school youth in Bahirdar, 31 percent in 1994 and in Mekele, 41 percent in 1995; in Addis in 1994, 57 percent for male out of school youth and 38 percent for females; among high school students in Mulatu's 1994 study, 30 percent and in AIDSCAP intervention areas in 1995, 54 percent. By 1996, among AIDSCAP's out of school youth population reached by interventions, reported ever-use of condoms was up to 72 percent for males and 57 percent for females. The FGDs with males featured a mix of different attitudes about condoms. Some examples include:
"I have tried to use condoms. It is very disgusting. It just holds my emotions. I do not use condoms with my girlfriend and I do not think I will ever use it. I never go to commercial sex workers. My [girl]friend also does not like it. It is not only her; I have a sickening dislike for condoms." [Male out of school youth, Nazareth 1996]
"I do not use condoms with my girlfriend. Whenever I go outside my girlfriend, even if I get drunk, I use condoms." (Male out of school youth, Nazareth 1996)
"My partner and I do not know whether we are infected with HIV or not. If I ask her to use a condom she will say we trust each other, why should we use condoms? If you ask someone to use a condom, then you are either not faithful or you are suspecting someone of adultery. So, I do sex without condoms. I even tell her that we can get the disease in different ways and it is safer to use condoms. But girls have the belief that they do not get satisfied with condoms." [Male out of school youth, Nazareth 1996]
"In Nazareth, all of us believe that condoms do not fulfill our desire for sex. We forget that condom is life. This is my problem and my friends as well. We are very careless and reluctant to use condoms. I do not agree with those two speakers who suggested that girls refuse or do not like condoms. I never faced any problem or never had a girl who protested using condoms. On the contrary, the need for condoms arises because we are not sure of ourselves of sticking together for a long time without having relations with a different person. Otherwise, as long as we are faithful, we do not need to use condoms." [Male out of school youth, Nazareth 1996]
In Bahirdar, describing reasons why their peers may not use condoms, female out of school youth said:
"Youths do not believe in condoms since they believe the lubricating material has the virus."
"Whenever the girl wants to use a condom the boy refuses to use it or vice versa."
"The youths complain that condoms reduce satisfaction and the condom itself has the HIV."
In Nazareth, young women said:
"Some youths say condom reduces feelings; we cannot get AIDS and so on. Why do we need to use condoms as long as we stick to a partner?"
"The education about condom use has no depth, and different people have different outlooks and myths, like, condoms are produced to control the population growth, condoms have the virus, condoms do not satisfy sexual needs, and condoms do not prevent the transmission of AIDS."
"Sex is done under pressures of emotions without giving much thinking about it. I sometimes use condoms, and I do not use [them] at other times. It reduces my love towards my partner and I do not have faith in it."
"I have never used condoms... I am always afraid that it may remain in the reproductive organs."
"Unless sex is started with condoms at the beginning of their courtship it is very difficult to start it afterwards or to recommend the use of condoms. Therefore, it is always better to discuss the use of condoms at the outset."
And in Addis Ababa:
"Youths that trust each other do not use condoms. They may sometimes use it for the purpose of contraception."
"It is not traditional to use condoms. Hence people do not tend to use condoms during sexual intercourse since it is a new thing."
"Usually female youths use contraceptive pills since their boyfriends do not want to use condoms."
"Because of alcoholic drinks their power of thinking may be clouded to recall about the use of condoms."
"Even if they know about AIDS, they do not practice safe sex. This is mere carelessness."
Condom use at last sex with different types of partners also varies widely by target group. The WHO/GPA 1993 field-test data (urban, general population) revealed that 48 percent of males and 47 percent of females reported condom use with last non-regular partner. DKT/PSI's 1993 study reported that among adult males, condom use at last intercourse was 65 percent for "casual" contacts and 21 percent for "non-casual" contacts. In the same study among adolescent males, condom use at last sex was reported for 61 percent of casual contacts and 7 percent of non-casual contacts. Among out of school youth in 1994/5, condom use with last non-regular partner varied from 21 to 49 percent depending on the location and gender. For example, in Addis in 1994, 49 percent of males and 21 percent of females (sexually active out of school youth) used a condom during last sex. Among high school students in the 1995 AIDSCAP study, 47 percent reported condom use at last intercourse (data not disaggregated by gender).
By 1996, 58 percent of males and 48 percent of females reported condom use with last non-regular partner in AIDSCAP's study across IA catchment areas serving out of school youth. Subgroups within these male and female samples showed higher levels of condom use (see Table 5). For example, among females who had sex within the past 12 months, who reported more than one partner, and who participated in group or individual discussions on AIDS, condom use was nearly 70 percent. Among males who had sex within the past 12 months, who reported more than one partner, and who participated in group discussions on AIDS, condom use at last sex was 68 percent. Even among males and females reporting only one partner during the previous 12 months, and who were exposed to group or individual discussions about AIDS, condom use rates ranged from 46 percent (females) to 62 percent (males). Table 5 shows that those who did participate in discussions had higher condom use rates than those who did not participate, and that those who reported more than one partner had higher rates than those who reported only one partner. Although the trends were consistent, the only statistically significant differences in condom use were among females participating in individual discussions, in which those females reporting more than one partner reported higher condom use (69 percent) than those reporting only one partner (46 percent). However, similar differences were also observed for females who did not participate in individual discussions.
Youth FGD participants in 1996 stated that they use condoms with new partners and MPSCs, but not usually with their permanent youth partners, however, much of the FGD data revealed that participants thought that youth were beginning to change condom use behaviors:
"We definitely say that youth have revealed behavior changes. Primarily they buy condoms from us. Secondly, when they contract STDs, they come to us and discuss their problems. Thirdly, they ask questions about HIV to which we give answers." [Male out of school youth peer educator, Awassa, 1996).
One young woman who has lived "for a long time with one person" said that "When we talk with friends and ask them how would they know if their relationship could continue long, they tell me that they use condom for one year until they know each other well and it is after that they do it without condom." (Bahirdar 1996)
In FGAE/Awassa's study of out of school youth (1995), sexually active respondents were asked what they would do if their partner refused condom use: 32 percent said they would try to negotiate use as much as possible, 21 percent said they would agree to have sex without a condom, 18 percent said they would refuse to have sex, and 21 percent did not know (8 percent gave other reasons).
Table 5: Condom use data for male and female out of school youth Ethiopia 1994-96
| Partner/Location |
Ever use of condoms |
Condom use at last sex |
| 1994 |
| FGAE/Bahirdar |
m/f 31% (n=659) |
– |
| MSIE/Addis |
m 57%; f 38% (n=279/210) |
m 49%; f 21% (n=229/210) |
| 1995 |
| FGAE/Awassa |
– |
m/f 28% (n=185) |
| TDA/Mekele |
m 79%; f 18% (n=85/150) |
m/f 30% (n=239) |
| FGAE/Nazareth |
– |
m 28%; f 29% (n=94/59) |
| 1996 |
AIDSCAP/E
Includes: TDA/Mekele, FGAE/Bahirdar, FGAE/Nazareth, FGAE/Awassa, MSIE/Addis |
m 72%; f 57% (n=370/405) |
m 58%; f 48% (n=208/180) |
Among MPSCs in DKT/PSI's 1993 study, 75 percent reported condom use at last intercourse (partner type unspecified), 53 percent said they used a condom with every customer, and 16 percent stated they never used condom with customers. Addis CSWs were significantly more likely to report condom use than those from Axum and Assela. In the WHO/DAC study in 1994, 64 percent reported every time with regular partners, 77 percent reported every time with regular paying partners, and 85 percent reported every time with non-regular paying clients. In 1994 in Bahirdar, 48 percent of MPSCs reported that they "regularly" use condoms, and in Addis, 45 percent of MPSCs reported condom use at last intercourse (type of partner not identified). Of those who did not use a condom, 41 percent said they did so because they trusted their partner.
By the 1996 AIDSCAP study across catchment areas, 58 percent of MPSCs reported condom use during the most recent sex act with a nonpaying partner, and 73 percent reported condom use at last sex with a paying partner. Comparison of results is difficult since the WHO/DAC study was conducted in cities not reached by AIDSCAP interventions, the DKT/PSI study was conducted in Addis, Assela and Axum (the latter two not reached by AIDSCAP interventions), and questions about condom use were often not worded in comparable ways in different instruments.
Table 6: Condom use data for female sex workers Ethiopia 1990-96
| Partner/Location |
Ever use of condoms |
Consistent condom use |
Condom use at last sex (non-regular partner) |
| 1990 |
DAC/WHO
Includes: Arba Minch, Jimma, Shashamene |
91% (n=361) |
55% (all clients) |
– |
|
55% (regular partners) |
|
(n=361) |
| 1993 |
| DKT/PSI. Includes: |
– |
– |
– |
| Addis Ababa |
69% (n=195) |
82% (n=65) |
75% (n=195) |
| Axum |
– |
– |
– |
| Asella |
53% (n=195) |
– |
99% (n=65) |
| 1994 |
| FGAE/Bahirdar |
50% (n=106) |
48% (n=106) "regularly" |
– |
| CCF/Addis |
51% (n=141) |
45% (n=141)* |
– |
| GOAL/Metahara |
97% (n=115) |
82% (n=115) "always" |
– |
DAC/WHO
Includes: Arba Minch, Jimma, Shashamene, Weliso |
96% (n=433) |
85% (nonregular clients) |
– |
|
77% (regular clients) |
|
64% (regular partners) |
|
(n=433) |
| 1996 |
| AIDSCAP/E. Includes: |
97% (n=825) |
61% (paying) (n=825) |
80% (n=825) |
| CCF/Addis |
89% |
– |
| FGAE/Bahirdar |
99.8% |
58% (nonpaying) (n=290) |
– |
| GOAL/Metahara |
90% |
– |
*Type of partner not specified.
Despite the difficulties in interpreting the quantitative data, evidence from qualitative studies overwhelmingly supports the perception of participants that condom use behavior is changing:
"When I was driving down to the refugee camp, I had to pass the night somewhere one hundred kilometers from here towards the south. I was talking to the hotel owner. There were many prostitutes there. He looked at my car which has a big logo [of DKT/PSI] and he invited me in for tea. I wanted to interview the person. He said, 'you know these condoms are really medicines. I do not know AIDS and I do not care about AIDS. But I had been raising many children of the prostitutes. Prostitutes used to have many children and as a [humane person], I had to support those girls. But, recently, I have never seen a bar girl becoming pregnant.' [DKT/PSI IEC project manager, Addis, 1996]
"In my observations plus from the workers and from the community, I have observed a lot of changes...condom demand in the beginning was very low. People did not want to listen about condoms...But bit by bit the demand has increased." [MPSC project manager, Metahara, 1996]
"These days, men carry condoms in their pocket. Previously, men used all sorts of excuses not to use condoms let alone carry them. They used to say condoms have the disease, and it does not give satisfaction...Now, men either bring one in their pocket or ask for a condom. Those who have stayed in the profession [CSWs] know about the disease well. Even a new comer who comes to work as a sex worker never gives herself without a condom." [MPSC peer educator, Addis, 1996]
"When we started the project, women [MPSCs] used to refuse to use a condom. But these days, no woman will accept sex without a condom." [MPSC peer health educator, Nazareth, 1996]
"Those who were CSWs are telling us that they have left the profession for fear of the disease." [Female MPSC peer health educator, Addis Ababa, 1996]
"They tell me that men do not come as often as they used to; in other words, the market is cold or has reduced [business is down; not many clients]...Some years ago, men used to tell us that condoms can't prevent AIDS. But now they demand condoms." [Female MPSC, peer health educator, Nazareth, 1996]
"...some of them [MPSCs] are telling us 'our partners are accepting us and we are using condoms. We feel safe. There are no complaints...The MPSCs tell us that the truck drivers are willing to use it [condom]. They had it with them. So this is an indication that there is behavior change." [MPSC project manager, Metahara, 1996]
The data obtained from behavioral surveys and qualitative research during the past few years in Ethiopia do provide some indication to implementing agencies of levels of risk behavior among their constituencies. Data points were established for target groups in some catchment areas for which data did not previously exist. Levels of knowledge of transmission modes and methods of prevention are high among most target groups. The surveys tell us where the misconceptions remain and how to structure future information campaigns. Condom availability is good; accessibility is good for sex workers with clients, but remains problematic for out of school youth. However, youth practicing higher-risk behavior do show higher rates of condom use. For all three groups, in the future, we need to ask how much additional change we might expect to see in the key indicators, considering the broader context of political, social, economic and ecological instability.
In urban Ethiopia, improvements in condom use among sex worker populations will more likely be noted in the indicator "condom use at last sex with a regular partner" although the definition of "regular" will need to be standardized and used consistently in future behavioral evaluation research. Additional qualitative exploration may help with descriptive categories of types of partners for various target groups to be reached by future interventions.
The apparent increases in multiple partner sexual networking among out of school youth have yet to be adequately explained. However, lack of comparability of data due to different sampling plans and geographic locations may also explain some of the inconclusive results. Future data points, using consistent probability sampling methods, can begin to provide data for trend analysis that will better explore these apparent increases in sexual activity among out of school youth.
The group of NGOs working under AIDSCAP funding has made impressive progress in understanding the complexities associated with tracking and interpreting behavior change and how it is effected by interventions. The quality of more recent data points is better than earlier ones. The data suggest that change is happening. Donors providing subsequent funding should consider including some system of behavioral surveillance (Mills et al 1997) -- a series of repeated cross-sectional surveys measuring risk behaviors in selected population groups -- as a way of tracking shifts in behavior change among certain key target populations. Likely target groups could include female MPSCs, male and female high school students, and male and female out of school youth reached by key implementing agencies. Behavioral surveillance of these five target groups should occur no more frequently than once a year (possibly every other year), depending on information needs of collaborating partners.
Table 7: Comparisons of Rates of Condom Use at Last Sex by Gender, Intervention Exposure, and Number of Partners among Male and Female Out of School Youth, 1996, Ethiopia
| |
People reporting only one partner during past 12 months |
People reporting >1 partner during past 12 months |
|
Males |
Females |
Males |
Females |
|
% |
n |
% |
n |
% |
n |
% |
n |
| Participated in group discussion on AIDS in past 12 months |
57 |
68 |
54 |
89 |
68 |
65 |
69 |
71 |
| p=.198 |
p=.0523 |
p=.198 |
p=.0523 |
| Did not participate (group) |
49 |
47 |
32 |
63 |
64 |
50 |
46 |
26 |
| p=.1345 |
p=.1977 |
p=.1345 |
p=.1977 |
| Participated in individual discussion on AIDS in past 12 months |
62 |
55 |
46 |
57 |
62 |
53 |
69 |
32 |
| p=.0356* |
p=.9619 |
p=.0356* |
| p=.9619 |
| Did not participate (individual) |
49 |
41 |
39 |
41 |
56 |
48 |
70 |
33 |
| p=.481 |
p=.0086* |
p=.481 |
p=.0086* |
*[Statistically significant differences in rates of condom use at last sex between females reporting only one partner and reporting more than one partner and who participated in individual discussions about AIDS within the past 12 months.]
STIs health seeking behavior
Data come from a variety of sources and have been reported in a variety of ways. Early in the program, AIDSCAP/Ethiopia sponsored the TIR research, reported above in the STI section, that highlighted different perceptions of STIs between patients and providers. STI intervention sites saw increasing numbers of patients in response to upgraded services, including availability of STI drugs:
"There is an increase in the number of patients but a decrease in the repeat cases. This is one indicator for behavior change." [STD project manager, Mekele, 1996]
Rates of self-reported STI prevalence varied widely, ranging from 15 to 49 percent among out of school youth, and from 6 to 26 percent of MPSCs depending on the symptom, throughout the life of the project. IAs report improved awareness of appropriate sources of care as a result of improved services under AIDSCAP.
"Over 95 percent of the target group [out of school youth] know where to go when they have STDs and other health problems." (CCF final subproject report, 1996)
In 1994, studies among MPSCs reported from 20 to 55 percent seeking treatment for STIs at an appropriate health facility. By the 1996 KABP, 73 percent reported seeking care at appropriate facilities.
Among in-school youth who experienced STIs in 1995, 58 percent sought appropriate treatment in a health care unit. A 1994 study of out of school youth in Addis, revealed that 99 percent of males and 97 percent of females reporting discharge mentioned seeking advice from a health facility but of those reporting genital ulcers, only 59 percent of males and 44 percent of females sought treatment in a health facility.
In contrast, in Mekele in 1995, of those youth reporting lesions or discharge, some of them went to a health clinic to get treatment, but most had used medicine available at home, asked advice from friends or went straight to the pharmacies. A study in Addis in 1995 asked out of school youth about preferred sites for STI treatment. The most frequently mentioned source for both males and females was government clinics (27 percent), although a substantial proportion also mentioned local injectors (17 percent) and private clinics (15 percent).
In the 1996 study of five NGO catchment areas reaching out of school youth, experience of STI symptoms was mentioned by 5 to 11 percent of sexually active males and 4 to 12 percent of sexually active females. The most frequently mentioned action taken by males in response to symptoms was doing nothing, followed by using medicines found at home, seeking advice from a friend or relative, buying medicines from a health facility or provider, buying medicine from a pharmacy or other shop, asking advice from health facility providers, and getting free medicine from health facilities. The least frequently mentioned action was asking advice from a traditional healer. For females, the most frequently mentioned action was asking advice from traditional healers, followed by getting free medicine from health facilities, asking advice from health facilities, buying medicine at a pharmacy, buying medicine from health facilities, asking friends for advice, and using medicines found at home.
Youth participants in FGDs in 1996 repeatedly mentioned that going to health institutions was unacceptable since it reveals their sexual activity before marriage in a public setting. Youth reported being embarrassed to talk to health providers about STI symptoms.
3. Other AIDSCAP Studies
In fall 1996, research was undertaken to identify communication experiences and lessons learned in AIDSCAP/Ethiopia projects in the words of the implementers (project managers and peer educators). The most effective aspects of interventions, as described by peer educators and project managers, tended to be those which involved:
- Building on existing relationships with target audiences by adding HIV prevention to other services (such as family planning) that are already offered by an NGO,
- Conducting outreach in a community context, rather than isolating target groups,
- Using behavioral data to convince gatekeepers of the importance of HIV prevention,
- Understanding the target audience's perspective by conducting thorough formative research, and
- Recognizing and responding to the economic context of high-risk behavior.
Targeting hard to reach audiences was easier using informal methods such as participant observation to understand local perspectives, mapping areas where target members gather, addressing people's broader concerns (such as economic difficulties), using traditional Ethiopian communication customs, and providing entertainment as a way to engage target audiences. The critical need to leverage gatekeeper support involves providing orientation seminars, recognizing the hierarchies of access to target audiences, and using data effectively to lobby gatekeepers. Successful interventions for out of school youth, for example, reached the wider community via outdoor sporting events and street theater. For FSWs, interventions were considered to be more successful when NGOs provided outreach to the community itself, thereby including potential FSW clients. The most successful media and materials included the "Fleet of Hope" imagery [Mahler 1996], traditional music, videos, drama, street theater, puppets, pocket risk assessment calendars, counseling cards (for the FSWs), humor, and contests.
The most important ways to support peer education, according to the peer educators and project managers, involve compensating peer educators for the time spent working, especially those who have no other income. Small media and linkages to condom social marketing projects were also considered crucial. The Ethiopia program's Focus Site Intervention Teams greatly enhanced the quality of behavior change programming at the regional level by organizing the local implementing groups, linking public and private efforts, coordinating materials distribution, and facilitating monitoring and evaluation activities.
