Saving a Generation: Ethiopian Youth Rally to Prevent HIV/AIDS

Fassil Nebyeleul was a 21-year-old university student when AIDS claimed one of his best friends.

The death shocked Fassil and his mates. They had never imagined that HIV could hit so close to home. But they knew the behavior that had led to their friend's death was no different from their own.

"We decided that we were all HIV-positive and calculated our time of death as four or five years," Fassil said. "So we said, let us do something before our lives are gone."

What they did was organize a group called Save Your Generation to warn other young people about the threat of HIV/AIDS. Each of the five founding members invited five friends to the first meeting, where they talked about how to prevent HIV transmission and urged new members to spread the word.

From that original group, Save Your Generation Association (SYGA) has grown into a registered Ethiopian nongovernmental organization (NGO) with a paid staff of 14 and more than 6,000 dues-paying members. The founding members (who later learned that they were not HIV-positive), are very much alive and have expanded the organization's activities well beyond the university community. Most of their efforts are aimed at saving Ethiopia's lost youth -- the tens of thousands of school dropouts and other unemployed young people who are particularly vulnerable to HIV/AIDS.

SYGA is one of seven NGOs that received support from the AIDS Control and Prevention (AIDSCAP) Project over three years to bring HIV/AIDS prevention education to out-of-school youth in six urban areas. These projects have enlisted the help of young volunteers and community organizations to inform and motivate a segment of the Ethiopian population that is difficult to reach and very much at risk.

Out of School, Out of Hope

The United Nations defines youth as the ages from 14 to 24, and most HIV/AIDS prevention programs for youth target people in that age group. But in Ethiopia, where unemployment is high and many people live with their families long after they leave school, the AIDSCAP program clearly needed a broader definition.

"In our case we call young people those who are still dependent on their families," said Fassil, whose organization works with young men and women up to 30 years old.

NGO staff and volunteer peer educators find these youth hanging out in the streets, small shops, billiard halls, table tennis courts, video houses and traditional drinking spots, trying to fill the hours of the day. Some dropped out of high school, and others were unable to get into a university or technical college. Some are college graduates. Almost all are unemployed.

Bored, hopeless and rejected by their families and communities, these young people often turn to dangerous escape mechanisms. "It's a deadly combination of alcohol, drugs and nothing to do," said AIDSCAP Evaluation Officer Jan Hogle, who helped AIDSCAP staff in Ethiopia conduct in-depth interviews with project managers and peer educators in September 1996.

A knowledge, attitudes and practices survey conducted by one of the AIDSCAP implementing agencies, Marie Stopes International-Ethiopia (MSIE), revealed that about 68 percent of its target population had had more than three sex partners during the previous 12 months.

Opening the Door

Identifying out-of-school youth and engaging them in HIV/AIDS prevention activities was the first challenge for the seven NGOs. By definition, out-of-school youth could not be found at school or work, so where could they be reached systematically?

"Our entry point was the kebele administration," said AIDSCAP/Ethiopia Resident Advisor Beletu Mengistu, explaining that as the local government arm, the kebele administration has a list of all the households and household members registered in its jurisdiction.

Kebele leaders helped the projects find out-of-school youth and in many cases provided meeting space for HIV/AIDS prevention activities. In the three woredas (districts) of Addis Ababa where MSIE works with out-of-school youth, kebele leaders were impressed with the organization's plans and asked how they could do more to help. MSIE formed three Woreda HIV/AIDS Committees of kebele leaders, other community representatives and peer educators, which meet regularly to plan and monitor prevention activities.

SYGA also works with another kind of community group, the Edirs, which are traditional organizations of 120 to 800 households. Established as an insurance system for funeral ceremony expenses, the Edirs have gradually assumed a larger role in community affairs. Through them, SYGA hopes to generate greater support for its activities from parents and other members of the community.

So far only a small number of Edir leaders have agreed to work with SYGA, but the ones who have are important allies because community members respect and trust them. "It is a very democratic system, and the leaders are elected by community," Fassil said. "If we open the door to the community system, then I think our objectives will be achieved."

Their Own Language

SYGA and other NGOs use drama, videos, puppet shows, sports events and other forms of entertainment to attract out-of-school youth to their meetings. "Street dramas are best," a SYGA peer educator said. "You don't need to invite people. They just join in when they see the group forming."

SYGA often performs dramas and puppet shows at the local football grounds during breaks in football games. MSIE works with the Woreda HIV/AIDS Committees to sponsor sports competitions among the kebeles to bring youth together. Another organization that received AIDSCAP funding, the Family Guidance Association of Ethiopia (FGAE), invites youth to its project offices to watch videos and dramas. Sometimes the NGO staff hold writing competitions and award prizes.

These events serve two purposes. They draw in youths and offer them alternatives to other forms of entertainment that may lead to risky behavior. But they also convey HIV/AIDS prevention messages in a way that speaks directly to the audience.

"In the drama, we use their own language and they see their own deeds," explained a SYGA peer educator.

MSIE hired professional artists to produce two dramas, one for staging and another for videotaping. Other projects brought in professionals to train their peer educators at regular intervals. But most of the dramas and puppet shows are created and performed by the peer educators themselves. The Tigray Development Association, which worked with out-of-school youth in the town of Mekele, gave 17 of its peer educators technical training so they could produce their own videos.

Prevention Options

Performances and other events are only one of the ways the projects reached out-of-school youth. Peer educators and even project staff spent much of their time talking to people one-on-one, advising them on how to prevent HIV transmission and negotiate safer sex with partners. "Whenever we have time, we go to the bars, to the restaurants, everywhere, and we talk about AIDS," Fassil said.

In personal conversations, printed educational materials and drama, the projects emphasized giving young people choices and a sense of control. Upbeat messages congratulated youth for adopting healthy sexual behavior.

"We teach every single prevention method equally: abstinence, fidelity and condom use," Fassil said. "We do not advise them to use one or the other. It is up to the person to choose."

This approach makes sense, he added, because different prevention options may be appropriate for the same person at different stages in his or her life.

Youth participating in MSIE's project liked the idea of different prevention options so much that they named their youth group the "Fleet of Hope Association" after a metaphor that has been used in AIDSCAP programs all over the world. The "Fleet of Hope," which originated in Tanzania, consists of three boats that people can board to escape the "flood" of HIV/AIDS: abstinence, fidelity and condoms.

Condom Access

Since many out-of-school youth are already sexually active, condoms are an important option. In Ethiopia, where AIDSCAP's social marketing subcontractor, Population Services International (PSI), has sold almost 44 million condoms in three years, inexpensive condoms are available in shops and kiosks throughout the country.

"We have many, many outlets," said Teshome Bongassie, MSIE's AIDS program officer. "In any corner of our catchment area, there are condom outlets."

But peer educators report that young people are often reluctant to buy condoms in public places for fear that someone they know will see them. "The most successful distribution mechanism was that of the PHEs [peer health educators], where youth easily get condoms from their friends without feeling shy," AIDSCAP's Beletu said.

Most of the out-of-school youth projects gave peer educators condoms to distribute. Some gave out condoms for free, while MSIE, GOAL Ethiopia, the Christian Children's Fund of Ethiopia and the Integrated Holistic Approach, Urban Development Project worked with PSI to sell subsidized condoms to youth at a low price.

SYGA tried selling condoms in one district, but found that this approach undermined prevention education efforts because young people looked upon the peer educators as agents of the condom companies. "They said, 'You are here just for selling condoms. You don't care about us,'" Fassil explained.

Others had more success. FGAE learned just how popular the sales were when the AIDSCAP program ended. Condom supplies ran out, but young people kept asking the peer educators for them. "It was only after discontinuing the selling that we realized there was such a high demand for condoms," an FGAE peer educator said.

Fassil believes that given the wide availability of condoms through the social marketing program, condom skills are even more important than condom supplies. Peer educators teach the youth how to use condoms, how to negotiate their use with partners, and even how to buy them, and give them opportunities to practice these skills. "People did not know how to use condoms properly until we showed them," said a SYGA peer educator.

Facing Challenges

It takes courage to talk about condoms, sexually transmitted disease (STD) and HIV/AIDS prevention in a culture where open discussion about sex is considered taboo. Young women who served as peer educators reported being harassed and ridiculed. "Some youth tell us that we are girls, and girls should not talk of such things in public," said one young woman who serves as a peer educator.

Others did not want to listen to anyone talk about HIV/AIDS prevention. "Some youth leave the room as soon as they hear the word AIDS," the young woman added.

Parental disapproval was another obstacle. For example, SYGA lost 30 of its first 40 peer educators after training because their parents would not let them continue their work. Since then, the organization has worked with the Edirs and kebeles to gain parents' support for its HIV/AIDS prevention activities with out-of-school youth.

While some parents objected to their children speaking in public about HIV/AIDS, others believed that the time the young people spent volunteering as peer educators would be better spent looking for a paying job.

"It was important to give some sort of incentive payment to the peer educators," AIDSCAP's Hogle said. "It didn't matter how much it was, just something to show their parents. If they didn't get incentives, the parents would say, 'You spend all your time on this, what do have to show for yourself?'"

Some of the NGOs were able to pay the peer educators a small sum or at least cover travel costs, but others were not. Peer educators volunteering for FGAE in Nazareth were resentful because they knew their counterparts in nearby Awassa received 50 Birr (about U.S.$8) for every day they worked.

But by far the greatest challenge for NGO staff and peer educators was convincing young people that their health was worth protecting. "For them, to value life, to value health, is useless," Fassil said. "They believe they do not have any future, and they do not want to worry about these things."

Progress and Change

AIDSCAP's program in Ethiopia ended earlier than expected with the conclusion of the U.S. Agency for International Development's (USAID's) HIV/AIDS control project there, so most of the out-of-school projects operated for only two years or less. Yet in that short time, the projects met many of their targets, reaching more than 112,000 young people, training more than 430 peer educators, and selling or distributing over 232,000 condoms.

Although the projects were part of the AIDSCAP program for too short a time to expect significant behavior change, project staff and peer educators believe their efforts have had an impact. As evidence they cite the large numbers of people who ask them questions about HIV/AIDS and STDs, many reports of changed behavior and frequent requests for condoms.

"We have seen that those who were shy to even say condom nowadays carry it in their pocket," a peer educator noted.

"They say, 'I cannot even manage my own girl, so why see different girls, because it is very dangerous,'" MSIE's Teshome said. "They go with one girl only, when they used to have five or six."

The effect on the attitudes and behavior of the peer educators has been the most dramatic. Even those who once thought HIV/AIDS did not exist have become firm believers. Peer educators say they are sticking to one sexual partner and using condoms.

One peer educator says the experience has changed his life. Before joining SYGA, he was addicted to several kinds of drugs and spent time in prison, but now he is a productive, drug-free member of the NGO's drama group.

The skills and experience they gained as peer educators also enabled some youth to find paid employment. One-third of the young people trained by MSIE, for example, have found permanent jobs. SYGA has hired several peer educators to serve on its staff. "I am now self-reliant and can earn my own money, so I am happy," said one, a young woman who was not permitted outside her parents' house until she became a peer educator.

Maintaining Hope

The NGOs have struggled to continue their HIV/AIDS prevention activities for out-of-school youth since December 1995, when most AIDSCAP funding for projects in Ethiopia ended. FGAE and GOAL have managed to conduct some prevention activities with their own funds, and a few NGOs have found support from other donors. MSIE received support through a USAID-AIDSCAP regional gender training initiative, and SYGA was awarded one of AIDSCAP's short-term Rapid Response Fund grants.

SYGA also received grants from several other organizations. Fassil, who remembers when donors shied away from supporting the group because they thought they were too young and inexperienced to manage grants, believes that SYGA is now in a good position to attract additional funding.

"At the beginning, we did not have a system and we did not know that evaluation is important," he said. "We started seeing it in different ways, thanks to AIDSCAP and different organizations that helped us in building our capacity to run a program."

More established groups such as FGAE and MSIE also benefited from their participation in the AIDSCAP/ Ethiopia program, which enabled them to expand their community-based family planning and health programs to address HIV/AIDS. Both groups are determined to continue HIV/AIDS prevention activities, but have not yet identified the necessary funds.

With support from USAID's Regional and Economic Development Services Office for Eastern and Southern Africa (REDSO-ESA) and AIDSCAP's Women's Initiative in 1995 and 1996, MSIE was able to train its peer educators in gender issues so that they can help youth develop negotiating skills that will protect them from HIV infection. "We're creating a forum where young people of both genders can talk openly and honestly about sex and how to protect each other," Teshome said.

MSIE also introduced income-generating activities into the project. Participants earn money by selling tea and soft drinks at the Fleet of Hope Association meeting room, where they also disseminate information about HIV/AIDS. Teshome and Fassil say that a source of income is essential to empowering young people -- particularly young women -- to refuse unwanted sex and negotiate safer sex.

But for now, just knowing that someone believes their health is important has given many out-of-school youth the incentive to change. "The youth came to understand that there's a hope of living somehow and there is a future," said Teshome.

-- Kathleen Henry

Transcripts of focus group discussions with peer educators and in-depth interviews with project managers conducted in September 1996 are quoted in this article.