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Final Report for the
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Table of Contents Executive Summary (See Below) I. Country Program Description A. FHI/AIDSCAP's Workplan in Ethiopia C. Accomplishments and Constraints II. Lessons Learned and Recommendations III. Subproject Highlights Executive Summary Epidemiology Ethiopia's first HIV positive individuals were reported in 1986 among hospital patients. Rates among female sex workers (FSWs) were already 15% in Awassa and 20% in Bahirdar in 1988, and increased by 1996 to 79% in Bahirdar. Rates among pregnant women aged 15-24 in Addis Ababa were 2% in 1989 and nearly 14% in 1993. By 1996, estimates of HIV prevalence in four antenatal clinics in Addis were 26.5%, 21.4%, 15.7% and 9.0% and among FSWs in Addis, 40 to 60%. The HIV epidemic is still in an expansion stage and it is believed that HIV incidence rates have remained high, based on studies conducted in 1994 and 1996. 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 increased 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 STD 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. Country Overview Northeast Africa's most populous country, Ethiopia has a history of 2000 years of continuous national existence, supporting over 70 ethnic groups speaking nearly 100 languages. The population, 90 percent rural, is predominantly Orthodox Christian, although there is a substantial Muslim population as well. 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. The government of Ethiopia took an early aggressive stance towards coping with the epidemic, and has continued its commitments within the constraints of major political changes. Between January 1993 and March 1997, AIDSCAP implemented a comprehensive set of HIV/AIDS prevention activities under two USAID/Ethiopia bilateral projects, via the Ministry of Health, the Ministry of Education and 15 non-governmental organizations (NGOs). Accomplishments AIDSCAP/Ethiopia helped to fill gaps left by the decentralization of AIDS control activities that occurred at the beginning of AIDSCAP. Twenty sites participated in STD services improvement interventions. Of those, four focus sites developed a model of integrated, comprehensive interventions, coordinating public and private resources at the regional level, featuring improved STI care and outreach to individuals at risk of infection. National condom social marketing supported all activities. 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. BCC The hub of AIDSCAP/Ethiopia's program was its behavior change interventions focusing on promoting options and choices for people making decisions that might put them at sexual risk. 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. 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. Results of evaluation research indicated knowledge and behavior change for most indicators, although among out of school youth, greater percentages reported they were sexually active, and percentages reporting more than one partner increased. However, condom use also increased. Key Baseline vs. Follow-up Comparisons: Percentages Reporting
Qualitative research also suggests that the intensive interventions have made substantial progress in changing knowledge, attitudes, and behaviors related to HIV/AIDS as this one example illustrates:
Condom Promotion and Distribution The Ethiopia Social Marketing Project (ESMP), implemented by DKT International in collaboration with Population Services International (PSI) has emerged as one of the most successful social marketing projects in Africa since it began in 1990. During the 33 months of collaboration with AIDSCAP, the ESMP sold close to 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 target of one million per month. 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. Of particular significance is the fact that sales through bars and hotels accounted for nearly 25 percent of all ESMP sales. 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. Just over a million condoms were also distributed free through public and private outlets. Strengthening STI Services Improving STI services was a significant component of the program. The 20 clinical sites were refurbished by providing STI drugs and laboratory equipment, improving infrastructure, training providers in syndromic management, developing case management guidelines, developing counseling protocols, and increasing availability of condoms. AIDSCAP/Ethiopia sponsored a rapid ethnographic study (Targeted Intervention Research or TIR) of beliefs and practices related to STI health seeking behavior among targeted populations that assisted with development of educational materials. The project also conducted a GC chemosensitivity study in two locations. A comprehensive assessment of the 20 clinical sites at the end of the project found that 97 percent of health care providers have the skills and knowledge required for appropriate STI case management, and have accepted syndromic management as an essential approach for managing STI cases. In all focus sites and in 80 percent of the STI clinical sites, STI services are integrated into MCH/FP services as a result of on-site training conducted for MCH/FP workers emphasizing STI screening of FP attendants and syphilis screening of pregnant women. Capacity Building Through its collaboration with local public and private partners, AIDSCAP/Ethiopia made a substantial contribution to developing local capacity to design, implement and evaluate HIV prevention programming, despite the massive decentralization of government activities during the first year of the program. Capacity building took a variety of forms in Ethiopia including training workshops, a study tour, sponsoring attendance at regional and international conferences, collaborating with local researchers for data collection activities, and serving as a resource for implementing agencies beyond the scope of AIDSCAP's contractual partners. A rapid organizational assessment performed at the end of the project revealed perceptions by implementing collaborators of significant improvements in technical skills building, organizational and management skills building, organizational systems development, and networks and global learning enhancement. Special Features 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. 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. Implementing Partners
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