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Final Report for the
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A. FHI/AIDSCAP's Workplan in Ethiopia In Ethiopia, AIDSCAP implemented HIV/AIDS prevention activities between the period January 1, 1993 through March 31, 1997 under two USAID/Ethiopia bilateral projects: the Support to AIDS Control (STAC) project, and the Essential Services for Health in Ethiopia (ESHE) project. USAID's STAC project ran from September 1992 until September 1995. ESHE is a seven-year project, which began in July 1995. AIDSCAP's work in Ethiopia, as outlined in USAID-approved workplans, is described below. 1. AIDSCAP's Role Under the Support to AIDS Control Project In September 1992, USAID/Ethiopia signed the Support to AIDS Control (STAC) project with the government of Ethiopia. The goal of STAC was to increase the capability of the NACP to reduce HIV transmission. The project's purpose was to strengthen specific institutions and to expand the scope/scale of government and private institutions to control the sexual transmission of HIV. At the time, STAC was expected to run for two years until September 1994. STAC's design reflected USAID's prioritization of reducing sexually transmitted HIV, targeting high-risk groups, focusing on prevention efforts in urban areas, and using the three primary technical strategies of information, education and communication/behavior change communication (IEC/BCC), sexually transmitted infection (STI) control and condom promotion and distribution. STAC also included the supporting strategies of improving HIV/STI surveillance and supporting behavioral research. The major implementing agencies with which AIDSCAP collaborated initially were the Ministry of Health's Department of AIDS Control (DAC) and the Ministry of education. In addition, non-governmental organizations were to be brought into the project to collaborate with the ministries, to implement complementary efforts, and reach under-served groups. The target groups under STAC were women with multiple partner sexual contact (MPSC), which is how the MOH refers to female sex workers, male clients of MPSCs, long-distance truck drivers, factory workers, demobilized soldiers, and men with symptomatic STIs, in-school and out-of-school youth and university students. The "focus areas" for STAC prevention interventions were Awassa,(SNNPRG) Bahirdar,(Region 3) Mekele (Region 1) and Nazareth(Oromia). FHI/AIDSCAP was selected by USAID/Ethiopia as the lead agency to manage the STAC project. The AIDSCAP Resident Advisor was hired by January 1993, and the AIDSCAP office was established in Addis Ababa in April 1993. During the '93 calendar year the mission requested AIDSCAP's assistance in developing recommendations for expanding the scope of STAC activities through September 1995. AIDSCAP incorporated recommendations for expanding STAC into its implementation plan, which was finalized in April 1993. Five months later, in September 1993, the USAID mission amended the STAC project paper, adopting some of AIDSCAP's recommendations and adding a number of new outputs based on negotiations with DAC. The STAC amendment called for increased emphasis on youth, both in- and out-of-school, because they are at risk of engaging in unsafe sex and because of the potential of successfully reaching them with behavior change messages. The amendment also called for adding additional activities in the focus areas in order to achieve comprehensive HIV/AIDS programming, including condom distribution, behavior change communications, behavioral research combined with maternal and child health activities. The focus area programs were to build on DAC activities, involve NGOs, particularly to help in reaching out-of-school youth, and eventually to expand activities to surrounding communities. The STAC amendment altered the outputs for each of the primary technical strategies being spearheaded by AIDSCAP. The following information illustrates the original outputs and the amended and additional outputs for which AIDSCAP was responsible under STAC. Sexually Transmitted Infection Control AIDSCAP's expected outputs under STAC were:
Amended/additional AIDSCAP outputs under the STAC amendment were:
Information, Education and Communication/Behavior Change Communication AIDSCAP expected outputs under STAC were:
Amended/additional AIDSCAP expected outputs under the STAC amendment were:
Condom Promotion and Distribution AIDSCAP expected outputs, through its subcontractor Population Services International (PSI) were:
The one additional AIDSCAP's expected output under the STAC amendment was:
Supporting Strategies Under the supporting strategy of HIV/STI surveillance, AIDSCAP was responsible for 1) sending one person for short-term epidemiological training abroad, 2) developing pilot facility-based STI surveillance in the four focus sites, with gradual extension to other sites, 3) improving surveillance methodology at the national and regional levels, and 4) conducting one HIV survey of antenatal clinic attendees in the four focus sites. Related to behavioral research, AIDSCAP was charged with 1) establishing a behavioral research grant program, 2) improving research capacity of NACP staff and others through a workshop, and 3) establishing a Social and Behavioral Research Committee. 2. AIDSCAP's Role Under the Essential Services for Health in Ethiopia Project (ESHE) ESHE was launched by USAID in September 1995; however AIDSCAP's role under the new project was not certain until April 1996, when USAID/Ethiopia provided FHI/AIDSCAP with a 12-month delivery order for the period April 1996-March 1997. Unlike the STAC project, AIDSCAP did not have a lead role in the ESHE project, which combines health and population activities. Instead, AIDSCAP was contracted to consolidate its program and implement only a limited number of HIV/STI prevention efforts in order to continue and/or build upon key activities implemented under STAC. Namely, FHI/AIDSCAP was charged with the following tasks:
A discussion of AIDSCAP's accomplishments, constraints and lessons learned in leading prevention efforts under STAC and in continuing selected efforts under ESHE is provided in the later sections of this report. 3. AIDSCAP Ethiopia's Key Target Groups Female sex workers (FSWs), also known in Ethiopia as "MPSCs" (multiple partner sexual contacts), were a key target group in the AIDSCAP country program. Most sex workers are employed as bar ladies in bars, hotels, or local drinking houses. Others are street girls working out of their own homes. Some women do not necessarily self-identify as FSWs:
While the hotels and bars are often concentrated in high-traffic areas of a town, the smaller drinking houses are dispersed throughout towns, making them more difficult to access for interventions or research. The local drinking houses sell tej (a fermented honey drink), tella (a local beer), or areki (a strong liquor served in small glasses somewhat like vodka) and are usually owned by one person. There may be one or two bar ladies based in the local drinking houses who also offer sex to the customers. Bar ladies who work in local drinking houses tend to be less well educated and charge less for their sexual services than bar ladies in hotels and bars. Because they are more difficult to reach, they are less likely to receive HIV prevention information and less likely to use condoms. "Out of school youth" in Ethiopia are young people aged 15 to 24 years old who have finished school for whatever reason, and are unemployed, unmarried and dependent on their birth families for support. Ninety-five percent of one sample in Addis reported in 1994 that they were not currently working to earn money. In Awassa in 1995, FGAE reported that for the previous three years, only three percent of the 1,739 students taking the Ethiopian School Leaving Certificate Examination (ESLCE) did well enough to continue their education at institutions of higher learning. FGAE/Awassa also reported that the Awassa Labor and Social Affairs Bureau was able to assist only five percent of 5,638 job seekers to find employment. The average number of years of school for the 1996 sample across NGO intervention sites, for example, was 11 for males and 10 for females; more than a third of the sample said they had completed the 12th grade but could not find a job. Another 22% had failed school repeatedly. Describing the youths' difficult circumstances, one project manager said in 1996, "most of them are unemployed, very hopeless, have nothing to do, and just sit idle at home. It is very difficult to convince these young people to value life or health...Because they [think] they do not have any future, they don't want to worry about these things.... Poverty is the cause of many circumstances. Most of the young people are hopeless and for them to feel that they are important is very difficult... Most of them think they have no chance to succeed... they are not considered valuable in the family or the community. They are in a very desperate situation... They engage in risky sexual activity as an escape mechanism." Because of their dependent social status and large amounts of idle time, urban out of school youth in Ethiopia become vulnerable to drug use ("chat" or "Catha edulis"), alcohol use, stimulation from pornographic videos, and resulting risky sexual behavior. "Alcoholic drinks and pornographic videos prevent behavior change. Youth see these videos because there is no other entertainment... they watch video films for fifty cents and want to practice what they see" [Male youth peer educator, Addis Ababa, 1996]. Young people's perceptions of their difficult social and economic status within communities contribute to negative coping strategies that increase their risk of acquiring HIV. 1. Epidemiology Data on AIDS cases and HIV/STI prevalence are available from the MOH's Epidemiology and AIDS Department, the WHO/GPA field-test of prevention indicators in 1993, and from independent studies conducted in various parts of the country. Since 1986, when the first AIDS case was reported to the MOH [Workalemahu 1990], AIDS has spread rapidly throughout all regions of the country. The cumulative number of reported AIDS cases jumped from 4,884 at the end of 1992 to 21,569 by the end of December 1996, as reported by the country's 57 hospitals. However, the estimated number of actual AIDS cases is currently about 350,000 with a projection of half a million by the year 2000 (MOH subproject narrative report 1997). The vast majority of cases (about 80 percent) involve a history of multiple partner sexual contact. About 44% are between the ages of 20-29 with male to female ratio of 1.7:1. AIDS cases will likely continue to rise in the immediate future as more infected people begin to fall ill. Among the factors contributing to the rapid spread of HIV in this country of 58 million people are: 1) seasonal migration of workers in search of employment and better economic conditions leading to increasing multiple partner sexual networking, 2) dislocation of populations due to the 17-year civil war, again creating social situations conducive to increased sexual networking, 3) high STI rates in high-risk and general populations, 4) increased sexual activity among youth, and 5) high population unemployment rates including 400,000 demobilized soldiers returning to rural areas, towns, and cities after 1991 [NACP 1992]. For the past three decades, a series of severe political, economic, and ecological crises including a long civil war, unstable government, recurrent drought, massive environmental degradation, and unfavorable international economic environments has created the context for rapid spread of HIV and other STDs. HIV Prevalence The MOH estimates that 1.7 million Ethiopians are currently infected with HIV. Seroprevalence rates remain higher in urban centers than in rural areas. HIV prevalence has continued to rise in Ethiopia among all target groups, the general population, and in all regions during the past decade. Rates among female sex workers (FSWs or MPSCs) were already 15 percent in Awassa in 1988 [BuCen 1994]. In Bahirdar, among sex workers, HIV prevalence increased from 20 percent in 1988 to 53 percent in 1990 to 70 percent in 1991 [NACP 1992]. In Addis Ababa in 1990, 54 percent of prostitutes in one study were HIV positive [BuCen 1994]. During the early 1990s, prevalence rates among truck drivers and their assistants from a variety of locations ranged from 13 to 41 percent [NACP 1992]. The table below summarizes available prevalence data for female MPSCs in Ethiopia. For some of the years listed, multiple studies and/or sites were sampled. Ranges represent multiple data points (different studies) within the urban centers listed in column one. Table 1: % HIV Prevalence among Female Sex Workers (MPSCs) in Ethiopia 1988-96
Sources: US Bureau of the Census, Population Division, International Programs Center; TDA/Mekele final report; FGAE/Bahirdar final report. Rates among pregnant women aged 15-24 in Addis Ababa were 2 percent in 1989 [BuCen 1992]. The 1992 sentinel surveillance results showed prevalence of HIV among 16-17 year old females to be around one percent, which was probably a good estimate of incidence in that age group just prior to the beginning of AIDSCAP/Ethiopia [GPA 1994]. In 1993, WHO/GPA field-tested its 10 prevention indicators (PIs) in four urban centers in Ethiopia, showing a prevalence of 13.6 percent among the 2,400 pregnant women in Addis who were tested [Mehret et al 1996]. Another study conducted between January 1993 and January 1995 found seroprevalence among 550 pregnant women in an Addis hospital to be 20.4% [Chamiso 1996]. At that time, there was no accurate data available on how many pregnant women attend clinics for medical checkups. In Addis Ababa, with over 30 public and many more private ANC clinics where services are provided, it was estimated that about 50 percent attend a clinic [GPA 1994]. Another 1993 serosurvey of 2,415 general population males and females aged 15-49 in six rural areas revealed an overall prevalence of 1.8 percent [BuCen 1994]. In 1994 in Addis Ababa, the prevalence of HIV in adults (> 15 years) was 6 percent for males and 6.9 percent for females with peak prevalence in the 25-29 year age groups of 16.3 percent (males) and 11.8 percent (females). From this same community-based study, estimates of HIV incidence in Addis (per susceptible per annum) for the age group 16-22 years range from 1.3 to 3.7 percent for males and from 2.4 to 3.2 percent for females [Messele 1996]. By 1996, estimates of HIV prevalence in four antenatal clinics in Addis were 26.5, 21.4, 15.7 and 9.0 percent and among FSWs in Addis, 40 to 60 percent [Rinke de Wit et al 1996]. The authors conclude that the HIV epidemic is still in an expansion stage in Addis Ababa and that HIV incidence rates have been high during the two years separating the surveys in 1994 and 1996. 2. Policy Environment During the start up of the STAC Project the Ministry of Health had a strong NACP under the Department of AIDS Control with 57 staff members (AIDSCAP Program Review 1994). However, this situation changed in 1994 when the Government's regionalization and restructuring policy left the DAC with only three technical staff and the Regional Health Bureaus responsible for implementing the project. The DAC was downgraded to a Division of Epidemiology and AIDS, and the DAC financial accounts were frozen and audited for six months. As a result of downsizing DAC, measures were taken by USAID and AIDSCAP in consultation with DAC to add a technical project coordinator in the AIDSCAP country office in order to expedite focus site and clinical site activities. Some of the activities in the 1994/95 implementation plan that were supposed to be conducted at the Central Laboratory (previously the NRIH), had to be conducted at regional laboratories because of restructuring. This change effected the GC study that was finally conducted in Awassa Regional Lab and Gonder Medical College. The only surveillance carried out in 1993 was the one conducted among the rural population in four sites with a prevalence of 1.5 percent. WHO/GPA had also conducted surveillance in 1993 among pregnant women in Addis, finding an HIV prevalence rate of 13% (reference 1997 published article). 3. Activities of Other International Donors and Agencies Before the assistance of USAID in HIV/AIDS prevention, WHO and Population Services International (DKT/PSI) supported the National AIDS Control Program and worked closely with the Department of AIDS Control of the Ministry of Health. With USAID's STAC Project, WHO/GPA entered into an agreement with USAID for the procurement of drugs, lab equipment, refurbishing and upgrading STI clinical and laboratory facilities through a letter grant. In this project, PSI (DKT) was subcontracted to establish condom distribution and design social marketing strategies through AIDSCAP task orders. AIDSCAP and its subcontractors were to provide technical assistance in training workshops, IEC materials development, monitoring and other needs as required. Before USAID's support, a pilot study was conducted on students in junior and senior secondary schools in selected areas with the technical and financial assistance of UNESCO, WHO and MOH between 1989-1990. Based on the results of the pilot study, Swedish International Development Authority (SIDA) began funding the Ministry of Education for AIDS prevention projects focused on establishing anti-AIDS clubs in the senior secondary schools. Just before USAID, the European Economic Commission also supported STI treatment interventions in 40 health centers in the country. |
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