HIV/AIDS in Ethiopia Lisa Garbus, MPP AIDS Policy Research Center, University of California San Francisco Published April 2003 Updated April 2003 (c) 2003 Regents of the University of California Table of Contents (click on page number to go directly to that section) PREFACE 4 EPIDEMIOLOGY 12 AT A GLANCE 12 HIV SENTINEL SURVEILLANCE 14 TRANSMISSION PATTERNS 21 UNAIDS ESTIMATES 22 AIDS CASES 22 AGE AND GENDER 22 AIDS MORTALITY 23 PREVALENCE PROJECTIONS 23 PROGRESSION OF THE HIV EPIDEMIC 24 DATA QUALITY ISSUES 25 POLITICAL ECONOMY AND SOCIOBEHAVIORAL CONTEXT 28 AT A GLANCE 28 COUNTRY OVERVIEW 34 GOVERNANCE 35 POPULATION MOBILITY 35 ECONOMY 37 PUBLIC EXPENDITURE TRENDS 39 DEBT 39 FOOD SECURITY 41 HUMAN DEVELOPMENT 42 HEALTH 43 SEXUAL & REPRODUCTIVE HEALTH 45 SEXUALLY TRANSMITTED INFECTIONS 46 EDUCATION 47 GENDER 47 KNOWLEDGE OF HIV/AIDS 50 STIGMA 52 SEXUAL BEHAVIOR 54 CONDOMS 57 SEX WORK 58 ALCOHOL AND DRUG USE 58 MALE CIRCUMCISION 59 IMPACT 60 AT A GLANCE 60 DEMOGRAPHIC 61 AIDS MORTALITY 63 MACROECONOMIC 64 HOUSEHOLD 65 ORPHANS AND OTHER VULNERABLE CHILDREN 67 RESPONSE 69 AT A GLANCE 69 GOVERNMENT RESPONSE 74 HUMAN RIGHTS 80 BUDGETS 81 DONORS 81 NGOS 84 ORPHANS 85 BLOOD 85 UNIVERSAL PRECAUTIONS 86 POST EXPOSURE PROPHYLAXIS 86 PMTCT 86 VCT 86 CARE AND SUPPORT 87 ART 87 MILITARY 88 OTHER MOBILE POPULATIONS 88 PRIVATE SECTOR 89 LINKS 90 GOVERNMENT 90 ACADEMIC AND RESEARCH INSTITUTES 90 NATIONAL NGOS AND CBOS 91 INTERNATIONAL NGOS 93 UN AGENCIES 94 BILATERAL DONORS 95 FOUNDATIONS 97 SUBREGIONAL ORGANIZATIONS 97 ELECTRONIC DISCUSSION FORA 97 OTHER INFORMATION SOURCES 97 Preface This research was undertaken as part of the Country AIDS Policy Analysis Project, which is managed by the AIDS Policy Research Center at the University of California San Francisco. The project is funded by the U.S. Agency for International Development, Cooperative Agreement PHN-A-00-01-00001-00. Stephen F. Morin, PhD, is the project's Principal Investigator. The views expressed in this paper do not necessarily reflect those of USAID. The overarching objective of the Country AIDS Policy Analysis Project is to inform planning and prioritizing of effective and equitable HIV/AIDS prevention and treatment interventions through multidisciplinary research on HIV/AIDS. The project evolved from the acute need for analysis of the epidemiology of HIV/AIDS in tandem with analysis of countries' political economy and sociobehavioral context ¾ at household, sectoral, and macro levels. This multidisciplinary analysis aims to: * help inform national HIV/AIDS policies * strengthen ability to plan, prioritize, and implement effective interventions * highlight the range of sectoral interventions that may affect or be affected by HIV/AIDS * facilitate multisectoral/interministerial coordination * facilitate intercountry information sharing * increase national and subregional capacity for effective partnerships The project develops and disseminates online, easy-to-download, continually updated analyses of HIV/AIDS in 12 USAID Rapid Scale-Up/Intensive Focus/Basic Program countries: Ethiopia, Kenya, Malawi, Senegal, South Africa, Uganda, Tanzania, Zambia, Zimbabwe, Brazil, Cambodia, and India . The primary audience for the country analyses is in-country HIV/AIDS planners, including those from government ministries and agencies, multi- and bilateral donors, international and local NGOs, health care institutions, prevention programs, academia, faith-based organizations, affected communities, and the private sector. International investigators and policymakers also report using the analyses in their work. All country analyses undergo peer review at the AIDS Research Institute of the University of California San Francisco. In addition, two in-country experts from each profiled country serve as peer reviewers. A scientific advisory board also reviews all analyses. Each analysis is linked with national strategic plans for HIV/AIDS prevention, care, and support. Analyses also include extensive links to related resources. An online database comprising 73 HIV/AIDS and socioeconomic indicators for 168 countries and 13 regions is also being developed and will allow users to conduct a variety of comparative analyses. Project staff are in regular contact with national HIV/AIDS professionals who provide and verify data as needed. Staff continually assess and incorporate new data to maintain the timeliness of the analyses. Acknowledgments The following individuals served as peer reviewers and provided valuable inputs to this paper: Dr. Assefaw Tekeste Ghebrekidan, Institute for Global Health, University of California San Francisco & University of California Berkeley; Dr. Yared Mekonnen and Dr. Mathias Aklilu, both of the Ethio-Netherlands AIDS Research Project, Ethiopian Health and Nutrition Research Institute, Addis Ababa. They are not responsible for any errors of fact or judgment. Executive Summary Epidemiology The first HIV infections in Ethiopia were identified in 1984, and the first AIDS cases reported in 1986. In 1987, the government established an HIV/AIDS department within the Ministry of Health, and in 1988, an HIV surveillance system was established. In 1989, the Health Bureau of the Addis Ababa City Administration began HIV sentinel surveillance. Currently, there are 34 HIV sentinel surveillance sites reporting to the MOH. As the overwhelming majority of them are in urban areas, an enormous segment of the rural population remains uncovered by the current system, despite that 85 percent of the population lives in rural areas. HIV/AIDS increased rapidly during the 1990s. By 1989, HIV prevalence among the general adult population was estimated at 2.7 percent, increasing to 7.1 percent in 1997 and to 7.3 percent in 2000. In 2001, this figure was 6.6 percent. However, the MOH does not believe that this fall indicates that the HIV epidemic in Ethiopia is declining; rather, it is primarily a result of the reclassification of one sentinel site. The MOH estimates that 2.2 million Ethiopians were living with HIV/AIDS in 2001, of whom 2 million were adults. During the early stages of the HIV/AIDS epidemic, there was a major effort to conduct serosurveys in Addis Ababa and other major urban centers among core transmitter groups. However, post-1990, there are very few data to indicate the level or progression of the epidemic among sex workers and truck drivers, as well as traders/merchants and the military. The Ethiopian Red Cross Society-Blood Transfusion Service (ERCS-BTS) has been collecting and reporting HIV prevalence data among blood donors since 1987. There are indications that HIV prevalence among blood donors has decreased; however, it is difficult to determine whether this trend is an accurate measure or is due to increasingly effective prescreening procedures in the transfusion services. Data indicate that heterosexual and MTCT transmission account for almost all HIV infections in the country. The few data available have not found an association between harmful traditional practices and acquisition of HIV. HIV transmission via unsafe injections appears to be very low. AIDS case reporting began soon after the establishment of the HIV/AIDS department within the MOH in 1987. AIDS cases are grossly underreported. Among women, AIDS cases peak between ages 20 and 29; for men, between ages 25 to 34. According to ANC data, the group with the highest HIV prevalence in the country is women ages 15 to 24. Data from blood donors, visa applicants, and police and army recruits indicate that HIV prevalence among men peaks between ages 25 and 29. This is likely related to age mixing, wherein young women have older male sex partners, primarily for economic reasons. It appears that the HIV/AIDS epidemic in most of urban Ethiopia began in the mid-1980s, plateauing in the mid-1990s and stabilizing thereafter. In rural Ethiopia, the epidemic began in the early 1990s. It is now progressing rapidly and is likely only in its early stages. Data are highly inadequate to capture the epidemic's dynamics in rural areas. There have been major gaps and variances in Ethiopia's HSS data collection, thus impeding trend analysis. The representativeness of ANC attendees has been questioned. There are also concerns regarding the validity of reported HSS results, with indications that the quality of HSS is low and laboratory quality control measures inadequate. Political Economy and Sociobehavioral Context The relationship between HIV prevalence and socioeconomic factors is highly complex. Increasingly, risk of HIV infection is recognized as related to, inter alia, one's socioeconomic status as well as the socioeconomic profile of the community in which one is situated. Additionally, Ethiopia's political history, civil war, conflicts with Eritrea, and current food crisis also affect HIV/AIDS dynamics. Ethiopia is one of the world's oldest continuous civilizations and one of the few in Africa that was never colonized. It is also one of the world's poorest countries, with a 2000 per capita income of US$100. Ethiopia's population, estimated at 68 million in mid-2002, is the second largest in sub-Saharan Africa and is projected to continue to grow by over 2 percent annually through 2025. Ethiopia's population is young and ethnically diverse. Ethiopia's political past has been marked by Italian occupation (1936-41), the removal of the Emperor Haile Selassie in 1974, and a Marxist military government that was in power from 1974-91. Civil war led to the overthrow of the Marxist regime and establishment of a transitional government in 1991. In 1994, Ethiopia held elections for a constituent assembly and adopted a new constitution. The present government t has promoted a policy of ethnic federalism, devolving significant powers to regional, ethnically based authorities. Although Ethiopians enjoy greater political participation, some fundamental freedoms, including freedom of the press, are limited. In 1993, Eritrea became independent. In 1998, an Ethiopian-Eritrean border conflict erupted into a full-scale war. After nearly two years of fighting, Eritrea and Ethiopia signed a comprehensive peace agreement. However, tensions between them remain high, and there are fears that the peace accord will be broken. Ethiopia's mobile populations include the rapidly increasing number of rural residents seeking employment in urban areas; military personnel; those displaced by war, drought, and/or environmental degradation; male transport workers; sex workers; émigrés; traders; orphans and vulnerable children; humanitarian and relief workers; and prisoners. During the 1990s, the government embarked on a program of structural reform. GDP growth rose during the 1990s, and the country has begun to attract much-needed foreign investment. However, per capita income in Ethiopia fell during the decade. Public expenditure on health increased only slightly, from 0.9 of GDP in 1990 to 1.2 percent of GDP in 1998. (As a percent of GDP, military spending in Ethiopia is almost eight times greater than public spending on health.) Several major health indicators either fell or stagnated during the decade. The scope of poverty in the country remains enormous. About 16 percent of Ethiopians are facing starvation. The current food crisis is on a par with (or may even exceed) that of the 1984-85 famine. Unlike in southern Africa, HIV/AIDS is not a major factor underlying the Ethiopian food crisis. However, the search for food and migration to food aid distribution points does spur population dislocation, which may be accompanied by regroupings of family units and exposure to new sexual networks. Malnutrition (already high in Ethiopia) is increasing and further weakening the immune systems of PWHA. Famine is likely to raise the opportunity cost of sending children to school. Girls, in particular, are affected. Lack of food, coupled with a subsequent breakdown in family structure, may place more children on the streets where they may be at higher risk of mistreatment, sexual exploitation, and physical and emotional abuse. Ethiopia's health expenditure per capita (both public and private) was less than US$5 during the 1990s. The health system in Ethiopia is severely underdeveloped. Transport constraints are severe. Ethiopians' general health status is poor both in absolute terms and in comparison with other African countries. A major concern is that as the central government reduces its role in health care delivery, with decentralization and privatization to fill the gap, safety nets for the poor (especially those in rural areas and women) may be threatened. There are no accurate serial prevalence data on STIs in Ethiopia. Several recent studies indicate that prevalence of herpes simplex virus type 2 (HSV-2) is high and may be fueling the HIV/AIDS epidemic. Gender disparities in enrolment ratios and educational attainment levels are high. The country's high maternal mortality ratio is also an indication not only of poor reproductive health, but of women's low status and poor access to basic health services. Many Ethiopian women have little power in sexual negotiation with their husbands. Almost 14 percent of currently married women in Ethiopia are in a polygynous union. About 80 percent of have been circumcised. Poverty and unemployment are leading to a dramatic increase in the trafficking of Ethiopian women. Other issues that render Ethiopian women vulnerable to HIV include rape, abduction, and early marriage. Knowledge of HIV/AIDS is high among Ethiopians. However, as is the case in many countries, women are less likely than men to have heard of HIV/AIDS. Women are also much less knowledgeable than men about programmatically important ways to avoid contracting HIV. HIV/AIDS-related stigma is high. There is an acute need for data on sexual behavior trends in Ethiopia. During 2001-02, Ethiopia undertook its first behavioral surveillance survey, involving over 30,000 respondents (official findings have not yet been released). Generally, condom use in Ethiopia is low. Recreational drug consumption is increasing, including among street children. Impact There are few data on the impact of HIV/AIDS in Ethiopia. AIDS is now recognized as the leading cause of adult morbidity and mortality in the country. Ethiopia's population will be up to 16 percent smaller than it would have been in a "no-AIDS" scenario. AIDS will reduce life expectancy by 9 to 13 percent through 2050. AIDS has already increased the number of deaths in Ethiopia by 6 percent. Between 2000 and 2015, it will increase the number of deaths in Ethiopia by 27 percent. By the end of 2002, 1.7 million Ethiopians had died because of AIDS. By 2014, there will be a cumulative total of 5.3 million AIDS deaths. There have been almost no studies of the impact of the epidemic on loss of skilled or unskilled labor, lost productivity because of illness or funeral attendance, or increased health care costs. The impact of AIDS on the rural economy is unknown. Currently, up to 42 percent of all hospital beds in the country are estimated to be occupied by AIDS patients. Ethiopia has the sixth-highest number of TB cases in the world. About 42 percent of adult (15-49) TB cases were HIV-positive during 2000. There are no reports on the impact of AIDS on Ethiopian households, particularly its effect on the extended family system. Given deep and persistent poverty in Ethiopia, HIV/AIDS will further strain coping mechanisms through its enormous and complex impact. At the end of 2001, there were 1.2 million AIDS orphans in Ethiopia. This number is projected to rise to 1.8 million by 2007 and to 2.5 million in 2014. There are insufficient social services for orphans, including health care, school fee subsidies, and shelter. Consequently, many become street children. Response In 1985 (before the first AIDS case had been officially diagnosed), the government of Ethiopia established a national HIV/AIDS task force. It issued the first AIDS control strategy at the end of 1985. In 1987, the government established an HIV/AIDS department within the Ministry of Health. The MOH developed a short-term plan in 1987 and medium-term plans in 1987 and 1992. As in many countries, these interventions were inadequate in scale; largely ineffective in implementation; lacked sufficient stakeholder involvement in planning and implementation, especially at the community level; were poorly or not at all coordinated and integrated across sectors and among service providers; and received relatively low priority within government, society in general, and in the international community, with a resultant low level of allocated financial and human resources. In 1989, the MOH drafted a four-point policy statement on AIDS prevention. The first draft of a national policy was created in 1991, though not approved until 1998. The National AIDS Prevention and Control Council was established in 2000 and is charged with implementing the Strategic Framework for the National Response to HIV/AIDS in Ethiopia for 2000-2004. The council, chaired by the president of Ethiopia and comprising members from government, NGOs, religious bodies, and civil society, has declared HIV/AIDS a national emergency. The Ministry of Education has yet to provide clear guidelines for a comprehensive HIV education curriculum. Despite that the agricultural and livestock sectors account for over 85 percent of the labor force, the Ministry of Agriculture is not actively involved in HIV prevention. Although Ethiopia began the HIV/AIDS policy process in 1989 ¾ far earlier than most other countries ¾ it took nine years to complete. Moreover, the process involved almost no participation by actors outside government. There was little high-level political involvement in HIV/AIDS during the 1990s. By 1999, however, President Negasso Gidada had become an active spokesman in the fight against HIV/AIDS. Current President Girma Woldegiorgis has also made high-profile statements about the epidemic. Ethiopia's response is constrained by extremely limited human, financial, technical, material, and management capacities. The country's health care infrastructure is massively underequipped to address HIV/AIDS, particularly outside Addis Ababa. The country's size and poor transport infrastructure are also key factors. Bureaucratic constraints are impeding the response. Although much more funding is required, building additional human capacity in the health sector, improving coordination, and using existing funds efficiently and effectively are paramount. That the HIV/AIDS program is so highly dependent on donors also raises concerns about its future sustainability. Responsibility for implementing HIV/AIDS interventions rests with regional and local entities. In the long term, this system is likely to enhance delivery of HIV/AIDS interventions. In the short term, however, it is expensive, requires large numbers of qualified staff to carry out programs at different levels of government, and renders coordination difficult. The National HIV/AIDS Policy states that PWHA "shall not be subject to special restrictions on employment, education, access to public facilities, or housing." However, there are no specific laws to enforce the policy. Although Ethiopia's 1994 Constitution outlaws discrimination of any form, it does not address HIV/AIDS-related discrimination. Existing laws are nondiscriminatory with regard to PWHA, but there is evidence of discriminatory practices in the workplace, health care facilities, schools, and housing. Enforcement of current laws (including the National Policy for Women) is paramount. The need for new legislation to specifically address HIV/AIDS must also be examined. Numerous donors fund HIV/AIDS activities in Ethiopia. The Global Fund to Fight AIDS, TB & Malaria has approved a grant of US$139.4 million to address HIV/AIDS in the country. Ethiopia was one of the first countries to receive funding from the World Bank's Multicountry HIV/AIDS Program for Africa (US$64.3 million). Given years of centralized power, civil society in Ethiopia remains weak and underdeveloped. Nevertheless, it has started mobilizing against HIV/AIDS. NGOs are largely concentrated in and around major cities. Two national and various local PWHA associations are providing an array of HIV/AIDS services. Some influential religious leaders appear to be publicly supporting action against HIV/AIDS (though not condom promotion and use), and faith-based organizations are providing HIV/AIDS services. Numerous NGOs and CBOs are providing support to AIDS orphans and other vulnerable children. Many Ethiopians with AIDS are likely to use traditional medicine to alleviate symptoms of OIs. The MOH has encouraged the involvement of traditional healers in AIDS care and a national committee comprising scientists and traditional healers has been formed. Only 50 clients received PMTCT services in Ethiopia during 2001. In 2002, national guidelines on PMTCT were released and a pilot PMTCT program initiated by the MOH. In 2002, the country had 23 VCT centers, at which 10,000 clients were seen. Almost all VCT services are located in Addis. There is a severe lack of trained HIV/AIDS counselors and concomitant high demand for VCT services. There are national guidelines on HIV/AIDS care and support. Some NGOs have been providing home-based care since 1992. However, there is great disparity with regard to resources between Addis and other regions of the country. Access to HIV/AIDS-related care and support services in Addis, other urban areas, and rural areas is deemed minimal. Although national guidelines on clinical management of HIV infection in adults and children have been in use for two years, they require updating. The Confederation of Ethiopian Trade Unions and the Addis Ababa Chamber of Commerce are beginning to design workplace interventions. The Ethiopian military is often cited as being at the forefront of HIV prevention. It has developed an extensive HIV/AIDS workplan. A major initiative under way is deploying demobilized soldiers as HBC providers. Epidemiology At a Glance The At a Glance section summarizes the more detailed data found below it. Background * The first HIV infections in Ethiopia were identified in 1984. In 1986, the first AIDS cases were reported. In September 1987, the government established an HIV/AIDS department within the Ministry of Health, and in 1988, an HIV surveillance system was established. In 1989, the Health Bureau of the Addis Ababa City Administration began HIV sentinel surveillance. * Currently, there are 37 HIV sentinel surveillance sites (31 urban, 6 rural), though only 34 report data to the MOH. * As the overwhelming majority of HSS sites are in urban areas, an enormous segment of the rural population remains uncovered by the current HIV sentinel surveillance system. Moreover, the six rural sites represent only two regions. This despite that 85 percent of the population lives in rural areas. Findings from ANC Data * Soon after detection of the first AIDS cases in 1986, high HIV prevalence was detected along Ethiopia's main trading routes. It increased rapidly during the 1990s. By 1989, HIV prevalence among the general adult population was estimated at 2.7 percent, increasing to 7.1 percent in 1997. * In 2000, analysis of the ANC data indicated that the national adult HIV prevalence was 7.3 percent. In 2001, this figure was 6.6 percent. However, the MOH does not believe that this fall indicates that the HIV epidemic in Ethiopia is declining; rather, it is primarily a result of the reclassification of one sentinel site. * The 2001 ANC data indicated that HIV prevalence among the adult urban population is 13.7 percent. Prevalence among adults in rural areas is estimated at 3.7 percent. However, the current HSS system in highly inadequate to measure the level of infection in rural areas. * The MOH estimates that 2.2 million Ethiopians were living with HIV/AIDS in 2001. Of them, 2 million were adults. HIV Prevalence among Core Populations, Blood Donors, and Visa Applicants * During the early stages of the HIV/AIDS epidemic in Ethiopia, there was a major effort to conduct serosurveys in Addis Ababa and other major urban centers among core transmitter groups. In 1990, prevalence among sex workers in five urban areas ranged from 36.4 to 55.0 percent. A 1989 survey among truck drivers and their assistants found HIV prevalence of 17.3 percent. * However, post-1990, there are very few data to indicate the level or progression of the epidemic among sex workers and truck drivers, as well as traders/merchants and the military. * The Ethiopian Red Cross Society-Blood Transfusion Service (ERCS-BTS) has been collecting and reporting HIV prevalence data among blood donors since 1987. * There are indications that HIV prevalence among blood donors has decreased; however, it is difficult to determine whether this trend is an accurate measure or is due to increasingly effective prescreening procedures in the transfusion services. * Addis Ababa Regional Health Bureau regularly collects, analyses, and reports HIV prevalence data among visa applicants, over 90 percent of whom are young women. HIV prevalence among visa applicants rose from 7.2 percent in 1993 to 9.1 percent in 1999. There are indications that reports on visa applicants underestimate prevalence by as much as 50 percent because of testing and reporting protocols. Transmission Patterns * Data indicate that heterosexual and MTCT transmission account for almost all HIV infections in the country. * The few data available have not found an association between harmful traditional practices and acquisition of HIV. * HIV transmission via unsafe injections appears to be very low. UNAIDS Estimates * At the end of 2001, UNAIDS estimates that there were 2.1 million Ethiopians living with HIV/AIDS (estimate range: 1.5 million to 2.7 million). There were 1.9 million HIV-positive adults, over half of whom (1.1 million, 57.9 percent) were women. * UNAIDS estimated that adult prevalence in 2001 was 6.4 percent. AIDS Cases * AIDS case reporting began soon after the establishment of the HIV/AIDS department within the MOH in 1987. * AIDS cases are grossly underreported. * Among women, AIDS cases peak between ages 20 and 29; for men, between ages 25 to 34. Age and Gender * Data from ANC surveys and from blood donors indicate that people below age 24 represent a major proportion of HIV infections among the general population. * According to ANC data, the group with the highest HIV prevalence in the country is women ages 15 to 24 (12.1 percent). * Data from blood donors, visa applicants, and police and army recruits indicate that HIV prevalence among men peaks between 25 and 29. This is likely related to age mixing, wherein young women have older male sex partners, primarily for economic reasons. * According to UNAIDS, HIV prevalence among women ages 15 to 24 was 5.65 to 9.99 percent at the end of 2001; among men in the same age group, the range was 3.17 to 5.62 percent. AIDS Mortality * AIDS is now recognized as the leading cause of adult morbidity and mortality in Ethiopia. * By 2000, 1.1 million Ethiopians had died because of AIDS. In 2001, UNAIDS estimated that were 160,000 adult and child AIDS deaths in the country. * According to the U.N. Population Division, AIDS has already increased the number of deaths in Ethiopia by 6 percent. It projects that by 2015, 5.2 million Ethiopians will have died because of AIDS; by 2050, this figure will reach 14.9 million. Progression of the HIV Epidemic * It appears that the HIV/AIDS epidemic in most of urban Ethiopia began in the mid-1980s, plateauing in the mid-1990s and stabilizing thereafter. * In rural Ethiopia, the epidemic began in the early 1990s. It is now progressing rapidly and is likely only in its early stages. Data are highly inadequate to capture the epidemic's dynamics in rural areas, where 85 percent of the population lives. * An analysis of five rounds of ANC surveys in Addis between 1995 and 2001 found that HIV prevalence among women ages 15-24 attending the inner city HSS sites declined from 24.2 to 15.1 percent. No change was observed for older age groups or in the outer city health centers, indicating stabilization of HIV prevalence. Although encouraging, these findings require validation using population-based and behavioral surveillance data. Data Quality Issues * There have been major gaps and variances in Ethiopia's HSS data collection, thus impeding trend analysis. * The representativeness of ANC attendees has been questioned because of reported discrepancies between results of population-based surveys and ANC-based surveillance systems in Addis Ababa. Subfertility of women with HIV may play a role. * There are also concerns regarding the validity of reported HSS results, with indications that the quality of HSS is low and laboratory quality control measures inadequate. HIV Sentinel Surveillance Background The first seven HIV infections in Ethiopia were identified in 1984. In 1986, the first AIDS cases were reported.1 In September 1987, the government established an HIV/AIDS department within the Ministry of Health and charged it with directing and coordinating the implementation of the AIDS control strategy.2 In 1988, the MOH established an HIV surveillance system. In 1989, the Health Bureau of the Addis Ababa City Administration began HIV sentinel surveillance (HSS).3 , 4 During 1992-93, national HIV sentinel surveillance based on women attending antenatal clinics (ANCs) was established in four urban sites in collaboration with the country's regional health bureaus: Addis Ababa, Metu, Bahir Dar, and Dire Dawa. These sites were subsequently discontinued. In Addis Ababa, ANC surveillance was reestablished in 1996. 5 In late 1998, an agreement was reached between regional health bureaus and the MOH to restart the ANC system in all regions, utilizing national guidelines released by the MOH in March 1999. These guidelines required that sites be selected on the basis of availability of functional laboratories, equipment, supplies, personnel, and adequate patient volume (250-400) over a 12-week period. This effectively excluded almost all rural areas and a significant number of urban areas. 6 Moreover, the actual number of HSS sites established was also limited. This is particularly of concern in a nation as large and diverse as Ethiopia, which has nine regional states, two urban administrations, 64 zones, and 550 districts (discussed in more depth in the following section). For large regional states such as Amhara and Oromiya, only two and four sites, respectively, were originally established. 7 (In 2001, these figures had increased to four and six, respectively.8) For the Southern Nations, Nationalities and Peoples Region (SNNPR), which includes 45 distinct and unique indigenous ethnic population groups spanning nine zones and five special districts, there are still only four HSS sites. 9 , 10 In 2000, 15 surveillance sites representing six regions reported their data to the MOH. In 2001, this figure increased to 34, of which 28 sites were urban and 6 rural (see figure 1). A total of 12,689 women ages 15 to 49 were surveyed in the 2001 HSS. 11 (Currently, there are 37 sentinel HIV surveillance sites [31 urban, 6 rural] in the country,12 though only 34 reported data to the MOH for the 2001 HSS.) As the overwhelming majority of HSS sites are in urban areas, an enormous segment of the rural population remains uncovered by the current HSS system.13 Moreover, the six rural sites represent only two regions (more detail below). This despite that 85 percent of the population lives in rural areas.14 Researchers from Addis Ababa University and the Ethio-Netherlands AIDS Research Project report that "Data from areas outside of Addis Ababa are patchy and incomplete."15 The HSS system is inadequate to capture the epidemic's dynamic in rural areas, compounded by a general scarcity of data on HIV/AIDS in rural areas. 16 (The MOH is planning to include more rural sites in future surveillance.17) Of all sites, only Addis Ababa participated in ANC surveys during all rounds except for 1998.18 The lack of ANC data from Addis in 1998 was due to difficulties in obtaining the required approval from the ethics committee of the Ethiopian Science and Technology Commission. In 1995, the Ethio-Netherlands AIDS Research Project (ENARP), based in the Ethiopia Health and Nutrition Research Institute (EHNRI), was established. Since 1995, it has been collaborating with the Health Bureau of the Addis Ababa City Administration to conduct HSS.19 , 20 Blood Donors The Ethiopian Red Cross Society-Blood Transfusion Service (ERCS-BTS) has been collecting and reporting HIV prevalence data among blood donors since 1987. Apart from Addis Ababa, there are nine regional blood transfusion centers spanning six regions. Four regional states (Afar, Somali, Gambella, and Benishangul-Gumuz) do not have such services. Regional transfusion services send their reports to the ERCS-BTS, although these reports have not as yet been sent to the MOH. Since 1989, serial prevalence data for the 10 blood transfusion centers have been available. In 1987, the ERCS-BTS instituted donor prescreening procedures.21 Ad Hoc Serosurveys Several ad hoc serosurveys among sex workers and other core groups in urban areas were undertaken between 1988 and 1990. These were followed by serosurveys among the general population in six rural sites during 1992-93. Samples collected in a citywide serosurvey in Addis Ababa were also utilized to report on the prevalence of HIV in the general population. A smaller survey among residents of a district in Addis Ababa was also completed in 1996. Subsequently, similar surveys were conducted among factory workers in Akaki and Wonji . There have been no reports of serosurveys based on random samples of the general population in rural areas since 1993. 22 Methodology HSS sites span ANCs located within hospitals and health centers. For health facilities to qualify as HSS sites, they must meet the following criteria: * sustainable antenatal services * access to a functional laboratory (ensuring adequacy of personnel, equipment, * and supplies) * adequate client volume for a required sample size (250 to 400) * regular blood drawing for other routine services * sustainable supply of rapid plasma reagin tests for syphilis screening * commitment of the regional and zonal and woreda health bureaus to coordinate and conduct HSS in a sustainable manner at specified intervals23 Ethiopia's HSS uses the unlinked, anonymous method recommended by WHO.24 Figure 1. HIV Sentinel Sites, 2001 Source: Ethiopian Ministry of Health, Disease Prevention and Control Department. AIDS in Ethiopia. 4th edition. Addis Ababa: October 2002 Ethiopia uses EPI-Info software to enter data and EpiModel to estimate prevalences. Prevalences are exported to the SPECTRUM Model, which includes DemProj (a population projection model) and AIM (AIDS Impact Model), both developed by the POLICY Project of The Futures Group International. The latter estimates the current and projected number of adults and children infected with HIV.25 Findings There are no data on HIV prevalence among the general adult population in the 1980s. A retrospective analysis of blood samples from outpatients and blood donors collected in 1982-83 found no HIV infections. Sera collected in 1984 from 167 patients with Bell's palsy showed the first two HIV infections reported in Ethiopia.26 After detection of the first AIDS cases in 1986, high HIV prevalence among truck drivers and sex workers along Ethiopia's main trading routes was found during the late 1980s and early 1990s. By 1989, HIV prevalence among the general adult population was estimated at 2.7 percent. Prevalence increased rapidly during the 1990s; by 1997, 7.1 percent of all adults were estimated to be HIV-positive (extrapolating from HSS data). 27 In 2000, analysis of ANC data indicated that national adult HIV prevalence was 7.3 percent. In 2001, this figure was 6.6 percent. Ethiopia's MOH notes that prior to 2001, Estie, a town in South Gondar Zone, was considered a rural sentinel site, on the assumption that a large share of its health center's ANC clients were from the surrounding countryside. However, this assumption was later proved false by a special expert group convened to analyze the 2001 data, which reclassified Estie as an urban site. In 2001, HIV prevalence at the Estie site was 10.7 percent. The reclassification of Estie led to a 2001 estimate of adult HIV prevalence of 6.6 percent and, according to the MOH, is the primary reason why the national adult HIV prevalence reported in 2001 is less than that reported in 2000. The MOH does not believe that this fall indicates that the HIV epidemic in Ethiopia is declining.28 (For further discussion, see the Data Quality Issues section below.) As shown in table 1, the highest HIV prevalence in Ethiopia found within the 2001 ANC survey was at the Bahir Dar health center site (23.4 percent) followed by Jigiga (19 percent) and Nazareth (18.7 percent). 29 The 2001 HIV prevalence for Addis Ababa was 15.6 percent. This figure represents average prevalence across the four sentinel sites located in the city (Teklehymanot, Kazanchis, Higher 23, and Gulele). The mean prevalence for the 24 urban areas other than Addis Ababa is 12.8 percent; the mean prevalence for all urban sentinel sites including Addis Ababa is 13.2 percent. Extrapolating these data for the total urban population indicated an urban prevalence rate of 13.7 percent. 30 Table 1. Percentage of Pregnant Women Testing HIV-Positive in 28 Urban Sentinel Surveillance Sites, 2001 Source: Ethiopian Ministry of Health, Disease Prevention and Control Department. AIDS in Ethiopia. 4th edition. Addis Ababa: October 2002 As mentioned, data on rural prevalence were collected from only six sites for the 2001 round (table 2). Of them, one was located in SNNP Region and five in the Oromiya Region. Omitting Estie, the mean prevalence of the six rural sites was 2.3 percent in 2001, a decline from 3.9 percent in 2000. However, the MOH cautions that these data might not represent a realistic picture of the rural situation. In seeking to corroborate these data, the MOH consulted data on HIV prevalence among 64,000 army recruits ages 18 and 25 from rural areas spanning the country. The estimated HIV prevalence for this group was 3.8 percent. MOH extrapolated the data from the rural ANC sites and the army recruits survey onto the total rural population using EpiModel, from which it estimated that HIV prevalence among adults in rural areas is 3.7 percent. 31 Table 2. Percentage of Pregnant Women Testing HIV-Positive at Rural Sentinel Surveillance Sites, 2001 Source: Ethiopian Ministry of Health, Disease Prevention and Control Department. AIDS in Ethiopia. 4th edition. Addis Ababa: October 2002 Using the above data, MOH estimates that 2.2 million Ethiopians were living with HIV/AIDS in 2001. Of them, 2 million were adults. 32 HIV Prevalence among Core Populations, Blood Donors, and Visa Applicants During the early stages of the HIV/AIDS epidemic in Ethiopia, there was a major effort to conduct serosurveys in Addis Ababa and other major urban centers among core transmitter groups. In 1988, HIV prevalence among sex workers in Addis (n=2,617) was 24.7 percent. In 18 other urban areas, it ranged from 5.3 to 38.1 percent. In 1989, surveys conducted in six urban areas (excluding Addis) found prevalences of 12.1 to 49.1 percent. In 1990, a survey found prevalence among sex workers in Addis at 54.3 percent; in four other urban areas, it ranged from 36.4 to 55.0 percent. Surveys among truck drivers and their assistants found HIV prevalence of 13.0 percent in 1988 (n=677) and 17.3 percent in 1989 (n=391). 33 However, post-1990, there are very few data to indicate the level or progression of the epidemic among sex workers and truck drivers, as well as traders/merchants and the military. In 1998, researchers from the Department of Community Health at Addis Ababa University undertook a survey among 372 sex workers attending two health centers in Addis Ababa. They found that HIV prevalence was 73.4 percent. Several factors were significantly associated with an increased risk of being HIV-infected (among others, working in "shared rooms," high number of clients, use of injectable contraceptives, and positive TPPA serology), and others with a decreased risk (being born in Addis Ababa, high level of education, peer education on sex work, condom use, use of oral contraceptive, and use of condoms for contraception). Sex workers who were using condoms for contraception were, compared with others, more likely to use condoms consistently (65 versus 24 percent, respectively; p < 0.001), and less likely to be HIV-infected (55 versus 86 percent, respectively; p < 0.001). In multivariate analysis, being born in Addis Ababa (PR = 0.74; 95% CI, 0.61-0.91), using condoms for contraception (PR = 0.73; 95% CI, 0.64-0.85), and a positive TPPA serology (PR = 1.21; 95% CI, 1.09-1.36) remained significantly associated with HIV infection.34 However, as the researchers caution, survey participants were selected from women attending two health centers for STI-related symptoms; therefore, self-selection of the participants may not fully represent the general population of sex workers in the city. 35 In Addis Ababa, prevalence among blood donors rose from 2.3 percent in 1987 to 9.0 percent in 1995, falling to 6.4 percent in 1999. In Dire Dawa, prevalence fell from 14.9 percent in 1992 to 6.5 percent in 1998. Similar declines during the 1990s were found in Arba Minch, Dessie, and Mekele. During the decade, prevalence fluctuated in Harar, Jimma, Yirgalem, and Gondar but remained fairly unchanged between 1990 and 1999. Despite indications that HIV prevalence among blood donors has decreased, it is difficult to determine whether this trend is an accurate measure or is due to increasingly effective prescreening procedures in the transfusion services, as researchers from Addis Ababa University and the Ethio-Netherlands AIDS Research Project stress.36 Another self-selected group of individuals for whom data on HIV prevalence are available is adult visa applicants. Addis Ababa Regional Health Bureau regularly collects, analyses, and reports HIV prevalence data among visa applicants. Reporting of prevalence data disaggregated by age and sex began in July 1997, indicating that over 90 percent of visa applicants are young women, most of whom apply to immigrate to Middle Eastern countries for employment as domestic workers. Data on residence have not been made available, although most applicants are likely from Addis Ababa. HIV prevalence among visa applicants rose from 7.2 percent in 1993 (n=3,222) to 9.1 percent in 1999 (n=10,930). There are indications that the prevalence reports from visa applicants are underestimated by as much as 50 percent because of testing and reporting protocols. Applicants who test positive on the first HIV test are requested to appear for another test. Only about one-third do so. Reports to the MOH, however, are based on confirmed test results (thus disregarding the first test results). Therefore, prevalence estimates are underestimated.37 Transmission Patterns Data indicate that heterosexual and MTCT transmission account for almost all HIV infections in the country.38 There are, however, no data to describe the magnitude of MTCT in Ethiopia. 39 There are few data on harmful traditional practices and the risk of HIV infection in Ethiopia. Harmful traditional practices include female genital mutilation (discussed below) and procedures, particularly in rural areas, that involve cutting the skin to permit bleeding as a purification/healing process, with the potential for reuse of blades and razors. An association between these practices and acquisition of HIV has not been found.40 , 41 There are also few data on unsafe medical practices and the risk of acquiring HIV infection. The MOH reports that most blood is screened for HIV and that only a small number of new infections are due to contaminated blood transfusions.42 Injections are patients' preferred method of receiving medicines, and they are administered by trained and untrained persons, with the potential for reuse of needles and syringes; however, the MOH reports that HIV transmission via unsafe injections is minor.43 The Ethio-Netherlands AIDS Research Project has examined the association between some medical practices and the risk of HIV infection but did not find any significant association. 44 , 45 UNAIDS Estimates At the end of 2001, UNAIDS estimates that there were 2.1 million Ethiopians living with HIV/AIDS (estimate range: 1.5 million to 2.7 million). There were 1.9 million HIV-positive adults, over half of whom (1.1 million, 57.9 percent) were women. UNAIDS estimated that adult prevalence was 6.4 percent. (See the discussion above and in the Data Quality section below concerning caveats regarding prevalence figures.) The number of people living with HIV/AIDS in Ethiopia was the sixth-highest in the world, following South Africa, India, Nigeria, Kenya, and Zimbabwe.46 AIDS Cases Surveillance reports based on AIDS case reporting began soon after the establishment of the HIV/AIDS department within the MOH in 1987.47 Since 1984, a cumulative total of 107,575 AIDS cases have been reported to the MOH. In 2001, there were 15,202 AIDS cases reported to the MOH; however, the MOH estimates that the actual number of new AIDS cases in 2001 was 219,400. Reasons for underreporting include: * The current reporting system is inefficient. * Delayed reports by regions are common. * Most Ethiopians never seek medical care for AIDS. * Some people with AIDS may die of other diseases before they are diagnosed as having AIDS. * Most rural hospitals and district health care facilities are unable to test for HIV. * Most private laboratories do not provide data to the MOH. * Most AIDS diagnoses are presumptive, not definitive. * There is a lack of laboratory facilities and of trained lab personnel (see below). 48 , 49 , 50 Among women, AIDS cases peak between ages 20 and 29; for men, between ages 25 to 34. 51 This is likely related to age mixing, wherein young women have older male sex partners, primarily for economic reasons.52 The median incubation period for Ethiopians is over eight years. The Ethio-Netherlands AIDS Research Project has recently found that the median incubation period is 10 years with survival.53 Age and Gender According to ANC data, the highest number of HIV-infected persons is found in the age groups 20-24 and 25-29. However, the group with the highest HIV prevalence in the country is women ages 15 to 24 (12.1 percent). (Data from blood donors, visa applicants, and police and army recruits indicate that HIV prevalence among men peaks between 25 and 29.54) Moreover, the number of women with HIV ages 15 to 19 is much higher than the number of males in the same age group. It also appears that in this age cohort, there are more women who have had sexual intercourse than there are men. Ethiopia's 2000 Demographic and Health Survey found that 69.3 percent of women ages 15-19 report never having had intercourse; among men in this age group, 84.6 percent report never having had intercourse. 55 (The 2000 Ethiopia Demographic and Health Survey is the first nationally representative sample survey on population and health. It was conducted between February and May 2000 and included 15,367 women ages 15-49 and 2,607 men ages 15-59. It was implemented by the Central Statistical Authority under the aegis of the MOH. Macro International Inc. provided technical assistance through its MEASURE EDHS+ Project. The survey was principally funded by the Essential Services for Health in Ethiopia Project through USAID; additional funding was provided by UNFPA.) According to UNAIDS, HIV prevalence among women ages 15 to 24 was 5.65 to 9.99 percent at the end of 2001; among men in the same age group, the range was 3.17 to 5.62 percent. 56 Data from ANC surveys and from blood donors indicate that young people (below age 24) represent a major proportion of HIV infections among the general population. 57 AIDS Mortality AIDS is now recognized as the leading cause of adult morbidity and mortality in Ethiopia. 58 The MOH projects that by 2004, AIDS may account for about 460 deaths each day among 15- to 49-year-olds. 59 According to the U.N. Population Division, AIDS has already increased the number of deaths in Ethiopia by 6 percent. By 2000, 1.1 million Ethiopians had died because of AIDS. 60 In 2001, UNAIDS estimated that were 160,000 adult and child AIDS deaths in Ethiopia.61 Ethiopia's MOH estimates that by the end of 2002, 1.7 million Ethiopians had died because of AIDS. It projects that by 2014, there will be an additional 3.6 million deaths because of AIDS, bringing the cumulative total to about 5.3 million by 2014. 62 This projection is about equal to those of the U.N. Population Division, which projects 5.2 million cumulative AIDS deaths through 2015. The UN projects that by 2050, 14.9 million Ethiopians will have died because of the epidemic. 63 (See Impact section for more detailed discussion.) Prevalence Projections In February 2003, the U.N. Population Division estimated that Ethiopia's HIV adult prevalence had already peaked, at 6.5 percent in 2000, and that prevalence would fall to 2.8 percent by 2050.64 (A September 2002 report by the U.S. National Intelligence Council estimated that the current number of Ethiopians living with HIV/AIDS is between 3 and 5 million. It projects that this range will rise to 7 to 10 million by 2010 and that adult prevalence will be between 19 and 27 percent. The NIC report was widely quoted in the popular press; however, the report did state that its projections entailed a "relatively high margin of error." 65) Progression of the HIV Epidemic The data currently available indicate that the HIV/AIDS epidemic has affected a large segment of the urban population. However, currently available data are extremely inadequate to measure the level of infection in the rural population, where 85 percent of Ethiopians live.66 According to a recent review undertaken by the Ethio-Netherlands AIDS Research Project of the Ethiopian Health and Nutrition Research Institute, the progression of HIV/AIDS in the country indicates that the epidemic in most of urban Ethiopia began in the mid-1980s, plateauing in the mid-1990s and stabilizing thereafter. In rural Ethiopia, however, the epidemic began in the early 1990s. It is now progressing rapidly and is likely only in its early stages.67 Apart from the paucity of rural HSS data, a brief analysis of ANC data for rural sites suggests that there may have been problems in ANC data collection or analysis in some of these sites. For example, in Attat, ANC prevalence was 0.8 percent in 1998, 4.0 percent in 1999-2000, and 1.5 percent in 2001, leading one to infer that data collection and/or analysis in one or more of these rounds might have been flawed. In Gambo Oromiya, prevalence rose from 0.7 percent in 1999-2000 to 1.1 percent in 2001. Data for the other rural sites (Aira Oromiya, Borena Dadim Oromiya, Borena Gosa Oromiya, and Ambo-Toke Oromiya) were not collected pre-2001. 68 Thus, trend analysis across HSS sites is constrained by major data gaps. The most consistent HSS data are for Addis Ababa, where four health centers are involved in ANC surveys. The two outer city health centers, Gulele and Higher 23, became HSS sites after 1996. The inner city health centers (Kazanchis and Teklehymanot) have traditionally had higher HIV prevalences compared to the outer city health centers. 69 In 1989, HIV prevalence at the two inner city health centers was 4.6 percent, rising to 11.2 percent in 1992-93, and to 21.2 percent in 1995.70 The Ethio-Netherlands AIDS Research Project analyzed the five rounds of HSS conducted in Addis between 1995 and 2001. It found that during this period, HIV prevalence among women ages 15-24 attending the inner city HSS sites declined from 24.2 to 15.1 percent (prevalence ratio for an increase in one calendar year, 0.91; 95% confidence interval, 0.87-0.95). No change was observed for older age groups or in the outer city health centers, indicating stabilization of HIV prevalence. The decline in the prevalence of active syphilis was more pronounced among and also restricted to the 15-24 age group in the inner city (from 7.6 percent in 1995 to 1.3 percent in 2001; prevalence ratio, 0.69; 95% confidence interval, 0.59-0.80). The researchers noted that although declining trends in HIV (and syphilis) prevalence among those 15-24 attending ANCs in the inner city are encouraging, these findings require validation using population-based and behavioral surveillance data.71 Further, such declines have not been observed in other urban sites (although, again, trend analysis is constrained). For example, in 1999-2000, HIV prevalence at the Bahir Dar health center site was 20.8 percent; in 2001, it reached 23.4 percent, the highest prevalence recorded at any HSS site in the country. (Data for Jigiga and Nazareth, which had the second and third, respectively, highest prevalences in the country in 2001, were not collected pre-2001.) Dire Dawa health center registered an HIV prevalence of 12.3 percent during 1992-93, rising to 13.6 percent in 1999-2000 and 15.2 percent in 2001. In Metu, prevalence was 10.7 percent in 1992-93; data were not collected again until 1999-2000, when prevalence was 4.0 percent; in 2001, it was 10.5 percent,72 leading one to infer that data collection and/or analysis in the 1999-2000 HSS round might have been flawed. Lower-prevalence urban sites, such as Awassa and Dilla (which did not participate in HSS in 1999-2000) have seen declines since 1998 (the first year for which data were collected in them). In Awassa, HIV prevalence declines from 14.4 percent in 1998 to 10.0 percent in 2001; for Dilla, the decline during this period was 14.5 to 9.8 percent.73 As discussed above, data from the 2001 HSS indicated a national adult HIV prevalence of 6.6 percent, a decline from 7.3 percent for 1999-2000. MOH was firm that this fall should not be interpreted to mean that the HIV/AIDS epidemic in Ethiopia is declining. It stresses that the 2001 HSS was more extensive and that the reclassification of Estie as an urban site played a major role. The MOH's caution is warranted, especially as trend analysis is so constrained by data gaps and inadequate rural data. Moreover, as the MOH observes, it must also determine how AIDS mortality is affecting prevalence.74 Data Quality Issues Currently available data are severely inadequate to measure the level of HIV infection in the general population, given scarce HSS data from rural areas, where 85 percent of Ethiopians live. Data on the level of infection in specific subgroups are also extremely insufficient, as are those related to trends; burden of disease; and the impact of preventive interventions in urban, rural, regional, and zonal areas. Accurate serial prevalence data on STIs are also lacking. 75 There have been major gaps and variances in Ethiopia's HSS data collection, thus impeding trend analysis.76ANC data currently serve as Ethiopia's primary sentinel surveillance of HIV/AIDS. Though ANC data are widely used, they are imperfect (see box 1). There have been reported discrepancies between results of population-based surveys and ANC-based surveillance systems in Addis Ababa, thus calling into question how representative ANC attendees are of the general female population.77 One factor may be subfertility. Comparative studies have shown that the HIV prevalence among pregnant women in sub-Saharan Africa underestimates prevalence in Box 1. HIV Sentinel Surveillance: Evaluating Data from Antenatal Clinics In many developing countries, estimates on the magnitude of and trends in the HIV epidemic are obtained through HIV seroprevalence surveys. These surveys are primarily conducted using sentinel populations. The most frequently used sentinel populations are women attending antenatal clinics and persons attending clinics for diagnosis and treatment of sexually transmitted infections. The objectives of sentinel seroprevalence surveys include: 1. obtaining information on the prevalence of HIV infection in the sentinel population 2. monitoring trends in HIV prevalence in the sentinel population 3. providing information for estimating future number of AIDS cases 4. providing information for program planning and evaluation of interventions Seroprevalence surveys are usually conducted annually at preselected clinics or hospitals. Surveys of women attending antenatal clinics can provide a reasonable estimate of HIV prevalence within the general population. The surveys are conducted among women ages 15 to 49 years attending the antenatal clinic for the first time during a current pregnancy. Surveys are usually conducted in an unlinked manner, in which serum remaining from routine syphilis screening is tested for HIV infection after all personal identifying information is removed from the specimen. Sampling is usually conducted during an 8- to 12-week period, and all eligible women are sampled consecutively until the desired sample size is achieved. In general, samples of 250 and 400 women are usually sufficiently large as to provide reasonable estimates of HIV prevalence over time. Although these surveys are extremely useful, there are several limitations to consider when interpreting the survey results. The surveys are not based upon a probability sample and therefore may not be representative of the population as a whole. True population-based surveys have found antenatal clinic data may overestimate or underestimate HIV prevalence. Moreover, the ANC studies do not provide information on mortality or HIV-associated morbidity. In addition, although monitoring trends in HIV prevalence provide information on the magnitude of the HIV epidemic, trends in prevalence cannot be relied upon to indicate trends in HIV incidence. However, examining trends in HIV prevalence in younger populations, particularly 15- to 19-year-olds, may provide some indication of trends in recently acquired HIV infection , as this group is unlikely to have been infected for a long period of time. Prepared by Sandy Schwarcz, MD, MPH Director, HIV/AIDS Statistics and Epidemiology Section, San Francisco Department of Public Health Adjunct Assistant Professor, Department of Epidemiology and Biostatistics, University of California San Francisco women of reproductive age because fertility among HIV-positive women is substantially lower than among uninfected women. 78 For example, Gregson et al. have found 25 to 40 percent lower fertility in women with HIV in high-prevalence African countries; they attribute about half of this "subfertility" directly to HIV infection.79 Another issue is laboratory quality control and reliability of HIV testing. Researchers from Addis Ababa University and the Ethio-Netherlands AIDS Research Project stress that outside Addis Ababa, where HSS is operational, systems are not fully supported by quality control. Thus, there are concerns regarding the validity of reported results. There are anecdotal indications that the quality of HIV surveillance data is low. There have been examples of reports submitted to the MOH with grossly inaccurate prevalence estimates calculated from raw data.80 A study presented at the XIV International AIDS Conference in Barcelona in July 2002 examined syphilis serodiagnosis, but the lessons may have import for HIV testing as well. The researchers, part of the Ethio-Netherlands AIDS Research Project, found a high false positivity rate, with shortcomings in quality control for data registration and tube handling, concluding that "the interpretation of specific serological tests remains a challenge for both clinician and microbiologist."81 (Recently, the MOH and regional health bureaus have licensed several private, commercial clinics and laboratories to undertake HIV testing (and counseling). In addition, the National HIV/AIDS Referral Laboratory at the Ethiopian Health and Nutrition Research Institute and regional public laboratories conduct HIV testing. Periodic reporting by these public and commercial labs is required, although most commercial labs do not do so.82 , 83) Poverty, conflict, drought, and famine may be affecting the population that attends ANCs. For example, these phenomena spur population dislocation and affect household activity, as the search for food and/or migration to food aid distribution points take priority. There are currently no data on whether these phenomena have any relationship to the profile of women attending ANCs, but they may merit monitoring. Finally, Ethiopia is a highly diverse country, with over 80 ethnic groups.84 It comprises 18 distinct agroecological zones, ranging from mountains to deserts.85 Analysis of HIV prevalence in the context of regional characteristics, religion, ethnicity, and occupation is lacking (the major exceptions are the Ethio-Netherlands AIDS Research Project's longitudinal study of factory workers and a few small studies of sex workers). Studies of mobile populations are also generally lacking, as are those that examine HIV/AIDS in the context of chronic food insecurity. Despite that Ethiopia, according to UNAIDS, has the sixth-highest number of people living with HIV/AIDS in the world,86 only 48 abstracts of the 8,824 presented at the XIV International AIDS Conference in Barcelona in July 2002 contained the word Ethiopia. (By comparison: South Africa: 524 abstracts; India: 788; Nigeria: 158; Kenya: 257; Zimbabwe: 153). There were 130 abstracts with the word Tanzania (seventh-highest number of people with HIV/AIDS) and 139 for Zambia (eighth-highest number of people living with HIV/AIDS). Strengthening surveillance and filling research gaps are critical. Political Economy and Sociobehavioral Context At a Glance The At a Glance section summarizes the more detailed data found below it. Overview * Many of the factors discussed in this section exist in countries whose HIV prevalence is lower than that of Ethiopia; these include poverty, gender inequality, and chronic food insecurity. * The relationship between HIV prevalence and socioeconomic factors is highly complex. Increasingly, risk of HIV infection is recognized as related to, inter alia, one's socioeconomic status as well as the socioeconomic profile of the community in which one is situated. Additionally, Ethiopia's political history, civil war, conflicts with Eritrea, and current food crisis also affect HIV/AIDS dynamics. * This section does not seek to demonstrate causality; rather, it aims to analyze key political economy and sociobehavioral contextual elements to highlight the range of sectoral policies and interventions that may affect or be affected by HIV/AIDS. * Ethiopia is one of the world's oldest continuous civilizations and one of the few in Africa that was never colonized. It is also one of the world's poorest countries, with a 2000 per capita income of US$100. * Ethiopia's population, estimated at 68 million in mid-2002, is the second largest in sub-Saharan Africa and is projected to continue to grow by over 2 percent annually through 2025. * Ethiopia's population is young and diverse. Eighty-five percent of the population lives in rural areas. * Ethiopia's political past has been marked by Italian occupation (1936-41), the removal of the Emperor Haile Selassie in 1974, and a Marxist military government that was in power from 1974-91. * Civil war led to the overthrow of the Marxist regime and establishment of a transitional government in 1991. In 1994, Ethiopia held elections for a constituent assembly and adopted a new constitution. * The present government t has promoted a policy of ethnic federalism, devolving significant powers to regional, ethnically based authorities. * Although Ethiopians enjoy greater political participation, some fundamental freedoms, including freedom of the press, are limited. * In 1993, Eritrea became independent. In 1998, an Ethiopian-Eritrean border conflict erupted into a full-scale war. After nearly two years of fighting, Eritrea and Ethiopia signed a comprehensive peace agreement. However, tensions between them remain high, and there are fears that the peace accord will be broken. Population Mobility * Ethiopia's mobile populations include: ? The rapidly increasing number of rural residents seeking employment in urban areas ? military personnel, including international peacekeepers ? persons displaced by war, drought, and/or environmental degradation ? male transport workers ? sex workers ? migrant workers ? miners ? individuals leaving Ethiopia to live/work overseas ? merchants/traders/vendors ? orphans and vulnerable children (e.g., street children) ? humanitarian and relief workers ? prisoners Economy * The agricultural and livestock sectors account for over 85 percent of the labor force. Coffee represents about 70 percent of the country's foreign exchange earnings. * During the 1990s, the government embarked on a program of structural reform. GDP growth rose during the 1990s, and the country has begun to attract much-needed foreign investment. * However, per capita income in Ethiopia fell during the decade. Public expenditure on health increased only slightly, from 0.9 of GDP in 1990 to 1.2 percent of GDP in 1998. Several major health indicators either fell or stagnated during the decade. The scope of poverty in the country remains enormous. Poverty * At the end of the 1990s, 44 percent of the population lived below the national poverty line. In 1995, 31 percent of the population was living below US$1 a day and 76 percent below US$2 a day. * Repeated and frequent shocks (such as drought and war) have meant that household assets have been diminished if not depleted. Public Expenditure Trends * As a percent of GDP, military spending in Ethiopia is almost eight times greater than public spending on health. Debt * During the 1970s and 1980s, Ethiopia's servicing of its public and publicly guaranteed debt ranged from 4 to 17 percent of central government revenues. * In November 2001, Ethiopia qualified for debt relief under the Enhanced Heavily Indebted Poor Countries Initiative (HIPC). HIPC is not debt cancellation; rather it is a restructuring of debt repayment through provision of grants. Under HIPC, an estimated US$1.93 billion was committed to Ethiopia as total debt relief from all its creditors. * Several social justice NGOs have calculated that Ethiopia will be paying almost as much in debt service payments under HIPC as it was before HIPC. * They also express concerns that the assumptions underlying HIPC are unrealistic. Food Security * In March 2003, the World Food Program reported that 11 million Ethiopians (about 16 percent of the population) are currently targeted for food distribution between April and July 2003. An additional 3 million people are at risk of starvation. * The current food crisis is on a par with (or may even exceed) that of the 1984-85 famine. * Unlike in southern Africa, HIV/AIDS is not a major factor underlying the Ethiopian food crisis. However, the search for food and migration to food aid distribution points does spur population dislocation, which may be accompanied by regroupings of family units and exposure to new sexual networks. Malnutrition (already high in Ethiopia) is increasing and further weakening the immune systems of PWHA, thereby contributing to higher rates of morbidity and mortality. * Famine is likely to raise the opportunity cost of sending children to school. Girls, in particular, are affected. * Lack of food, coupled with a subsequent breakdown in family structure, may place more children on the streets where they may be at higher risk of mistreatment, sexual exploitation, and physical and emotional abuse. Women and girls may undertake sex work to survive. They may also offer sex to workers involved in transporting and distributing food aid to try and obtain preferential treatment in the distribution of supplies and services. Human Development * Ethiopia ranks 168 out of the 173 countries for which UNDP has calculated a human development index value. * Although Ethiopia's child and infant mortality rates have fallen over the last 30 years, they remain extremely high. Maternal mortality is also high. Health * Ethiopia's health expenditure per capita (both public and private) was less than US$5 during the 1990s. * The health system in Ethiopia is severely underdeveloped. Transport constraints are severe. * Given low incomes, low levels of education, poor access to health services, and a highly uneven distribution of health facilities favoring urban areas, Ethiopians' general health status is poor both in absolute terms and in comparison with other African countries. * A major concern is that as the central government reduces its role in health care delivery, with decentralization and privatization to fill the gap, safety nets for the poor (especially those in rural areas and women) may be threatened. Sexual & Reproductive Health * UNFPA ranks Ethiopia a category "A" country, meaning that it is furthest from achieving the sexual and reproductive health and rights goals of the 1994 International Conference on Population and Development held in Cairo. * Ethiopia's MMR is extremely high, as are fertility levels. Childbearing begins early. * Awareness of contraception is high; however, current use of modern contraceptive methods is only 6 percent. There is high unmet need for family planning. * The incidence of unsafe abortions is high and constitutes a major cause of maternal morbidity and mortality. * A key issue is delivering sexual & reproductive health information and services to young people, including those who are unmarried. This is particularly crucial as there has been an increase in the percentage of never-married women over the last 10 years. Sexually Transmitted Infections * There are no accurate serial prevalence data on STIs in Ethiopia. * Several recent studies indicate that prevalence of herpes simplex virus type 2 (HSV-2) is high and may be fueling the HIV/AIDS epidemic. Gender * UNDP ranks Ethiopia 142 out of 146 countries on its Gender-related Development Index. * Although the constitution of 1994 guarantees gender equality and permits affirmative action, implementation of the National Policy for Women is hindered by varying degrees of commitment across regions. * Gender disparities in enrolment ratios and educational attainment levels are high. The country's high MMR is also an indication not only of poor reproductive health, but of women's low status and poor access to basic health services. * Many Ethiopian women have little power in sexual negotiation with their husbands. * Almost 14 percent of currently married women in Ethiopia are in a polygynous union. * Female circumcision is widespread in Ethiopia: 80 percent of all women have been circumcised. * There is also widespread support for female circumcision among Ethiopian women. * Poverty and unemployment are leading to a dramatic increase in the trafficking of Ethiopian women. * Other issues that render Ethiopian women vulnerable to HIV include rape, abduction, and early marriage. Knowledge of HIV/AIDS * Knowledge of HIV/AIDS is high among Ethiopians. However, as is the case in many countries, women are less likely than men to have heard of HIV/AIDS. * In some regions, the majority of women do not believe that HIV can be avoided. * Women are much less knowledgeable than men about programmatically important ways to avoid contracting HIV. * About 63 percent of women do not believe that a healthy looking person can have HIV/AIDS; among men, this figure is 45 percent. * Another major knowledge gap is mother-to-child transmission of HIV. Only 58 percent of women (and 72 percent of men) know that HIV can be transmitted from mother to child. * Of those who have heard of HIV/AIDS, 26 percent of women and 48 percent of men currently married or living with a partner have discussed HIV prevention with their spouse or partner. Stigma * Among those who have heard of AIDS, nearly twice as many women as men believe that the HIV positive status of a family member should remain a secret. * About 45 percent of women and 50 percent of men report that they are willing to care for relatives with HIV in their house. * Concerns about casual transmission ¾ despite knowledge ¾ persist. In a recent study, 61 percent of respondents reported that although they know that HIV is not transmitted casually, they would not buy food from a vendor with HIV. Many would separate utensils, linens, and other household items used by PWHA from those used by other household members. * Much of the stigmatizing language and description of stigmatizing and discriminatory behavior centers on the sexual transmission of HIV. The belief that HIV is a divine punishment for sins committed is particularly strong. Nevertheless, many community members feel that PWHA deserve sympathy or support. * Some stigmatizing behavior is caused by limited resources and fatigue. Although family and community members provide care, they often regard PWHA as a burden. Those who provide care to PWHA are often themselves stigmatized. Sexual Behavior * There is an acute need for data on sexual behavior trends in Ethiopia. * Between December 2001 and June 2002, Ethiopia undertook its first behavioral surveillance survey, involving over 30,000 respondents in rural and urban areas in every region of the country, including in- and out-of-school youth, female sex workers, military personnel, farmers and pastoralists, long-distance drivers, and factory workers. Official findings have not yet been released. * According to the 2000 EDHS, the median age at first intercourse for women ages 20-49 is 16.4 years and the median age at first marriage 16.0. * The median age at first sexual intercourse among men is 20.3 years, three years lower than their median age at first marriage (23.3 years). * Among those unmarried, 13 percent of women and 22 percent of men reported sexual intercourse in the last year. * Among women, AIDS cases peak between ages 20 and 29; for men, between ages 25 to 34. This is likely related to age mixing, wherein young women have older male sex partners, primarily for economic reasons. * There are no data on transactional sex in Ethiopia. Poverty, conflict, drought, and famine may increases instances in which sex is traded for food or other necessities. Condoms * According to the 2000 EDHS, only 35 percent of all women know about condoms; the comparable figure for men is 68 percent. * Only 12 percent of women know a source for condoms and only 11 percent report that they could obtain condoms for themselves. The rural-urban differential is very wide: 7 percent vs. 37 percent on source and 6 percent vs. 34 percent on ability to obtain. * Generally, condom use in Ethiopia is low, although the BSS appears to have found that it is high among sex workers. According to the 2000 EDHS, the use of condoms during last sexual intercourse with a spouse or cohabiting partner was negligible among both women and men. With a noncohabiting partner, 13 percent of women and 30 percent of men reported condom use at last intercourse. Sex Work * Several HIV serosurveys among sex workers have been conducted since the beginning of the epidemic. The most recent, a 1998 study of 372 sex workers in Addis Ababa, found that most SWs were from the city's slums and that about 35 percent lived in "shared rooms," renting a small room in which three to five women live. These SWs must give about half their income to the owner of the room. * Family Health International notes that estimates of the number of sex workers in Addis Ababa range from a few thousand to 150,000. There is an acute lack of data on sex worker networks. Alcohol and Drug Use * Recreational drug consumption in Ethiopia is increasing, including among street children in Addis Ababa and in the city's slum areas. * Although there are no data on drug abuse and the Ethiopian-Eritrean conflict, the U.N. does highlight that armed conflicts throughout the world have led to rapid spread of drug control problems in affected zones. Male Circumcision * There are no data on male circumcision in Ethiopia. Some observational studies from sub-Saharan Africa have indicated that male circumcision may reduce the risk of HIV acquisition, though circumcision does not appear to affect transmission from HIV-positive men to their partners. Many of the factors discussed in this section exist in countries whose HIV prevalence is lower than that of Ethiopia; these include poverty, gender inequality, and chronic food insecurity. The relationship between HIV prevalence and socioeconomic factors is highly complex. Increasingly, risk of HIV infection is recognized as related to, inter alia, one's socioeconomic status as well as the socioeconomic profile of the community in which one is situated. Additionally, Ethiopia's political history, civil war, conflicts with Eritrea, and current food crisis also affect HIV/AIDS dynamics. This section does not seek to demonstrate causality; rather, it aims to analyze key political economy and sociobehavioral contextual elements to highlight the range of sectoral policies and interventions that may affect or be affected by HIV/AIDS. Country Overview Ethiopia is one of the world's oldest continuous civilizations and one of the few in Africa that was never colonized (though it was occupied).87 It is also one of the world's poorest countries, with per capita income of US$100. 88 The depth and breadth of poverty are enormous. Ethiopia's population, estimated at 67.7 in mid-2002, 89 is the second largest in sub-Saharan Africa (following Nigeria) and is projected to continue to grow by over 2 percent annually through 2025. 90 Ethiopia's population is young, with 44 percent under age 15.91 In 2000, the median age of the population was 16.9.92 Eighty-five percent of the population lives in rural areas.93 Ethiopia comprises 18 distinct agroecological zones, ranging from mountains to deserts. 94 There are wide disparities in demographic and socioeconomic indicators between urban and rural areas, as well as among the nation's nine regional states, Addis Ababa City Administration, Dire Dawa Administrative Council, 64 zones, 550 districts (woredas), and over 1,000 community-level associations (kebeles). There are over 80 ethnic groups in Ethiopia; the major ones are Oromo (35 percent), Amhara (30 percent), Tigre (6 to 8 percent), and Somali (6 percent).95 Christianity and Islam are the main religions: 51 percent of the population is Orthodox Christian, 33 percent Muslim, and 10 percent Protestant.96 Generally, most Christians live in the highlands, whereas Muslims and adherents of traditional African religions tend to inhabit lowland regions. Amharic is the official language; Tigrinya, Oromifa, and Somali are also used. English is the most widely spoken foreign language.97 In 1936, the reign of Emperor Haile Selassie ¾ the last emperor of a dynasty claiming descent from the biblical Solomon ¾ was disrupted when Italian Fascist forces invaded and occupied Ethiopia. Haile Selassie was forced into exile in England. Five years later, the Italians were defeated by British and Ethiopian forces, and the emperor returned to the throne. 98 After a period of civil unrest that began in February 1974, Haile Selassie was deposed in September 1974, and a provisional administrative council of soldiers, known as the Derg (committee) seized power and installed a Marxist military government headed by Lt. Colonel Mengistu Haile Mariam.99 , 100 Mengistu's years in office were marked by totalitarian government and massive militarization, financed by the Soviet Union and the Eastern Bloc and assisted by Cuba.101 Droughts, famine, and insurrections ¾ particularly in the northern regions of Tigray and Eritrea ¾ brought about the Derg's collapse. In 1989, the Tigrayan People's Liberation Front (TPLF) merged with other ethnically based opposition movements to form the Ethiopian Peoples' Revolutionary Democratic Front (EPRDF). In May 1991, EPRDF forces advanced on Addis Ababa. Mengistu Haile Mariam fled the country and was granted asylum in Zimbabwe. 102 In July 1991, the EPRDF, the Oromo Liberation Front (OLF), and others established the Transitional Government of Ethiopia (TGE), comprising an 87-member Council of Representatives and guided by a national charter that functioned as a transitional constitution. The TGE pledged to oversee the formation of a multiparty democracy in Ethiopia. An election for a 547-member constituent assembly was held in June 1994; in December of that year, the assembly adopted the constitution of the Federal Democratic Republic of Ethiopia. 103 The elections for Ethiopia's first popularly chosen national parliament and regional legislatures were held in May 1995 and June 1995, respectively. Most opposition parties chose to boycott these elections, ensuring a landslide victory for the EPRDF. However, international observers and NGOS believed that opposition parties would have been able to participate had they chosen to do so. 104 The Government of the Federal Democratic Republic of Ethiopia was installed in August 1995. The EPRDF-led government has promoted a policy of ethnic federalism, devolving significant powers to regional, ethnically based authorities. Ethiopia's semiautonomous administrative regions have the power to raise and spend their own revenues. Although Ethiopians enjoy greater political participation, some fundamental freedoms, including freedom of the press, are limited (discussed in more depth in Governance section below).105 In May 1991, the Eritrean People's Liberation Front (EPLF) assumed control of Eritrea and established a provisional government. This provisional government independently administered Eritrea until April 1993, when Eritreans voted overwhelmingly for independence in a UN-monitored referendum.106 In May 1998, an Ethiopian-Eritrean border conflict erupted into a full-scale war. After nearly two years of fighting, Eritrea and Ethiopia signed a cessation of hostilities agreement and a comprehensive peace agreement, and a contingent of U.N. peacekeepers was deployed in a 25-km wide temporary security zone (TSZ) running the length of the border. 107 However, tensions between Ethiopia and Eritrea remain high, and there are fears that the peace accord will be broken.108 Governance There have been no studies on governance and HIV/AIDS in Ethiopia. However, a general overview of governance might provide a sense of the context in which the epidemic is unfolding, as well as in which it is being addressed. In 1991, Ethiopia emerged from three decades of protracted civil war and a repressive, centrally planned economy, which undermined poverty reduction efforts, among others.109 Transparency International posits that Ethiopia's current coalition government is "generally held together by the ability of the ruling party to keep the pockets of its partners oiled, while it openly suppresses the opposition." Civil society's ability to fight corruption is hampered by the restrictions on press freedoms. 110 Ethiopia passed legislation in May 2001 establishing the Federal Ethics and Anticorruption Commission (FEACC). Transparency International believes that this was largely a result of donor pressure. In one of its first major cases, the FEACC filed corruption charges against 41 past and present officials of the Ethiopian Commercial Bank. Charges were also brought against 12 former heads of government institutions and businessmen arrested in May 2001. One of the accused was the leader of a dissident group within the ruling party. To what degree FEACC will be effective, given its underfunding and ties to the ruling party, is unclear.111 Population Mobility As mentioned above, there are very few data on HIV/AIDS and Ethiopia's mobile populations, which include: * the rapidly increasing number of rural residents seeking employment in urban areas * military personnel, including international peacekeepers * persons displaced by war, drought, and/or environmental degradation * male transport workers (see Epidemiology section) * sex workers (see Epidemiology section) * migrant workers * miners * individuals leaving Ethiopia to live/work overseas (see Epidemiology section) * merchants/traders/vendors * orphans and vulnerable children (e.g., street children) * humanitarian and relief workers * prisoners In March 2003, Ethiopia's Ministry of Federal Affairs highlighted that the country is facing a massive urban population explosion as families move from rural areas to cities. Against the backdrop of drought and food crisis, Ethiopia is experiencing one of Africa's highest rates of migration from villages to urban areas.112 In October 2002, the UN Office for the Coordination of Humanitarian Affairs estimated that there were at least 235,000 internally displaced Ethiopians, rendered mobile by war, famine, and drought. 113 (Note that this figure does not take account of the current food crisis, see below.) The International Committee of the Red Cross is assisting families in Eastern Tigray on the border with Eritrea who were displaced by the Ethiopia-Eritrea war. Some were unable to return to their home areas because of landmines or other security concerns. Other families that did return found that their homes had been partially or completely destroyed. Some of the families in this region are also moving in search of better soils on which to farm. 114 War The U.S. National Intelligence Council report discussed in the Epidemiology section states that war has "significantly contributed" to HIV transmission in Ethiopia. This is a crucial point to examine, though the report does not back up its assertions with any data (at least declassified data). NIC contends that "many" soldiers contracted HIV during the civil war in the 1980s and when that war ended in 1991, subsequently transmitted HIV to their sex partners in their home villages and towns. Sex workers who followed the military also moved when the civil war ended.115 David Shinn, former U.S. ambassador to Ethiopia and contributor to the NIC report, states that HIV prevalence among military personnel in front-line positions along the border with Eritrea is about 15 percent; it declines 12 percent behind the front lines and 7 percent where soldiers are living with or near their spouses in a "fairly normal" living environment. 116 Shinn did not provide a source for these data, though they may have been provided to him by the Ethiopian Ministry of Defense. According to the U.N. Office for the Coordination of Humanitarian Affairs, Ethiopia's 1998-2000 war with Eritrea displaced 1 million people, of whom 76,000 still have not returned to their homes.117 Since the December 2000 peace accord and April 2002 border decision, issued by the independent Boundary Commission, 150,000 Ethiopian soldiers have been demobilized 118 , 119. There is also a UN peacekeeping mission in Ethiopia and Eritrea (UNMEE).120 Thus, mobility of military personnel within Ethiopia remains high. Ethiopia itself has not yet participated in UN peacekeeping operations. However, in early 2003 it announced that it was sending about 800 soldiers to Burundi as part of a pan-African peacekeeping force that would observe the Burundi ceasefire until U.N. peacekeepers arrive. 121 The Response section examines how UNMEE and the Ethiopian military are addressing HIV/AIDS. Transportation Corridors A landlocked country, Ethiopia uses the seaports of Assab and Massawa in Eritrea. Ethiopia also uses the port of Djibouti, connected to Addis Ababa by rail, for international trade.122 In addition to commercial transport companies, humanitarian and relief workers also use these corridors; for example, the World Food Program is employing over 2,000 truck drivers to deliver food aid from the Port of Djibouti to distribution points throughout Ethiopia.123 The CDC undertook a small, rapid study of the Ethio-Djibouti corridor using focus group discussions, in-depth interviews, and key informant interviews with sex workers, truckers, their assistants, military personnel, construction workers, job-seeking women, and bar owners. The study was conducted on the two main highways and 14 towns along the corridor. It found that mobility was very high. For example, many women gravitate to the area seeking work, including sex work. Others are trafficked into sex work by brokers. Sex workers had the most positive attitude toward use of condoms, whereas most men had a negative attitude. Although condoms are accessible to respondents, their utilization is low, especially among soldiers, young men, and truckers. The main places where high-risk activities occur are liquor-selling establishments, nightclubs, bars, hotels, and brothels.124 Prisoners The only data on HIV prevalence among prisoners are from 1990 in Dire Dawa (n=450), indicating prevalence of 6.0 percent.125 Economy Ethiopia has one of the lowest exports per capita in the world. Gold, marble, limestone, and small amounts of tantalum are mined in Ethiopia. Other resources with potential for commercial development include large potash (potassium carbonate) deposits, natural gas, iron ore, and possibly oil and geothermal energy. Although Ethiopia has good hydroelectric resources, which power most of its manufacturing sector, it is completely dependent on imports for oil.126 Agriculture accounts for 40 percent of GDP and includes coffee (which represents 65 to 75 percent of the country's foreign exchange earnings), teff (a grain native to Ethiopia), wheat, barley, sorghum, millet, maize, khat (a shrub whose leaves and buds provide a habituating stimulant when chewed or used as a tea), meat, hides, and skins. Industry accounts for 13.7 percent of GDP and includes textiles, processed foods, construction, cement, and hydroelectric power.127 The agricultural and livestock sectors account for over 85 percent of the labor force. Given the country's agriculture-centered economy, Ethiopia is particularly vulnerable to the adverse effects of fluctuations in commodity prices (especially coffee), and drought, which is frequent.128 (See Food Security section below.) Soil degradation caused by overgrazing, deforestation, high population density, and poor infrastructure also render it difficult and expensive to get goods to market.129 Ethiopia's current land rights system derives from the 1994 constitution, which states that land is exclusively state property. The constitution further specifies that rural residents can have user rights over the land. The administration of land and, thus, the specific rules and regulations governing land tenure lie with the regions, which have the right to reallocate land. In recent years, lease papers have been issued in some regions that provide some land tenure security for a specified period. Lease papers cannot be sold or used as collateral. However, the sublease of land is allowed and is frequent. Regions also provide leaseholding permits for urban land. 130 Studies indicate that farmers are not encouraged to invest in or conserve their land due to the insecurity of land tenure. Related to this is growing population pressure that contributes to diminishing farm size and soil degradation.131 Landlessness, particularly among young people, is a growing concern and a major determinant of rural poverty. Among the consequences of landlessness is increased migration of landless youth to nearby cities, placing considerable pressure on urban social services.132 During the 1990s, the government embarked on a program of structural reform, including privatization of state enterprises and rationalization of government regulation. Although the process is still ongoing, the reforms have begun to attract much-needed foreign investment. 133 According to the World Bank, the extensive system of price controls has been almost entirely dismantled, tax rates have been lowered, and some restrictions on the private sector have been removed. 134 GDP growth did rise during the 1990s, from 2 to 5 percent.135 However, per capita income in Ethiopia fell during the 1990s.136 Public expenditure on health increased only slightly, from 0.9 of GDP in 1990 to 1.2 percent of GDP in 1998.137 Several major health indicators either fell or stagnated during the decade (see Health section below). The largely subsistence economy cannot support high military expenditures (see Public Expenditure Trends section below), drought relief, an ambitious development plan, and crucial imports such as oil; it therefore remains highly dependent on foreign assistance.138 The scope of poverty in the country remains enormous. Poverty According to Ethiopia's 1999-2000 Household Income and Consumption Expenditure Survey, 44 percent of the population lives below the national poverty line.139 With regard to international poverty lines, in 1995, 31.3 percent of the population was living below US$1 a day and 76.4 percent of the population was living below US$2 a day.140 As mentioned above, per capita income in Ethiopia fell during the 1990s. In 1990 it was US$160, in 1995 US$110, and in 2000, US$100.141 Concurrently, official aid fell by over 20 percent between 1995 and 2000. 142 Repeated and frequent shocks (such as drought and war) have meant that household assets have been diminished if not depleted. Ethiopia's poor tend to live in large households with high dependency ratios and relatively young and uneducated household heads. Most poor households are in rural areas and depend almost exclusively on agriculture for their income, with a few assets in the form of livestock holdings. The poor in urban areas depend on casual labor and petty trade for their livelihoods.143 Public Expenditure Trends As a percent of GDP, military spending in Ethiopia is almost eight times greater than public spending on health. According to UNDP, public expenditure on health increased only slightly during the 1990s, from 0.9 of GDP in 1990 to 1.2 percent of GDP in 1998. However, military expenditure as a percent of GDP rose from 8.5 in 1990 to 9.4 in 2000. 144 This rise is doubtlessly related to the war with Eritrea as well as continuing tensions with the National Islamic Front in Sudan and several groups in Somalia. 145 Examining military expenditures as a percent of the central government budget finds that in 1990, Ethiopia spent 39.8 percent of the budget on the military; this figure fell to 29.1 percent in 1990. However, this is still a massive percentage, as the accompanying indicator table demonstrates. Arms imports in 2000 accounted for 20.5 percent of all imports, again an extraordinarily large percentage when compared to regional and global figures. 146 Debt During the 1970s and 1980s, Ethiopia's servicing of its public and publicly guaranteed debt ranged from 4.2 to 16.9 percent of central government revenues.147 In November 2001, Ethiopia qualified for debt relief under the Enhanced Heavily Indebted Poor Countries Initiative (HIPC). HIPC is not debt cancellation; rather it is a restructuring of debt repayment through provision of grants. Ethiopia is required to continue servicing its debt. Moreover, HIPC does not preclude that a country will have to continue to borrow indefinitely. Ethiopia, for example, is and will continue to be heavily dependent on donors and foreign creditors. Several social justice NGOs, including Christian Aid and Oxfam U.K., have calculated that Ethiopia will be paying almost as much in debt service payments under HIPC as it was before HIPC. 148 Under HIPC, an estimated US$1.93 billion was committed to Ethiopia as total debt relief from all its creditors. This is equal to US$1.275 billion in net present value (the present value of future cash), of which bilateral donors are providing US$482 million, multilateral donors US$763 million, the IMF US$34 million, and the World Bank US$463 million.149 The World Bank projects that under HIPC, Ethiopia will save about US$96 million annually until 2021. It projects that debt service as a percentage of exports will fall by over half, declining from 16 percent to 7 percent by 2003, and declining steadily thereafter to below 4 percent by 2021. The resources made available by debt relief provided under the HIPC Initiative will be allocated to key antipoverty programs, outlined in Ethiopia's poverty reduction strategy paper (which some claim is simply a new name for structural adjustment programs). Poverty-targeted expenditures are projected to increase from 10.9 percent of GDP in 2000-01 to 14.7 percent in 2001-02 and 15.5 percent 2002-03.150 All these projections are predicated on assumptions made by the IMF and World Bank that Ethiopia's real GDP growth will grow annually by 6.5 percent on average over the next 20 years and that the country's export earnings will increase as coffee prices recover from 2002-03 onward after five years of steady decline. Other assumptions include that food and military imports will decline. (See Public Expenditure Trends section below.) Gross domestic investment flows are projected to increase steadily from 17 percent of GDP in 2000-01 to 22 percent by 2015-16. Foreign direct investment is projected to rise from 0.8 percent of GDP in 2000-01 to 1 percent by 2010-11 and to 1.4 percent by 2018-19.151 Many NGOs have argued that these assumptions are highly unrealistic. Jubilee Plus, for example, notes that HIPC assesses whether a country can afford to pay its debts by looking primarily at its export earnings and often making very optimistic assumptions about them. For countries such as Ethiopia, heavily dependent on one export commodity (coffee), this is unrealistic, as it is vulnerable to external shocks such as changes in the price of and demand for coffee as well as climatic fluctuations. 152 , 153 In September 2002, the World Bank and IMF themselves noted that although most commodity prices are forecast to rise over the medium term: ...recovery would be slow and key export commodity prices of the HIPCs would remain below the levels projected two years ago for quite some time. This will have adverse effects on future export earnings of the HIPCs and hence on the debt and debt service-to-exports ratios.154 The World Bank and IMF consider debt sustainable if its net present value is less than 150 percent of export earnings. In September 2002, the World Bank and IMF also noted that about half of the 20 countries in the HIPC interim period (including Ethiopia) are expected to show NPV of debt-to-export ratios in excess of the HIPC sustainability threshold at their completion (or final approval) points,155 again highlighting the fallibility of the assumptions that underlie HIPC. In its quest to qualify for HIPC, Ethiopia has had to undertake some activities that ¾ at least on paper ¾ have resulted in increased attention to the poor, social services, and HIV/AIDS, as well as consultation with civil society. For example, it was required to produce a poverty reduction strategy paper (PRSP) and demonstrate how funds from HIPC would be used to finance social sector services. Panos reports that in Ethiopia, some civil society groups believe that the government undertook the PRSP solely to obtain debt relief rather than out of genuine antipoverty commitment. They point to the lack of solid analysis and gaps in areas such as urban poverty and conflict-prone pastoral areas.156 As discussed in the Stigma section below, the PRSP analysis of HIV/AIDS was flawed. However, the Ethiopian government would hardly be the first that has sought to meet conditions imposed by the international financial institutions to obtain financial assistance. Ethiopia is currently in its interim HIPC period, 157 meaning that to qualify for the full amount of debt relief available via HIPC, it must successfully implement its PRSP for at least a year. Other criteria include: * strengthen public expenditure management, with an emphasis on reconciling monetary and fiscal accounts starting in fiscal year 2001-02, and consolidate federal and regional budgets for each fiscal year starting in 2002-03 * introduce value-added tax by January 2003 * complete financial restructuring of the Commercial Bank of Ethiopia and increase competitiveness of the financial sector through a number of specific actions * improve competitiveness and efficiency of the fertilizer input market * increase the gross enrollment rate for girls in primary level from 40 to 50 percent and reduce repetition rate at primary levels * increase DPT vaccination coverage to 50 percent and achieve a higher utilization rate of health outreach facilities * combat HIV/AIDS through complementing the government's overall strategy with increased distribution of condoms (by 6 million) throughout the country158 These are all critical actions, but whether it is realistic to assume that they will be met in the near term and permit release of HIPC funds to Ethiopia is questionable. Food Security In March 2003, the World Food Program reported that 11 million Ethiopians (about 16 percent of the population) are currently targeted for food distribution between April and July 2003. An additional 3 million people are at risk of starvation.159 The current food crisis is on a par with (or may even exceed) that of the 1984-85 famine. 160 The crisis has been triggered by rain failure.161 Oxfam U.K. and the International Food Policy Research Institute also point to structural causes of the famine, including: 1. poverty 2. (primarily past) poor governance (see below) 3. population pressure 4. vulnerability of Ethiopian farmers: Ethiopia's millions of small-scale farmers remain rooted in subsistence agriculture. They are almost entirely dependent on the weather, and the country is prone to drought three to four years out of every ten. Little investment has been made in irrigation or other systems to manage water supply; only about 5 percent of potentially irrigable land is irrigated. 5. poorly functioning markets 162 , 163 Ethiopia's transport and telecommunications infrastructure is among the least developed in the world. There is no public market information system and no system for inspecting and certifying products. There is virtually no commercial legal system available for enforcing contracts. Consequently, transaction costs of marketing are very high. Only one-quarter of food produced reaches the market. 164 Unlike in southern Africa, HIV/AIDS is not a major factor underlying the Ethiopian food crisis. However, as mentioned in the Epidemiology section, the search for food and migration to food aid distribution points does spur population dislocation, which may be accompanied by regroupings of family units and exposure to new sexual networks. Malnutrition (already high in Ethiopia) is increasing and further weakening the immune systems of people living with HIV/AIDS, thereby contributing to higher rates of morbidity and mortality. 165 Famine is likely to raise the opportunity cost of sending children to school. Girls, in particular, are affected. Lack of food, coupled with a subsequent breakdown in family structure, may place more children on the streets where they may be at higher risk of mistreatment, sexual exploitation, and physical and emotional abuse (discussed in depth below). Women and girls may undertake sex work to survive. They may also offer sex to workers involved in transporting and distributing food aid to try and obtain preferential treatment in the distribution of supplies and services. After a late 2002 mission to Ethiopia, Carol Bellamy, executive director of UNICEF, reported that: Clearly families are affected. They are first losing their livestock, secondly their crops. Thus far, the human life component had not been as dramatically affected as the crop and livestock [components], but the crops and the livestock are what will sustain human life. 166 Oxfam U.K. missions to Ethiopia have already reported massive livestock losses, rising grain prices, the distress sale of household assets and livestock at depressed prices, migration, increased labor competition leading to reduced wages, and rising malnutrition. 167 According to Save the Children U.K., in the northeastern highlands: [T]here are fewer people now whose livelihoods are sustainable, there is an increasing number who are vulnerable to external shocks and there is an unacceptably high number who are basically destitute. We really do need to understand, it is not as if Save the Children and other agencies and the Ethiopian government haven't put in a lot of support over the years but nevertheless the situation is still going in the wrong direction.168 Human Development One method of tracking human development in Ethiopia is to analyze trends in its Human Development Index. The HDI was created by UNDP to measures average achievements in life expectancy at birth; adult literacy and combined primary, secondary, and tertiary gross enrollment ratios; and GDP per capita (most U.N. agencies are now calling this gross national income [GNI]; details on its calculation can be obtained from the World Bank). An HDI of 0.800 or above = high human development; 0.500 - 0.799 = medium human development; less than 0.500 = low human development. 169 In 2000, Ethiopia's HDI value was 0.327, placing it among "low-human development" countries and ranking it 168 out of the 173 countries for which UNDP calculated an HDI. Ethiopia's HDI value is lower than that of the median for the world's least-developed countries (0.445) as well as for sub-Saharan Africa (0.471).170 A critical indicator of the well-being of children is the under-five mortality rate. In 2000, UNICEF reports that Ethiopia had the world's 21st-highest under-five mortality rate: 174 deaths per 1,000 live births. Although this is a vast improvement over the 1960 figure of 269, Ethiopia's under-five mortality rate for 2000 exceeds that of all the world's least-developed countries (161) and is about equal to the figure for sub-Saharan Africa (175). 171 Infant mortality, another key human development indicator, fell between 1960 (180) and 2000 (117). However, it still exceeds that of all the least-developed countries (102) and of sub-Saharan Africa (108). 172 Another critical human development indicator is the maternal mortality ratio (MMR), the number of deaths to women per 100,000 live births that result from conditions related to pregnancy, delivery, and related complications. The 2000 EDHS estimated that the maternal mortality ratio during 1994-2000 was 871 deaths per 100,000 women. (As the accompanying indicator table shows, UNFPA estimates that Ethiopia's 2001 MMR was 1,800. This figure is a continually revised consensus estimate of WHO, UNICEF, and UNFPA.173) Health Ethiopia's health expenditure per capita (both public and private) was US$4 to US$5 during the 1990s. This is far below the average for the region (US$37) and for all low- & middle-income countries (US$73). 174 As mentioned above, public spending on health rose only slightly during the 1990s, from 0.9 percent of GDP in 1990 to 1.2 of GDP in 1998. In 1998, private health expenditure accounted for 2.4 percent of GDP. 175 The health system entails four tiers comprising primary health care units (PHCU), district hospitals, zonal hospitals, and specialized hospitals. The PHCU is the frontline health facility and is composed of one health center with five satellite health posts.176 Ethiopia has three medical training centers: Addis Ababa University, Jimma Institute of Health Sciences, and Gondar College of Medical Sciences. It has 87 hospitals (11,685 beds), 257 health centers, 196 private clinics, and 1,483 physicians177 (about 1 for every 45,651 population). Brain drain is a major problem, as many trained medical personnel leave the country after their required in-country service. Reasons for emigration include low pay, difficult working conditions, lack of opportunity for professional development, and insufficient autonomy.178 AIDS-related morbidity and mortality among health care staff may also be increasing workloads. The health system in Ethiopia is severely underdeveloped. Transport constraints are severe.179 According to WHO, only about 55 percent of Ethiopians have access to (i.e., live within 10 km of) general health services.180 The majority of the population resides in rural areas and has little access to any type of modern health institution.181 Given low incomes, low levels of education, poor access to health services, and a highly uneven distribution of health facilities favoring urban areas, Ethiopians' general health status is poor both in absolute terms and in comparison with other African countries. 182 (See the accompanying indicator table.) As the table shows, only 24 and 15 percent of the population, respectively, have access to safe water and sanitation. 183 Only 10 percent of births are attended by trained health staff.184 Against a backdrop of chronic food insecurity, the nutritional status of the population is low; 47 percent of children under five are malnourished.185 The coverage for ante- and postnatal care is generally very low. A large proportion of health workers are male, which further limits use of reproductive health services by women. 186 During the 1990s, immunization coverage (DPT) fell from 49 to 21 percent and for measles, from 38 to 27 percent. 187 Also during that decade, life expectancy for both males and females did not improve.188 As discussed in the Human Development section, infant and under-five mortality have fallen over the past 30 years, but still remain very high.189 Approximately 75 percent of Ethiopia's land mass is malarious, rendering over 40 million people at risk. Malaria affects about 4 to 5 million Ethiopians annually.190 TB is discussed in the Impact section. Other major health problems include leishmaniasis, leprosy, respiratory diseases, polio, measles, and diarrheal disease. The health situation is particularly of concern as Ethiopia's population continues to grow rapidly. Because of continued high fertility and declining (albeit still high) mortality (and despite substantial AIDS mortality, discussed in the Impact section below), Ethiopia's population will increase to over 170 million by 2050. The annual population growth rate is projected to be over 2 percent through 2025, after which it will fall to 1.3 during 2045-2050.191 According to the MOH, national health service coverage has risen to 51 percent, from 30 percent a decade ago. It notes that the accelerated training of health professionals has yielded encouraging signs of deployment to rural areas. It states that the health system's major weakness "lies primarily in its failure to bringing about behavioral change in the attitude of [the majority of] Ethiopians toward personal and environmental hygiene."192 This remark appears to place most responsibility for the health system's weaknesses on the general population. It ignores the very low government spending on/investment in health care, particularly in light of high military spending and of increased educational spending that favors the better-off, as discussed below. It also ignores the myriad constraints the government and its citizens face; for example, according to the U.N., Ethiopia has one of the lowest amounts of water availability in the world.193 Certainly, behavior change is a crucial component of improved health care, but the systemic weakness of the public health care delivery infrastructure must also be noted. The central government's devolution of responsibility for health care to regions and local entities has many positive elements. However, whether regional and local governments can take on the responsibility is questionable, given their own burdens. As private expenditure on health represents 66 percent of all health care spending,194 a major concern is that as the central government reduces its role in health care delivery, with decentralization and privatization to fill the gap, safety nets for the poor (especially those in rural areas and women) may be threatened. Sexual & Reproductive Health UNFPA ranks Ethiopia a category "A" country, meaning that it is furthest from achieving the sexual and reproductive health and rights goals of the International Conference on Population and Development (ICPD), held in Cairo in 1994. Group A countries have the greatest need for external assistance and the lowest capabilities for mobilizing domestic resources to close this gap. 195 As mentioned in the Human Development section above, Ethiopia's MMR is extremely high. Fertility levels are also high; the total fertility rate (TFR: average number of children a woman would have assuming that current age-specific birth rates remain constant throughout her childbearing years, usually considered to be ages 15 to 49) during 2000-2005 is 6.75.196 Ethiopia is still in the early stages of demographic transition.197 According to the U.N. Population Division, the TFR will fall to 5.29 during 2010-2015, to 4.29 during 2020-2025; and to 2.55 during 2045-2050. 198 Childbearing begins early in Ethiopia. Physiological immaturity and inexperience associated with child care practices influence maternal and infant health. Early childbearing also greatly reduces women's educational and formal employment opportunities. According to the 2000 Ethiopian Demographic and Health Survey (EDHS), 16 percent of women ages 15-19 have already become mothers or are currently pregnant with their first child. The percentage of women who have begun childbearing increases rapidly with age, from 1 percent among women age 15, to 40 percent among women age 19. Twice as many teenagers residing in rural areas as in urban areas have begun childbearing. The level of teenage parenthood is also more than twice as high among women with no education than among women with primary or higher levels of education. Childbearing among teenagers is lowest in Addis Ababa (5 percent) and highest in the Gambela Region (26 percent).199 Over 50 percent of women age 30 and above first gave birth in their teens; even among the cohort 20-24, a sizable proportion (44 percent) have had a birth before age 20. The median age at first birth is 20 years for the youngest age cohort (age 25-29) for whom a median could be computed and varies between 18 and 19 for the older cohorts, indicating a rise in the median age at first birth during the most recent period. The median age at first birth is higher in urban areas than in rural areas. Addis Ababa has the highest median age at first birth (21.7), followed closely by Dire Dawa (21.4). The Amhara Region has the lowest median age at first birth (18). The median age at first birth is 19 years among women with no education and increases to 20 years among women with primary education and to 23 years among women with at least secondary education.200 Awareness of contraception is high: 81.5 percent of all women ages 15-49 and 86.1 percent of all men ages 15-59 know at least one method of family planning.201 However, current use of modern contraceptive methods is very low at 6 percent (though this is double the figure of 3 percent for 1990). The major reason for nonuse of contraceptives is the desire for more children: among those currently married, 41.8 percent of women and 64.7 percent cite this reason. Moreover, when the 2000 EDHS surveyed currently married women nonusers of contraception who intend to use in the future which methods they prefer to use, only 0.1 percent replied that they intended to use the condom. (Men were not asked this question.) Hormonal methods (injectables and pill) were the most frequently cited methods. 202 Granted, the condom is not particularly effective for family planning; however, it has been central to HIV/STI prevention. Thus, dual protection (pregnancy and HIV/STI) and male condom acceptability as a prevention method are critical issues for examination in Ethiopia. The unmet need for family planning is very high: 35.8 percent of currently married women have an unmet need for family planning, with 21.8 percent having an unmet need for spacing and 13.9 percent having an unmet need for limiting. Unmet need is higher among rural than urban women (37.3 percent and 25.0 percent, respectively). The difference is more pronounced for unmet need for spacing than for limiting. The overall unmet need for family planning is the highest in the Amhara Region (40.9 percent) and the lowest in the Affar Region (12.3 percent).203 The incidence of unsafe abortions is high and constitutes a major cause of maternal morbidity and mortality. 204 According to WHO, more women die in Ethiopian hospitals from complications arising from (illegal) abortions than from any other cause except TB. WHO officials estimate that 70 percent of women admitted to Ethiopian hospitals after undergoing an illegal abortion will die, and most of these deaths occur among women ages 16 to 20. 205 As mentioned, Ethiopia's population is young, with 44 percent under age 15.206 A key issue is delivering sexual & reproductive health information and services to young people, including those who are unmarried. This is particularly crucial as the 2000 EDHS found that there has been an increase in the percentage of never-married women over the last 10 years, from 18.0 percent in the 1990 National Family and Fertility Survey to 24.0 percent in the 2000 EDHS. According to the 2000 EDHS, among women, 70.0 percent of those ages 15-19, 26.9 percent of those ages 20-24, and 9.6 of those ages 25-29 have never been married. Among men, these figures are 96.6, 76.3, and 29.2 percent, respectively.207 Sexually Transmitted Infections There are no accurate serial prevalence data on STIs in Ethiopia.208 STI surveillance is practically nonexistent. Trend figures for STIs are available only for the Oromiya Region, where the number of reported STI cases has declined continuously from 1994 to 1999. Data from RPR testing for syphilis among ANC sentinel surveillance participants in Addis Ababa also show a declining trend in syphilis infections (ENARP records); however, these estimates are based on serial data for only three years.209 Several recent studies indicate that prevalence of herpes simplex virus type 2 (HSV-2) is high and may be fueling the HIV/AIDS epidemic. For example, studies conducted by researchers from Addis Ababa University found high prevalence of HSV-2 in Addis and HSV-2 association with HIV infection. Using two cross-sectional surveys, one community-based (June to September 1996, n=506) and one factory-based (February to November 1997, n=657), they found that in the first study, HSV-2 prevalence increased with age until 25 years, then leveled off at 50 percent for both women and men. The same independent predictors of HSV-2 infection were identified in men and women: older age, higher lifetime number of sexual partners, positive HIV serology, and positive syphilis serology. 210 Only MSF-Belgium is supporting the syndromic management approach, which is currently available in two regions: Addis Ababa (20 health centers) and the Tigrai region. The national STI treatment guidelines, based on the WHO syndromic management guidelines, were developed in May 2001. However, they have not been adequately introduced for national use. CDC-Ethiopia, in collaboration with the MOH and the Ethiopian Health and Nutrition Research Institute, is currently conducting research on validating the syndromic approach and developing clinical algorithms and treatment guidelines.211 Education From the mid-1980s through the mid- to late 1990s, Ethiopia increased spending on education, from 3.1 percent of GDP in 1985-87 to 4.0 percent of GDP during 1995-97. Education's share of the government budget also rose, from 9.3 to 13.7 percent.212 During the 1990s, Ethiopia reduced illiteracy rates. Among adult males, the illiteracy rate fell from 62 to 53 percent; among women, from 80 to 69 percent. Among young women, illiteracy fell from 66 to 52 percent, and among young men, from 48 to 39 percent. However, as the accompanying indicator demonstrates, illiteracy rates are still much higher than those for the entire sub-Saharan Africa region, as well as for all low- and middle-income countries. 213 A worrisome trend is that within public expenditure on education, spending on preprimary and primary education fell, from 51.5 in 1986-87 to 46.2 during 1995-97. Spending on secondary education also fell during this period, from 28.3 to 23.7 percent of all public expenditure on education. However, spending on tertiary education rose, from 14.4 to 15.9 percent.214 Children attending primary school are more likely to be from the poorest groups than from better-off groups; those who are not yet or able to be in school are also disproportionately poor. Secondary education shares this pattern, though the effect is not as pronounced as in primary education. The poor do not benefit from the substantial subsidies to university education. The education system in Ethiopia is characterized by inefficiency and low quality, with high dropout rates, poor cognitive performance at all levels, low and declining levels of teacher qualification, inadequate facilities, and scarce teaching materials.215 The education sector is undergoing rehabilitation. During the 1990s, enrollment stagnated, but it is beginning to increase. The government's new educational policy places greater emphasis on technical and vocational education at the secondary level. 216 Gender Status of Women UNDP measures gender inequality by using the unweighted average of three component indices: life expectancy, education, and income. Its Gender-related Development Index (GDI) value ranges from 0 (lowest gender equality) to 1 (highest gender equality). In 2000, UNDP calculated Ethiopia's GDI value at 0.313, ranking it 142 out of 146 countries on this index. (For comparison, GDI values range from 0.263 [Niger] to 0.956 [Australia].)217 Although the constitution of 1994 guarantees gender equality and permits affirmative action, implementation of the National Policy for Women is hindered by varying degrees of commitment across regions. 218 Gender disparities in enrolment ratios and educational attainment levels are high, as seen in the accompanying indicator table. According to the 2000 EDHS, the majority of Ethiopians have little or no education, with females much less educated than males. Sixty-two percent of males and 77 percent of females have no education, and 27 percent of males and 17 percent of females have only some primary education. Less than 3 percent of males and 1 percent of females have completed primary education only, and 6 percent of males and 4 percent of females have attended, but not completed, secondary school. Only 3 percent of males and 1 percent of females have completed secondary school or higher. The male-female gap in education is more obvious at lower levels of education primarily because the proportion of males and females attending higher levels of education is so small. 219 The status of women is low, both in absolute terms and when compared with men.220 The country's high MMR (see above) is also an indication not only of poor reproductive health, but of women's low status and poor access to basic health services. Sexual Negotiation Data from the 2000 EDHS suggest that many Ethiopian women have little power in sexual negotiation with their husbands. A sizable majority (84.5 percent) believe that a husband is justified in beating his wife for at least one of the following reasons: if she burns the food, argues with him, goes out without telling him, neglects the children, or refuses sexual relations with him. Of all women, 50.9 percent believed that a husband is justified in beating his wife if she refuses sexual relations. The differences are more notable by level of education and urban-rural residence.221 Polygyny is also a factor. The 2000 EDHS measured the extent of polygyny in Ethiopia by asking currently married women whether their husband or partner had other wives and if so, how many. Overall, 13.7 percent of currently married women in Ethiopia are in a polygynous union, that is, married to a man who has more than one wife. Older women are more likely to be in a polygynous union than younger women, presumably because husbands are more likely to marry again when their wives get older. Polygyny is also higher among rural than among urban women (14.6 percent and 7.0 percent, respectively). There are substantial regional variations in the extent of polygyny. Polygyny is widely practiced in the Gambela (28.9 percent), Affar (24.4 percent), and SNNP (21.9 percent) regions. In the Amhara Region and in Addis Ababa, 2.1 and 2.4 percent of currently married women, respectively, are in a polygynous union. Among women with no education, 14.6 percent are in a polygynous union; with primary education: 10.1 percent; and with secondary or higher education: 5.1 percent.222 Economic Autonomy The 2000 EDHS found that younger women (ages 15-24) and older women (ages 40-49) are somewhat more likely to make independent decisions about their earnings than women in the middle age groups. Among currently married women, 62 percent reported that they alone make the decisions about how their earnings will be used, whereas 32 percent replied that decisions are made jointly with their husband/partner. Women with no children are more likely than women with one or more children to make independent decisions on the use of their earnings and are also more likely than other women to make joint decisions with someone other than their husband. There are no significant differences between urban and rural women regarding decisions about how their earnings will be spent. However, regional differences exist, with the proportion of women making independent decisions ranging from 82 percent in the SNNP Region to 35 percent in the Benishangul-Gumuz Region. Women were more likely to decide jointly with their husband on how to spend the money they earn if they had completed at least secondary school than if they had only primary education. 223 Other issues that render Ethiopian women vulnerable to HIV include rape, abduction, early marriage, and female circumcision. Harmful Traditional Practices Female circumcision is widespread in Ethiopia: 79.9 percent of all women have been circumcised. Urban (79.8 percent) versus rural (79.9) percent residence, education (no education: 80.4 percent; primary education: 78.4 percent; secondary or higher education: 78.2 percent); and work status (not employed: 79.5 percent; employed for cash: 84.4 percent; employed but not for cash: 77.3 percent) do not make any notable difference in the practice of female circumcision. However, the practice is slightly lower among younger women. 224 There is also widespread support for female circumcision among Ethiopian women. Support is greatly influenced by residence and level of education. Rural women (66.1 percent) are twice as likely to support the practice as urban women (31.0 percent). Women living in Addis Ababa (16.2 percent) and in the Tigray (25.3 percent) and Gambela (26.8 percent) regions are relatively less likely to support the continuation of the practice than women in other regions. Women with secondary and higher levels of education (18.6 percent) are also significantly less likely to support the practice, compared with women with no education (67.0 percent) and primary education (48.5 percent), as are women working for cash (56.1 percent), compared to unemployed women (59.1 percent) and women employed but not for cash (62.7 percent) 225 Women interviewed in the 2000 EDHS who had at least one living daughter were asked about the circumcision experience of their daughters. Over half of the women reported that at least one of their daughters has been circumcised. Older, rural, and less-educated women are more likely to have at least one circumcised daughter, compared with other women. Women with secondary education or higher are least likely (26 percent) to have a circumcised daughter, compared with 56 percent among uneducated women and 36 percent among those with primary education. There is substantial variation by region in the percentage of women with at least one circumcised daughter, ranging from 94 percent among women in the Affar Region to 37 percent in the SNNP Region. Women who are not employed are less likely than women who are employed to have at least one circumcised daughter. Over half of the daughters were reported by their mothers to have been circumcised before age one. Ninety-two percent of circumcisions were performed by a traditional circumciser; a traditional birth attendant performed 6 percent; and less than 1 percent were performed by another health professional.226 In an effort to obtain basic information on the severity of female circumcision, women who have been circumcised were asked whether their vaginal area was sewn closed. The same information was asked about their most recently circumcised daughters. Only 2.9 percent of circumcised women and 3.4 of their most recently circumcised daughters had had their vaginal area sewn closed, suggesting that the most severe form of circumcision is not common in Ethiopia. 227 Trafficking of Women Ethiopia's Ministry of Labor and Social Affairs recently reported that poverty and unemployment are leading to a dramatic increase in the trafficking of Ethiopian women.228 Trafficked women are especially vulnerable to fraud and exploitation, including sexual abuse; lack of freedom of movement; and poor access to sanitation, nutrition, and health care. Moreover, they are separated from their families and spouses or regular sex partners. Disillusionment, despair, loneliness, racial and cultural discrimination, marginalization, dangerous and demeaning work, lack of recreational outlets, and uncertainty about employment and legal status can lead to risk behaviors, such as casual sex without a condom and alcohol and drug use. All these factors render them vulnerable to acquiring HIV. Trafficked women have little or no access to HIV/STI information, VCT, or health services. Cultural and linguistic barriers exacerbate their lack of access to such services. The section below highlights gender disparities in knowledge of HIV/AIDS. Knowledge of HIV/AIDS General Knowledge According to the 2000 EDHS, knowledge of HIV/AIDS is high among Ethiopians. However, as is the case in many countries, women are less likely to have heard of HIV/AIDS (84.7 percent) than men (95.5 percent). Among rural women, this figure is 81.9 percent, among urban women, 97.2 percent. Among rural and urban men, these figures are 94.9 and 98.8 percent, respectively. Women residing in the Somali Region, and men residing in the Gambela Region are less likely than residents of urban areas and other regions to have heard of HIV/AIDS. (In Addis, 99.0 percent of women and 97.9 percent of men have heard of HIV/AIDS.) 229 (Note that the preliminary findings of Ethiopia's first behavioral surveillance survey also found high knowledge of HIV/AIDS.) Among those ages 15-19, 78.9 percent of women and 87.8 percent of men had heard of HIV/AIDS. For ages 20-24, these figures rose to 85.4 and 97.3 percent, respectively. Among those never married, 80.6 percent of women and 91.3 percent of men had heard of HIV/AIDS. Among those who have ever had sex, 95.7 percent of women and 99.1 percent of men had heard of HIV/AIDS.230 Among those who had heard of HIV/AIDS, 72.2 percent of women and 89.5 percent of men believed that HIV/AIDS can be avoided. In rural areas, these figures fell to 67.5 for women and 88.1 for men. The majority of women in Affar (54.5 percent) and Somali (58.5 percent) regions do not believe that HIV can be avoided. Regionally, the highest percentage of men who did not believe that HIV could be avoided was in Affar (38.1). Among never-married women, 30.9 percent did not believe that HIV could be avoided; among never-married men, 16.5 percent. Among those ages 15-19, 66.6 percent of women and 79.8 percent of men believe that there is a way to avoid infection. Among those ages 20-24, these figures rose to 73.8 and 89.3 percent, respectively. Across the board, education improved respondents' knowledge of HIV/AIDS and belief that it could be avoided. 231 Most respondents (52.6 percent of women and 69.6 percent of men) spontaneously replied that having sex with only one partner was the single most effective way to avoid contracting HIV. Men were twice as likely as women to mention using condoms (35.6 percent and 17.1 percent, respectively). Very few mentioned avoidance of mosquito bites (0.1 percent for women and 0.2 percent for men) or seeking of protection from a traditional healer (0.4 percent of women and 0.3 percent of men). However, 2.1 percent of women and 1.0 percent of men did mention avoidance of kissing, and a sizable percentage of women and men also mentioned avoiding the sharing of razors/blades (26.0 percent and 30.7 percent, respectively). 232 More men than women spontaneously responded that abstaining from sex (17.1 vs. 10.8 percent, respectively), and avoiding sex with sex workers (18.4 vs. 10.2 percent) can help prevent the risk of acquiring HIV. Abstaining from sex, using condoms, and limiting the number of sexual partners have been identified as programmatically important ways to avoid the spread of HIV/AIDS. Women were much less knowledgeable about programmatically important ways to avoid contracting HIV than men. Only 36.8 percent of women (compared to 63.3 percent of men) knew of two or three programmatically important ways to avoid HIV/AIDS. With regard to specific ways to avoid HIV/AIDS, 33.5 percent of women and 60.0 percent of men mentioned the use of condoms; 65.4 percent of women and 88.0 percent of men mentioned limiting number of partners. Residence and education were the two most influential background characteristics on respondents' knowledge of programmatically important ways to avoid contracting HIV/AIDS. Women and men residing in urban areas were much more likely to know of at least two programmatically important ways, as were those with at least secondary education.233 A major knowledge gap is mother-to-child transmission of HIV. Only 58.2 percent of women (and 72.1 percent of men) knew that HIV can be transmitted from mother to child.234 Another is that 62.8 percent of women did not believe that a healthy looking person can have HIV/AIDS; among men, this figure was 45.3 percent. Source of Knowledge For both women and men who had heard of HIV/AIDS, community meetings were the most important source of information on HIVAIDS (80 percent and 71 percent, respectively). Men were much more likely than women to have heard of AIDS on the radio and television. Friends and relatives were also an important source of information on AIDS for both men and women, as were health workers. Exposure to AIDS information on the radio was nearly four times as high among urban than rural women and twice as high among urban than rural men. 235 Younger respondents were more likely to mention school as a source of information on AIDS. Among all women and men, those never-married who had ever had sex, lived in urban areas, and had some education were more likely to receive information on AIDS from the media than other women and men.236 Of those who have heard of HIV/AIDS, 25.5 percent of women and 48.4 percent of men currently married or living with a partner have discussed HIV prevention with their spouse or partner. Women ages 20-39 and men ages 25-49 are more likely to have discussed HIV prevention with their spouse or partner. Discussion on this topic was also more common among highly educated respondents than others. Twice as many urban than rural women and one and half times as many urban than rural men had discussed HIV prevention with their spouse or partner. Residents of Addis Ababa were the most likely to have had this discussion. 237 Stigma Shinn reports that HIV "is essentially a verboten discussion topic even among relatives and friends. The culture of secrecy, at least among those from the highlands, almost certainly contributes to this situation. Talking openly and frankly about personal subjects is not part of Ethiopian culture." 238 According to the 2000 EDHS, nearly twice as many women (16.3 percent) as men (9.1 percent) who have heard of AIDS believed that the HIV positive status of a family member should remain a secret. Younger women (15-24), those never-married, those residing in rural areas and in Benishangul-Gumuz and Gambela regions, and those with little or no education are more likely than others to believe that this information should be kept secret. Similar patterns are observed for men by age and marital status, but in contrast to women, urban men and men with at least secondary education are more likely to oppose making this information public. 239 Among those who have heard of AIDS, 45.3 percent of women and 50.1 percent of men are willing to care for relatives with HIV in their house. Young respondents (15-19), never-marrieds, urban residents, those living in Addis Ababa, and respondents with at least secondary education are more willing than others to care for relatives with HIV/AIDS in their house. 240 The International Center for Research on Women is conducting research on HIV/AIDS-related stigma in Ethiopia. It is working in Melka Oda, Shashemene Woreda, Oromiya Region as well as in Addis Ababa, using key informant interviews with community leaders, in-depth interviews with community members, and FGDs. Preliminary data found that 61 percent of those surveyed reported that although they know that HIV is not transmitted casually, they would not buy food from a vendor with HIV. Many respondents, again despite their knowledge, would separate utensils, linens, and other household items used by the PWHA from those used by other household members. 241 The persistence of concerns about casual transmission despite knowledge is linked to strong fears of death and the severity of suffering that accompanies AIDS. The fear of death is so strong that people avoid those suspected of having HIV, even when they know that HIV is not transmitted casually. 242 Much of the stigmatizing language and description of stigmatizing and discriminatory behavior centers on the sexual transmission of HIV. Respondents report that "those" with HIV contract it through their own bad behavior, namely sexual activity that is not socially sanctioned or goes against religious teachings. Respondents describe behaviors such as pre- and extramarital sex and multiple partners as immoral and leading to HIV. Those who have HIV are "promiscuous," "careless," or "unable to control themselves" and have brought HIV upon themselves; they are also blamed for bringing it into the community. The belief that HIV is a divine punishment for sins committed is particularly strong. 243 Over 70 percent of respondents in the ICRW study believe that PWHA are at fault, deserve what they got, or should feel guilty; yet at the same time, they feel that PWHA deserve sympathy or support. There is a call for PWHA to go public and "teach" and be an "example" to others. Concurrently, respondents note that most people would fear disclosing an HIV-positive status because of how they would be treated and viewed by others. They feel that family and community need to be more open and supportive to make disclosure easier. Respondents state that people rarely find out about someone's HIV-positive status through a PWHA's own disclosure and usually infer status through change in behavior, symptoms, or weight loss. 244 ICRW highlights that these contradictions are an indication of the "elusive and pervasive nature of stigma and how it will be difficult to diminish." Some of this stigmatizing behavior is caused by limited resources and fatigue. Although family and community members provide care, they often regard PWHA as a burden. The feeling of burden is fueled by the knowledge that there is no cure and the belief that PWHA will soon die. Communities tend not to acknowledge the capabilities of PWHA. In some cases, PWHA are described as "useless" and "worthless." The perception of PWHA's being "worthless" is attributed to the commonly held belief that they could not or should not work hard because of the detrimental impact on their health.245 The Medical Missionaries of Mary Counseling & Social Services Center, which provides support to PWHA and their families in Addis, has also found that those who provide care to PWHA are themselves stigmatized.246 In discussing HIV/AIDS in its 2002 poverty reduction strategy paper, Ethiopia's Ministry of Finance and Economic Development advocates that "There should be a mechanism for close follow-up of commercial sex workers since they are the most vulnerable and risk group of the society [sic]." 247 No other group is singled out for any such follow up. Indeed, several paragraphs down, the PRSP states: m) Emphasis on High-Risk Groups To fully cover and provide educational and preventive efforts to high risk groups such as commercial sex workers [bold is part of original document] and their clients, mobile groups (long distance truck drivers, military personnel) youth groups, street children, refugee, prisoners and others within the coming five years. This strategy will have positive impact on the economy higher proportions of the transmissions occurs in these groups. 248 Further down, the PRSP states that SWs are "more likely to abuse substances," 249 although there is no reference provided. This assertion is not found in MOH documents or in any other materials the present author consulted on HIV/AIDS in Ethiopia. It may be an unpublished, preliminary finding from Ethiopia's first behavioral surveillance study (see below), which did find that 47 percent of respondents (which included sex workers) had ever tried drugs. 250 However, why sex workers were singled out on drug use in the PRSP is unclear. This treatment of SWs in a key, national document ¾ one on which debt relief and other assistance from the World Bank and IMF are predicated ¾ is worrisome, as it appears to lay blame for HIV transmission on SWs and thus women. It also minimizes married, monogamous women's risk of acquiring HIV. This type of demonization of SWs is not present in the Ethiopian MOH's two most recent major AIDS reports.251 , 252 This suggests that although the Ministry of Finance and Economic Development states that it consulted with a wide array of stakeholders in creating the PRSP, its consultation with the MOH and HIV/AIDS experts was very superficial and/or it simply is not interested in understanding the epidemic. Either scenario does not bode well for ensuring that HIV/AIDS is integrated into the country's macroeconomic and poverty reduction planning. Sexual Behavior There is an acute need for data on sexual behavior trends in Ethiopia. Two large, nationwide studies on sexual behavior were conducted in 1987-88 and 1993; however, their findings are not comparable because of differing methodology and survey instruments. Some serial data on the proportion of students who use condoms are available for Addis Ababa and Gondar only; however, again, the various (small-scale) studies did not follow similar methods and did not use similar instruments. Ethio-Netherlands AIDS Research Project Factory Worker Cohort The Ethio-Netherlands AIDS Research Project followed a cohort of male workers (n=1,124) at two factories near Addis Ababa between February 1997 and December 1999. In early 2003, the project published data demonstrating a decline in risky sexual behaviors reported by cohort participants; part of this decline occurred independently of cohort interventions. At baseline, the prevalence of casual sex in the past year, sex with sex worker, condom use with last casual partner, history of genital discharge in the past five years, and history of genital ulcer in the past five years were 9.7, 43.4, 38.8 (Akaki site only), 10.6, and 2.1 percent, respectively. At the Wonji site, the baseline prevalence of casual sex, sex with sex worker, and history of genital discharge decreased significantly by calendar year between 1997 and 1999. At both sites combined, between the first and the fourth follow-up visits, there was a decline in the proportion of males reporting recent casual sex (from 17.5 to 3.5 percent, p < 0.001), sex with sex worker (from 11.2 to 0.75 percent, p < 0.001), and genital discharge (from 2.1 to 0.6 percent, p = 0.004). 253 Behavioral Surveillance Survey Between December 2001 and June 2002, Ethiopia undertook its first behavioral surveillance survey. Addis Ababa University's Department of Community Health implemented the first round of the BSS with technical support from Family Health International. The BSS involved over 30,000 respondents in rural and urban areas in every region of the country, including in- and out-of-school youth, female sex workers, military personnel, farmers and pastoralists, long-distance drivers, and factory workers. Preliminary findings include: * About 98 percent of the study population is aware of HIV/AIDS. * Almost all groups know at least one HIV prevention method. * Nearly 60 percent know all three programmatically important prevention methods. * Knowledge of prevention methods increases with the number of media source for AIDS messages. * Nearly two out of three young people out of school reported that they are sexually active and had sex with two or more partners in the last year. * In some areas, sexually active girls out of school are more likely than boys to report multiple partners. * Condom accessibility and cost are not barriers to condom use among most groups. * Condom use is high among sex workers. * Significant proportions of respondents do not always use condoms with nonregular partners, though they know that condoms can prevent HIV transmission. * A little over one out of five married respondents who have had multiple sex partners in the last 12 months do not always use a condom. * Forty-seven percent of respondents have ever tried drugs. * About two-thirds of respondents who consume khat at least weekly and drink alcohol once a week have had recent unprotected sex with a nonmarital partner. * Commercial sex is more common among mobile men with money. * Noncommercial sex is relatively very high among in and out of school youth. * Misconceptions about HIV/AIDS transmission remain high in almost all groups and regions. * Misconceptions about HIV/AIDS are high irrespective of level of knowledge. * Own-risk perception is very low in almost all target groups. * Most respondents who had unprotected sex with nonmarital partners do not feel that they are at risk. * Despite a high level of knowledge, a significant proportion of the population, particularly youth, is at high risk of HIV infection.254 Once the BSS findings are released, they will be integrated into this paper. Below are findings from Ethiopia's 2000 Demographic and Health Survey. 2000 EDHS Age at First Sexual Intercourse According to the 2000 EDHS, the median age at first intercourse for women ages 20-49 is 16.4 years. Among these women, 27.2 percent of women have had sexual intercourse by age 15, 64.2 percent by age 18, and 87.6 percent by age 25. Over two-thirds (69.3 percent) of women ages 15-19 report never having had intercourse. This proportion declines to 24.6 percent for women ages 20-24 and to 7.4 percent for ages 25-29. 255 The median age at first sexual intercourse among men is 20.3 years, three years lower than their median age at first marriage (23.3 years). Among those 15-19, 84.6 percent report never having had intercourse, falling to 46.8 percent for ages 20-24 and 14.9 percent for 25-29. 256 The median age at first intercourse is lower among women in rural areas than in urban ones. The age at first sexual intercourse increases with women's education but decreases with men's education. For example, women with at least some secondary education initiate sex four years later than women with no education; however, men with at least secondary education initiate sex two years earlier than men with no education. 257 Age at First Marriage The median age at first marriage for all women ages 25-49 is 16.0. The median age at first marriage among women in Ethiopia has risen slowly over the last two decades, from 15.8 for women ages 30-49 to 17.2 for women ages 25-29 and to 18.1 for women ages 20-24. There has been a sharp decline in the proportion of women married in their early teens; the percentage of women married by age 15 has declined from 35.1 percent among women ages 35-39 to 14.4 percent among those currently between 15 and 19. 258 Overall, urban women ages 20-49 marry about 1.5 years later than rural women. The median age at first marriage among women ages 25-49 varies significantly by region, ranging from 14.3 years in Amhara to 19.4 years in Dire Dawa. There is a strong relationship between education and age at marriage. Women ages 25-49 with at least secondary education marry 5.4 years later than women with no education.259 The median age at first marriage for men is 23.3 years. Men in all age groups tend to marry much later than women; for example the median age at first marriage for men ages 25-29 is 23.2 years, compared with 17.2 years for women in the same age group.260 Sexual Activity In Ethiopia, 62.8 percent of all women and 55.7 percent of all men are currently married. Among women, 2.5 percent are divorced, 6.2 percent separated, and 3.6 percent widowed. For men, these figures are 1.0, 2.6, and 0.5 percent, respectively. 261 About one-half (50.8 percent) of all women were sexually active during the four weeks preceding the 2000 EDHS, and 22.8 percent had never had sexual intercourse. The proportion of women who were sexually active in the four weeks prior to the survey increases with age up to 30-34 and declines thereafter. Higher proportions of rural women (54.8 percent) were sexually active than urban women (32.6 percent). (NB: A higher proportion of urban women ages 15-49 are unmarried than rural women.) Among men, 47.0 percent were sexually active in the four weeks prior to the survey, 29.2 percent had never had sex. 262 Among those married, 98.5 percent of women and 92.6 of men reported sexual intercourse only with their spouse in the 12 months preceding the survey. Sexual intercourse with multiple partners was higher among women ages 15-19 and men ages 40-49, urban women and rural men, female residents of the Benishangul-Gumuz Region, and male residents of the Gambela Region. There was little difference in sexual activity by educational level of women; however, men with little or no education were more likely to have had sexual intercourse with multiple partners than men with at least secondary education. 263 Among those unmarried, 12.9 percent of women and 22.3 percent of men reported sexual intercourse in the last year. Of them, 1.1 percent of women and 5.4 percent of men had two or more sex partners. Multiple partners among unmarried persons was relatively more common among women age 20 and above than among women ages 15-19, urban women, those residing in the Amhara and Affar regions, and women with little or no education. Among men, sexual intercourse with multiple partners was more common among those ages 20-49, in urban areas, among those residing in the Affar Region, and among those with at least secondary education. 264 Transactional Sex As previously mentioned, among women, AIDS cases peak between ages 20 and 29; for men, between ages 25 to 34. 265 This is likely related to age mixing, wherein young women have older male sex partners, primarily for economic reasons.266 There are no data on transactional sex in Ethiopia.267 , 268 Poverty, conflict, drought, and famine may increases instances in which sex is traded for food or other necessities. Condoms Knowledge According to the 2000 EDHS, only 34.8 percent of all women know about condoms; the comparable figure for men was 67.8 percent. For urban women, this figure was 86.0 percent and for rural women, 23.5 percent; for men, the comparable figures were 97.1 and 62.8 percent, respectively. Women ages 25-29 had the highest knowledge of condoms (39.6 percent), followed by those ages 20-24 (37.3 percent). For men, those ages 25-29 also had the highest knowledge of condoms (76.0 percent), but were followed by those ages 30-39 (75.6 percent). 269 Among never-married women, 41.7 percent knew of condoms, whereas this figure was 66.0 among men. Among those who had ever had sex, 82.7 percent of women and 84.9 percent of men knew about condoms. For both men and women, knowledge was highest in Addis (97.0 and 94.2 percent, respectively) followed by Dire Dawa (where the gender difference became more pronounced: 92.6 percent of men vs. 74.8 percent of women). For men, the regions with the next highest percentages of those who knew about condoms were Tigray (82.9 percent) and Harari (78.5 percent); for women, Harari (64.5 percent) and Tigray (53.4 percent). 270 Knowledge of condoms varied widely by background characteristics. Respondents who were urban, ages 25-39, never-married, who had ever had sex, and with at least secondary education were more likely than their counterparts to know about condoms. 271 Women were also asked whether they knew a source for condoms and could obtain condoms for themselves. Only 12.1 percent of women knew a source for condoms and only 11.1 percent reported that they could obtain condoms for themselves. The rural-urban differential was very wide (6.6 percent vs. 36.6 percent on source and 6.0 percent vs. 34.2 percent on ability to obtain). Regionally, the lowest figures were found in SNNP (5.6 percent on source and 4.9 percent on ability to obtain). Education was positively associated with both these variables, although note that still, among women with at least secondary or higher education, only 41.3 knew a source for condoms and only 38.2 could obtain one.272 These findings appear to diverge from those of the BSS. Again, once the final BSS findings are released, they will be incorporated into this paper. Use Generally, condom use in Ethiopia is low. (NB: The BSS appears to have found that it is high among sex workers.) According to the 2000 EDHS, the use of condoms during last sexual intercourse with a spouse or cohabiting partner was negligible among both women (0.4 percent) and men (0.1 percent). With a noncohabiting partner, 13.4 percent of women and 30.3 percent of men did use a condom at last intercourse. Condom use with a noncohabiting partner was much more common among men and women who were never-married, urban, and had at least secondary education; women under 30 and men ages 30-39 were also more likely to have used a condom with a noncohabiting partner at last intercourse.273 Currently, over 80 percent of condom sales and distribution are handled through DKT-Ethiopia. Since 1990, there has been a progressive increase in the sale and distribution of condoms, from a baseline figure of 699,500 to 41.8 million in 1999. About 20 percent of all sales and distribution occur in Addis Ababa.274 Sex Work Several HIV serosurveys among sex workers have been conducted since the beginning of the epidemic (as discussed in the Epidemiology section). The most recent, the 1998 study of 372 sex workers in Addis Ababa, found that most SWs were from the city's slums and that about 35 percent lived in "shared rooms," renting a small room in which three to five women live. These SWs must give about half their income to the owner of the room. 275 Family Health International notes that estimates of the number of sex workers in Addis Ababa range from a few thousand to 150,000. To address the lack of data on numbers of sex workers, their networks, and organization, FHI is working with local partners to conduct a mapping of sex workers in Addis Ababa.276 Alcohol and Drug Use In March 2003, Dr. Bulti Gutema, who heads the Children, Youth and Family Welfare Department in the Ministry of Labor and Social Affairs, stated that: The problems of Ethiopian youth are many, complex and inter-related. Because of their limited access to training and educational opportunities and the acute shortage of recreation and sport centers, they fall victims to drug and alcohol abuse, delinquency and criminal activities.277 According to the U.N. Office on Drugs and Crime, recreational drug consumption in Ethiopia is increasing, including among street children in Addis Ababa and in the city's slum areas. Young people are the main consumers of cannabis (which is illegal), used for recreation as well as in certain religious rites and for curative purposes. Khat has been used for centuries in the eastern part of the country, and is currently consumed throughout Ethiopia. Cultivation and consumption of khat ¾ which are increasing ¾ are legal, though the government discourages them. Khat abuse begins at a young age. Some heroin abuse has been recorded, though to a very limited extent vis-à-vis cannabis and khat.278 Although the U.N. does not believe that Ethiopia is important with regard to money laundering, precursor chemicals, or production of narcotic drugs, it is a prime target for drug trafficking (most drugs transiting Ethiopia are mainly destined for Europe and, to a lesser extent, the U.S.). The country has no central body coordinating antidrug activities; resources allocated to antidrug activities are grossly insufficient. 279 Although there are no data on drug trafficking and abuse and the Ethiopian-Eritrean conflict, the U.N. does highlight that armed conflicts throughout the world have led to rapid spread of drug control problems in affected zones, with the military often involved in illicit trafficking and selling; another result of conflict has sometimes been the growing drug abuse of inhabitants of affected regions.280 Male Circumcision There are no data on male circumcision in Ethiopia. 281 , 282 Some observational studies from sub-Saharan Africa have indicated that male circumcision may reduce the risk of HIV acquisition,283, 284 though circumcision does not appear to affect transmission from HIV-positive men to their partners.285 The limitations of these studies have been highlighted, and further study is needed on both biomedical and sociobehavioral issues before promoting male circumcision as a public health intervention. Impact At a Glance The At a Glance section summarizes the more detailed data found below it. * There are few data on the impact of HIV/AIDS in Ethiopia. Demographic * AIDS is now recognized as the leading cause of adult morbidity and mortality in the country. * Ethiopia's population will be up to 16 percent smaller than it would have been in a "no-AIDS" scenario. Factors include AIDS deaths, as well as reduction in fertility due to condom use to prevent infection, fewer births because of a smaller reproductive age population, and fertility reduction associated with HIV infection. * AIDS will reduce life expectancy by 9 to 13 percent through 2050. * AIDS has already increased the number of deaths in Ethiopia by 6 percent. Between 2000 and 2015, it will increase the number of deaths in Ethiopia by 27 percent. * By the end of 2002, 1.7 million Ethiopians had died because of AIDS. By 2014, there will be a cumulative total of 5.3 million AIDS deaths. Macroeconomic * There have been almost no studies of the impact of the epidemic on loss of skilled or unskilled labor, lost productivity because of illness or funeral attendance, or increased health care costs. The impact of AIDS on the rural economy is unknown. Health Sector * Currently, up to 42 percent of all hospital beds in the country are estimated to be occupied by AIDS patients. * According to WHO, Ethiopia has the sixth-highest number of TB cases in the world. * TB notification rates (all cases) increased from 40,096 in 1980 to 91,101 in 2000. * WHO estimates that 42 percent of adult (15-49) TB cases were HIV-positive during 2000. Household * There are no reports on the impact of AIDS on Ethiopian households, particularly its effect on the extended family system. Given deep and persistent poverty in Ethiopia, HIV/AIDS will further strain coping mechanisms through its enormous and complex impact. * As AIDS severely affects the most economically active members of the household, income and consumption patterns are likely to change dramatically, reducing or depleting income, savings, and remittances, and increasing expenditures on care and funerals. * Drought is depleting households assets, which may in turn be further reduced to pay for AIDS care (especially as most health care expenditure in Ethiopia is in the private sector); transport to reach care providers; burials; and household necessities. * HIV/AIDS also exacts an enormous psychosocial toll. Those who are most involved in care of AIDS patients may be more prone to stress and anger, emotions that may be made manifest in ways that convey stigma or discrimination toward PWHA. * Households that are headed by a single parent, have only one breadwinner, and/or have more than one HIV-infected member are particularly vulnerable to economic and psychosocial shocks. * Female-headed households tend to be poorer than those headed by men and thus have fewer resources with which to respond to HIV/AIDS. In Ethiopia, 24 percent of households are headed by women; in rural areas, this figure is 35 percent. * Moreover, women are traditional caregivers and thus take on additional responsibilities when family members become ill. And in single-parent households or those in which one parent has already died, girls are more likely than boys to provide care. Curtailing girls' education (and thus potential for formal labor force participation) may render them more vulnerable to acquiring HIV. Orphans and Other Vulnerable Children * At the end of 2001, there were 1.2 million AIDS orphans in Ethiopia. This number is projected to rise to 1.8 million by 2007 and to 2.5 million in 2014. There are insufficient social services for AIDS orphans, including health care, school fee subsidies, and shelter. Consequently, many become street children. * Orphans are particularly vulnerable to malnutrition, illness, abuse, child labor, and sexual exploitation. Concurrently, they suffer HIV/AIDS-related stigma and discrimination, not just from their relatives and communities, but also health service providers and teachers. * In Ethiopia, there are few governmental institutions for orphans, as extended families have usually taken them in. These families are themselves likely to be poor and must therefore stretch already inadequate resources to provide for both orphans and their own children. * As extended families' own AIDS burdens constrain their ability to foster orphaned children, orphans may be become heads of households and responsible for caring for younger siblings. There are few data on the impact of HIV/AIDS in Ethiopia. Shinn reflects that "persons who follow the issue closely are unanimous that the impact has been horrendous. They just do not know how horrendous."286 Demographic Ethiopia's mid-2002 population was 67.7 million; 287 50.3 percent of the population is female. 288 The U.N. Population Division examined population under a "no-AIDS" scenario. Because of continued high fertility and declining (albeit still high) mortality, Ethiopia's population will continue to increase substantially, to over 170 million by 2050. However, the population will be up to 16 percent smaller than it would have been in a "no-AIDS" scenario. (tables 3 and 4).289 Factors include AIDS deaths, as well as reduction in fertility due to condom use to prevent infection, fewer births because of a smaller reproductive age population, and fertility reduction associated with HIV infection. 290 Table 3. Projected Population with and without AIDS, 2000, 2015, and 2050 (Thousands) Period 2000 2015 2050 With AIDS Without AIDS With AIDS Without AIDS With AIDS Without AIDS 65,590 66,973 93,845 101,835 170,987 203,423 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 Table 4. Projected Population Reductions, 2000, 2015 AND 2050 Period 2000 2015 2050 Population Reduction (Thousands) Percentage Reduction Population Reduction (Thousands) Percentage Reduction Population Reduction (Thousands) Percentage Reduction 1,383 2 7,989 8 32,436 16 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 Life Expectancy Table 5 indicates that although Ethiopia's life expectancy is projected to increase, AIDS will reduce life expectancy by 9 to 13 percent through 2050. 291 Table 5. Life Expectancy with and without AIDS, 2000-2005, 2010-2015, and 2045-2050 Period 2000-2005 2010-2015 2045-2050 With AIDS Without AIDS Reduction in Life Expectancy Percentage Reduction With AIDS Without AIDS Reduction in Life Expectancy Percentage Reduction With AIDS Without AIDS Reduction in Life Expectancy Percentage Reduction Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 45.5 52.5 7 13 48.2 56.5 8 15 63.2 69.5 6 9 (NB: The figures for 2000-2005 and 2010-2015 in the table above are higher than those estimated by the U.S. Bureau of the Census. The Census Bureau figures, released in July 2002, indicate that life expectancy in Ethiopia was 41.6 in 2002, whereas it would have been 53.1 without AIDS; the comparable Census figures for 2010 were 40.1 and 56.3, respectively.292) AIDS Mortality AIDS is now recognized as the leading cause of adult morbidity and mortality in the country. 293 The MOH projects that by 2004, AIDS may account for about 460 deaths each day among 15- to 49-year-olds. 294 According to the U.N. Population Division, AIDS has already increased the number of deaths in Ethiopia by 6 percent. By 2000, 1.1 million Ethiopians had died because of AIDS.295 In 2001, UNAIDS estimated that were 160,000 adult and child AIDS deaths in Ethiopia.296 Ethiopia's MOH estimates that by the end of 2002, 1.7 million Ethiopians had died because of AIDS. It projects that by 2014, there will be an additional 3.6 million deaths because of AIDS, bringing the cumulative total to about 5.3 million by 2014. 297 This projection is roughly equal to the latest estimates of the U.N. Population Division, which projects 5.224 million cumulative AIDS deaths through 2015. Between 2000 and 2015, AIDS will increase the number of deaths in Ethiopia by 27 percent. The U.N. projects that by 2050, 14.851 million Ethiopians will have died because of the epidemic. (tables 6 and 7.)298 Table 6. Projected Number of Deaths with and without AIDS, 1980-2000, 2000-2015, and 2015-2050 (Thousands) Period 1980-2000 2000-2015 2015-2050 With AIDS Without AIDS With AIDS Without AIDS With AIDS Without AIDS 18,957 17,864 19,652 15,521 50,071 40,444 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 Table 7. Excess Deaths Because of AIDS, 1980-2000, 2000-2015, and 2015-2050 Period 1980-2000 2000-2015 2015-2050 Excess Deaths (Thousands) Percentage Increase Excess Deaths (Thousands) Percentage Increase Excess Deaths (Thousands) Percentage Increase 1,092 6 4,132 27 9,627 24 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 The U.S. Bureau of the Census's projection of the impact of HIV/AIDS on infant and child mortality in Ethiopia is found in Table 8. Table 8. Infant and Child Mortality with and without AIDS, 2002 and 2010 Indicator 2002 2010 With AIDS Without AIDS With AIDS Without AIDS Infant Mortality Rate (deaths per 1,000 live births) 104.3 92.1 94.9 77.9 Under-Five Mortality Rate (deaths per 1,000 live births) 169.9 150.0 150.8 123.3 Source: K. A. Stanecki. The AIDS Pandemic in the 21st Century. Washington, DC: U.S. Bureau of the Census, July 2002. Draft report prepared for the XIV International AIDS Conference, Barcelona, July 7-12, 2002 . Research undertaken by UNAIDS and WHO found that for Ethiopia, the HIV-attributable under-5 mortality rate (per 1,000 and corrected for competing causes of mortality) was 15.8 during the 1990s. (Rates among the 39 countries studies ranged from Madagascar [0.2] to Botswana [57.7].) The HIV-related population proportional attributable risk of dying before age 5 (i.e., the proportion of all-cause under-5 mortality attributable to HIV) was 8.1 percent; the average for the 39 sub-Saharan African countries studies was 7.7 percent, ranging from 0.1 percent in Madagascar to 42.4 percent in Botswana. 299 Although the impact of AIDS in Ethiopia has been far less intense than that seen in the hardest-hit southern Africa countries, it has been substantial and has eroded critical gains in human development. Macroeconomic There was a study conducted on 1994-95 on the direct and indirect costs of HIV/AIDS. Kello estimated that for 1997-2000, the direct medical costs of HIV/AIDS ranged from US$32 million to US$49 million (low-cost scenario). Income loss as a result of premature death was estimated at 23 to 42 percent of GNI. (The present author was not able to secure details on the methodolgy used by Kello.) Since the Kello study, there have no others on the effect of the epidemic on loss of skilled or unskilled labor, lost productivity because of illness or funeral attendance, or increased health care costs. The impact of AIDS on the rural economy is unknown.300 In Ethiopia's 2002 poverty reduction strategy paper, the Ministry of Finance and Economic Development stated: HIV/AIDS will also put a significant pressure on the country's limited foreign exchange reserves. As the epidemic accelerates, the country will be forced to import more and more of antiretroviral drugs which will certainly crowd out other imports of the country in a situation where the foreign exchange generating capacity of the economy shows no sign of significant improvement.301 Certainly, the foreign exchange requirements to import drugs would be very large if all AIDS patients received complete drug treatment.302 However, the Ministry of Finance and Economic Development's statement seems odd, as the government has not as yet provided ART and has not released firm numbers with regard to projected coverage. Moreover, any ART expenditures, at least in the next five years or so, would seemingly be heavily subsidized by loans or grants from the World Bank and the Global Fund to Fight AIDS, TB & Malaria (discussed below). Health Sector Currently, up to 42 percent of all hospital beds in the country are estimated to be occupied by AIDS patients. By 2004, the MOH projects that over half (54 percent) of all hospital beds will be occupied by AIDS patients (assuming current number of hospital beds remains constant).303 HIV and Tuberculosis According to WHO, Ethiopia has the sixth-highest number of TB cases in the world. In the Africa region, it is second only to Nigeria. In 2000, there were 249,457 active, reported TB cases (of which 104,734 were smear-positive). TB incidence (all cases) in 2000 was 397 per 100,000 population. The case rate was 114 per 100,000 population in 1980, 177 in 1985, 187 in 1990, 47 in 1995, and 145 in 2000. TB notification rates (all cases) have increased from 40,096 in 1980 to 71,731 in 1985 to 88,634 in 1990 to 91,101 in 2000. The notification rate for new, smear-positive cases rose from 11 per 100,000 population in 1993 to 48 in 2000.304 WHO estimates that 42 percent of adult (15-49) TB cases were HIV-positive during 2000.305 TB is the most common OI in Ethiopia. DOTS was introduced in 1995.306 At the end of 2001, about 875 of 2,563 (34 percent) health facilities were using DOTS. Given that only about 55 percent of Ethiopians have access to (i.e., live within 10 km of) general health services, DOTS expansion will be very difficult.307 WHO has also identified the following constraints: * TB and HIV teams are not collaborating sufficiently. * The TB Program is highly donor-dependent and its future sustainability questionable * NGOs, including the private sector, are not actively involved in TB control. * Chronic understaffing of the central TB unit and regional health bureaus has hampered regular supervision. Staff turnover is high. * There is insufficient provision of continuing medical education to health workers at various levels. * Training manuals, modules, and supervision guidelines are inadequate. * There are serious delays in drug procurement and distribution. * There is long delay in supply of laboratory materials. * Quality control measures are not fully operational. * There is a lack of emphasis on information, education, and communication at community level.308 Household Given deep and persistent poverty in Ethiopia, HIV/AIDS will further strain coping mechanisms through its enormous and complex impact on households. There are no reports on the impact of AIDS on Ethiopian households, particularly its effect on the extended family system.309 The impacts below are being seen in other hard-hit countries and thus may have import for Ethiopia. As AIDS severely affects the most economically active members of the household, income and consumption patterns are likely to change dramatically, reducing or depleting income, savings, and remittances, and increasing expenditures on care and funerals. Families may have to sell assets or increase their labor to pay for care (especially as most health care expenditure in Ethiopia is in the private sector); transport to reach care providers; burials; and household necessities. Household income often declines though (1) illness and death of the breadwinner, (2) wages lost by other household members who stop (or reduce) working to care for the sick, and/or (3) wages lost by (or opportunity cost of) attending funerals. Lost employment may be accompanied by loss of insurance and medical benefits. Household members ? including its oldest and youngest members ? may have to enter or remain in the workforce longer to compensate for the loss of the main breadwinner's earnings. Exacerbating this scenario is that more than one household member is often infected with HIV/AIDS.310 As the Stigma section indicated, HIV/AIDS also exacts an enormous psychosocial toll. Those who are most involved in care of AIDS patients may be more prone to stress and anger, emotions that may be made manifest in ways that convey stigma or discrimination toward PWHA. As mentioned in the Food Security section, drought is depleting household assets, which may in turn be further reduced to pay for AIDS care and/or supplement lost income of breadwinners. To survive, female household members may engage in activities such as sex work, increasing their risk of exposure to HIV. In some households, the death of a family member to AIDS may result in a loss of remittances, if that member is a government employee or trader who sends money back to the family. The death of a family member because of AIDS also leads to a reduction in savings and investment.311 Households that are headed by a single parent, have only one breadwinner, and/or have more than one HIV-infected member are particularly vulnerable to economic and psychosocial shocks. Female-headed households, for example, tend to be poorer than those headed by men and thus have fewer resources with which to respond to HIV/AIDS. In Ethiopia, 23.6 percent of households are headed by women; in rural areas, this figure is 35.4 percent.312 Moreover, women are traditional caregivers and thus take on additional responsibilities when family members become ill. And in single-parent households or those in which one parent has already died, girls are more likely than boys to provide care. When family breadwinners become ill or die, girls are often the first to be taken out of school313 to help care for those who are ill, carry out household chores, and/or undertake income-generating activities. Curtailing girls' education (and thus potential for formal labor force participation) may render them more vulnerable to acquiring HIV. Orphans and Other Vulnerable Children No statistics can adequately capture the human tragedy that orphans are facing in Ethiopia. For those children that have lost their parents to AIDS, grief is only the beginning of their troubles. When AIDS takes a parent, it usually takes a childhood as well. Children must witness death and suffering. The death of a parent threatens their psychosocial and physical well-being. Children lose love, affection, and nurturing. The loss of a father or both parents often results in loss of income and property rights. Children who grow up without parents may be left impoverished and unprotected.314 UNAIDS defines an AIDS orphan as a child under age 15 who has lost one or both parents to AIDS.315 Many Ethiopian AIDS orphans have lost (or will soon lose) both parents to AIDS. In a July 2002 report, UNAIDS estimated that there were 990,000 AIDS orphans living in Ethiopia at the end of 2001.316 Ethiopia's MOH put this figure at 1.2 million; it projects that the number of orphans living in Ethiopia will rise to 1.8 million by 2007 and to 2.5 million in 2014.317 Children on the Brink 2002, a report on AIDS orphans commissioned by USAID, estimated that the percent of Ethiopia's orphans due to AIDS rose from 2.3 percent in 1990 to 25.8 percent in 2001; it projected that this percentage will rise to 35.4 percent in 2005 and 43.0 percent in 2010.318 Before HIV/AIDS, Ethiopia had a large number of children orphaned by civil war and famine. The MOH underscores that the increase in the number of orphans because of AIDS is likely to exacerbate the already severe problem of homeless children who seek to subsist by working and living in urban streets.319 Orphans are particularly vulnerable to malnutrition, illness, abuse, child labor, and sexual exploitation. Concurrently, they suffer the stigma and discrimination associated with HIV/AIDS.320 UNICEF highlights that Ethiopia's AIDS orphans face stigmatization from not just their relatives and communities, but from health service providers and teachers. There are insufficient social services for AIDS orphans, including health care, school fee subsidies, and shelter. Consequently, many become street children.321 GOAL, one of the leading NGOs working with street children in Ethiopia, reports that the scale of the problem is immense and that the enormous number of street children has rendered interventions highly complex. GOAL believes that greater coordination among agencies working with street children is inadequate and must be improved. 322 In Ethiopia, there are few governmental institutions for orphans, as extended families have usually taken them in. These families are themselves likely to be poor and must therefore stretch already inadequate resources to provide for both orphans and their own children.323 Drs. Marta Segu and Sergut Wolde-Yohannes of the Boston University School of Public Health examined AIDS orphanhood in Bahir Dar, capital of the Amhara Region, 570 km northwest of Addis Ababa. Bahir Dar, which literally means "by the sea side," is situated on the southern shore of Lake Tana, the source of the Blue Nile River. It is one of the most rapidly growing cities in Ethiopia, attracting many migrants because of its substantial tourist industry and the lack of economic opportunity in surrounding areas. Government social services, grossly inadequate before HIV/AIDS, are now severely overburdened and underresourced. 324 As extended families' own AIDS burdens constrain their ability to foster orphaned children, orphans may be become heads of households and responsible for caring for younger siblings. 325 In many areas of Bahir Dar, for example, weakening safety nets are leading orphans to assume the role of head of household at a very young age. Children as young as eight report caring for younger siblings. Orphan-headed households must deal not only with survival but also with grief, prejudice, and social exclusion. In Bahir Dah, orphan heads of households and organizations working with them identified the following as major issues: * insufficient income to meet basic needs, including food and clothing * shortage of housing * constraints to school attendance, including inability to pay school fees and purchase school materials and uniforms * lack of vocational and skills training * lack of employment opportunities * lack of access to health care * stigmatization and rejection by community members * lack of moral support * lack of assistance with household tasks326 Response At a Glance The At a Glance section summarizes the more detailed data found below it. Government Response * In 1985 (before the first AIDS case had been officially diagnosed), the government of Ethiopia established a national task force to address prevention and control of HIV/AIDS. The task force issued the first AIDS control strategy by the end of 1985. * In September 1987, the government established an HIV/AIDS department within the Ministry of Health. The MOH developed a short-term plan in March 1987 and medium-term plans in 1987 and 1992. * As in many countries, these interventions were inadequate in scale; largely ineffective in implementation; lacked sufficient stakeholder involvement in planning and implementation, especially at the community level; were poorly or not at all coordinated and integrated across sectors and among service providers; and received relatively low priority within government, society in general, and in the international community, with a resultant low level of allocated financial and human resources. * In August 1989, the MOH drafted a four-point policy statement on AIDS prevention. The first draft of a national policy was created in 1991, though not approved until 1998. * The policy has the overall objective of providing an enabling environment for the prevention and mitigation of HIV/AIDS. Its specific objectives are to: ? establish effective HIV/AIDS prevention and mitigation strategies to curb the spread of the epidemic ? promote a broad, multisectoral response to HIV/AIDS, including more effective coordination and resource mobilization by government, NGOs, the private sector, and communities ? encourage government sectors, NGOs, the private sector, and communities to take measures to alleviate the social and economic impact of HIV/AIDS ? support a proper institutional, home-, and community-based health care and psychological environment for PWHA, orphans, and surviving dependents ? safeguard the human rights of PWHA and avoid discrimination against them ? empower women, youth, and other vulnerable groups to take action to protect themselves against HIV ? promote and encourage research activities targeted toward preventive, curative, and rehabilitative aspects of HIV/AIDS * The Strategic Framework for the National Response to HIV/AIDS in Ethiopia for 2000-2004 focuses on reducing the transmission of HIV and associated morbidity and mortality, and its impact on individuals, families, and society at large. The strategy is built on four issues: multisectoralism, participation, leadership, and efficient management (including adequate monitoring and evaluation). * The National AIDS Prevention and Control Council and its secretariat were established in 2000. The council is chaired by the president of Ethiopia and comprises members from government, NGOs, religious bodies, and civil society. The council oversees the implementation of the Strategic Framework for the National Response to HIV/AIDS in Ethiopia for 2000-2004, examines and approves annual plans and budgets, and monitors plan performance and impact. * At its fourth regular session in June 2001, the National AIDS Prevention and Control Council declared HIV/AIDS a national emergency. Ministries outside Health * The Ministry of Education has yet to provide clear guidelines for a comprehensive HIV education curriculum. * Despite that the agricultural and livestock sectors account for over 85 percent of the labor force, the Ministry of Agriculture is not actively involved in HIV prevention. * The Ethiopian Ministry of Youth, Sports, and Culture is using a youth-based participatory process to develop an HIV/AIDS and sexual health program. Assessment of Government Response * Although Ethiopia began the HIV/AIDS policy process in 1989 ¾ far earlier than most other countries ¾ it took nine years to complete. Moreover, the process involved almost no participation by actors outside government. * There was little high-level, political involvement in HIV/AIDS during the 1990s. By 1999, however, President Negasso Gidada had become an active spokesman in the fight against HIV/AIDS. Current President Girma Woldegiorgis has also made high-profile statements about the epidemic. * Ethiopia's response is constrained by extremely limited human, financial, technical, material, and management capacities. The country's health care infrastructure is massively underequipped to address HIV/AIDS, particularly outside Addis Ababa. The country's size and poor transport infrastructure are also key factors. * Bureaucratic constraints are impeding the response. The Ministry of Health has traditionally been one of the weakest ministries in Ethiopia, and its ability to absorb and manage new funding has been problematic. * Although much more funding is required, building additional human capacity in the * health sector, improving coordination, and using existing funds efficiently and effectively are paramount. That the HIV/AIDS program is so highly dependent on donors also raises concerns about its future sustainability. * Tensions with Eritrea and drought, among others, may lessen the government's focus on HIV/AIDS, as well as divert resources that could be used to address it. * Responsibility for implementing HIV/AIDS interventions rests with the regional HIV/AIDS councils. These, in turn, work through the zones, woredas, and kebeles. In the long term, this system is likely to enhance delivery of HIV/AIDS interventions. In the short term, however, it is expensive, requires large numbers of qualified staff to carry out programs at the different levels of government, and renders coordination difficult. Human Rights * The National HIV/AIDS Policy states that PWHA "shall not be subject to special restrictions on employment, education, access to public facilities, or housing." However, there are no specific laws to enforce the policy. * Although Ethiopia's 1994 Constitution outlaws discrimination of any form, it does not address HIV/AIDS-related discrimination. A study undertaken in 1999 found that although existing laws are nondiscriminatory with regard to PWHA, there is evidence of discriminatory practices in the workplace, health care facilities, schools, and housing. * Enforcement of current laws (including the National Policy for Women) is paramount. The need for new legislation to specifically address discrimination of PWHA, preemployment testing, orphan care, and other issues must also be examined. Budgets * Ethiopia's 2002 GFATM proposal indicated that the government is annually allocating US$1 million to coordinate the national response. * The country requires at least US$166 million annually for HIV/AIDS prevention and care (this figure does not include ART). Ethiopia's 2002 GFATM proposal stated that the HIV/AIDS funding gap was US$120 million. Donors * Major donors vis-à-vis HIV/AIDS include Christian Relief and Development Agency, WHO, UNICEF, UNAIDS, UNDP, World Bank, USAID, Ireland Aid, DFID, Netherlands, Norway, CDC, and GTZ. Japan and Italian Cooperation are also funding HIV/AIDS activates in Ethiopia. * Ethiopia was one of the first countries to receive funding from the World Bank's Multicountry HIV/AIDS Program for Africa (MAP). The US$64.3 million MAP project is meant to finance a portion of the government's 2000-2004 HIV/AIDS strategic plan. Almost half of the loan is earmarked for community-based activity at the woreda and kebele level. Global Fund to Fight AIDS, Tuberculosis & Malaria * Ethiopia has been approved for US$139,403,241 for HIV/AIDS, US$26,980,649 for TB, and US$76,875,212 for malaria. As of March 2003, no funds from either the first or second round had yet been released. NGOs * Given years of centralized power, civil society in Ethiopia remains weak and underdeveloped. Since the country has moved toward a multiparty democracy, civil society is becoming increasingly crucial to the country's socioeconomic development; however, compared to other African countries, Ethiopia's NGO sector is small and has limited capacity. * Nevertheless, civil society has started mobilizing against HIV/AIDS. Most NGOs concentrate on HIV/AIDS awareness. Activities are largely concentrated in and around major cities and, thus far, have had little impact on rural populations. They are also on a limited scale, reaching only a small fraction of the population in need of services. They are not inadequately funded and are often intermittent because of irregular and insufficient funding. * The two national PWHA associations in Ethiopia are Dawn of Hope and Mekdim Ethiopia HIV Positive Persons and AIDS Orphans National Association, both of which are providing an array of HIV/AIDS services. There are also local associations of PWHA. Faith-based Organizations * According to the 2000 EDHS, only 7 percent of women and 8 percent of men cited a mosque or church as an information source for HIV/AIDS. These data highlight a major "missed opportunity" in terms of HIV/AIDS education. * There are, however, faith-based organizations in Ethiopia providing HIV/AIDS prevention, care, and support. * Some influential religious leaders appear to be publicly supporting action against HIV/AIDS (though not condom promotion and use). Orphans * Numerous NGOs and CBOs are providing support to AIDS orphans and other vulnerable children. Traditional Medicine * Many Ethiopians with AIDS are likely to use traditional medicine to alleviate symptoms of OIs. The MOH has encouraged the involvement of traditional healers in AIDS care and a national committee comprising scientists and traditional healers has been formed. * The Department of Drug Research at the Ethiopian Health and Nutrition Research Institute is working with traditional healers who claim to have cures for AIDS and some OIs. Blood * The MOH has recently published a national blood service strategy that mandates the Ethiopian Red Cross Society to operate blood transfusion services throughout the country. GFATM funding will be used to increase the number of blood banks and initiate other improvements. Universal Precautions and Post Exposure Prophylaxis * The MOH has prepared draft national guidelines on UP and PEP, with GFATM funding expected to finance their implementation. PMTCT * Only 50 clients received PMTCT services in Ethiopia during 2001. There were three public/NGO sites providing basic PMTCT services in 2001, with no such services in the commercial sector. * In January 2002, national guidelines on PMTCT were released. In addition, the national policy on ART promotes improving the coverage of PMTCT in all parts of the country. * The MOH has initiated a pilot PMTCT program. The MOH envisions using GFATM financing to scale up PMTCT to 50 sites spanning all regions. It is also planning to implement PMTCT+ services. * Addis Ababa University's Medical Faculty is currently conducting a research project on the efficacy of a longer course of NVP among breastfeeding mothers in three sites. VCT * Only 2 percent of Ethiopian men have been tested for HIV. However, 65 percent of all men who have not been tested for HIV want to be tested. * During 2001, only 2,400 to 3,500 clients were seen at Ethiopia's 20 publicly funded/NGO VCT centers. (Twenty percent of VCT services were offered in the commercial sector.) * In 2002, the country had 23 VCT centers, of which 3 were government, 12 private, and 8 NGO. It estimated that 10,000 clients were seen at these facilities in 2002. With GAFTM financing, this figure is projected to rise to 500,000 by year five. * Almost all of the country's VCT services are located in Addis. There is a severe lack of trained HIV/AIDS counselors in the country. Care and Support * The Ethiopian MOH and Addis Ababa University have developed national guidelines on HIV/AIDS care and support for adults and children. There are multiple care and support activities occurring in Ethiopia. However, there is great disparity with regard to resources for HIV/AIDS care and support between Addis and other regions of the country. * Some NGOs have been providing home-based care since 1992. National guidelines on HBC were developed in 2001. ART * Although national guidelines on clinical management of HIV infection in adults and children have been in use for two years, they require updating. * No adults with HIV/AIDS received isoniazid prophylaxis during 2001. Access to HIV/AIDS-related care and support services in Addis, other urban areas, and rural areas is deemed minimal. There were no public/NGO nor private sites providing ART during 2001. * The Ethio-Netherlands AIDS Research Project is exploring alternatives to the biologic markers used to determine initiation of ART in wealthy countries. Military * The Ethiopian National Defense Force (ENDF) has approximately 100,000 personnel, rendering it one of the largest military forces in Africa. * Ethiopian defense forces are often cited as being at the forefront of HIV prevention. The Ethiopian military has developed an extensive HIV/AIDS workplan that includes training at all levels, widespread distribution of condoms, information dissemination, surveillance, and research. A major initiative under way is deploying demobilized soldiers as HBC providers. * ENDF is working with the CDC on a peer education project; other collaborators Family Health International, the Civil-Military Alliance to Combat HIV & AIDS, the POLICY Project of The Futures Group International, the U.S. Naval Health Research Center, Population Services International, the U.S. Department of Defense, USAID, and UNAIDS. * The U.N. peacekeeping mission in Ethiopia and Eritrea is training troops from both countries, as well as its own peacekeepers, to instruct fellow soldiers and civilians on HIV prevention. Other Mobile Populations * The World Food Program is working with local NGOs and transport companies to train over 2,000 WFP-employed truck drivers and their assistants in HIV/AIDS awareness and prevention. * The International Organization for Migration is deploying mobile units along the Ethio-Djibouti trucking route and in a gold mining area in Ethiopia. The units provide free services and easy access to VCT and syndromic treatment of STIs. Private Sector * According to the 2000 EDHS, only 4 percent of men and 1 percent of women have heard about HIV/AIDS at their workplace. Note, however, that of "employed" women, 56 percent work in the agriculture sector, and of these women, 94 percent work on their own land. Among employed men, 84 percent work in agriculture. Thus, reaching those in rural areas is crucial. * Some workplace interventions are beginning to occur. For example, the Confederation of Ethiopian Trade Unions and the Addis Ababa Chamber of Commerce have received funding from USAID to implement HIV prevention programs in the workplace. Government Response In 1985 (before the first AIDS case had been officially diagnosed), the government of Ethiopia established a national task force to address prevention and control of HIV/AIDS. The task force issued the first AIDS control strategy by the end of 1985.327 In September 1987, the government established an HIV/AIDS department within the Ministry of Health and charged it with directing and coordinating the implementation of the AIDS control strategy.328 In collaboration with WHO's Global Program on AIDS, the MOH developed a short-term plan in March 1987 and the first medium-term plan in May 1987. This latter (1987-91) focused on public awareness, establishment of laboratory services, HIV surveillance, and training of health workers. The second medium-term plan (1992-96) emphasized interventions to stop the spread of HIV through a multisectoral approach and decentralization of HIV/STI prevention and control activities. 329 As in many countries, these interventions were inadequate in scale; largely ineffective in implementation; lacked sufficient stakeholder involvement in planning and implementation, especially at the community level; were poorly or not at all coordinated and integrated across sectors and among service providers; and received relatively low priority within government, society in general, and in the international community, with a resultant low level of allocated financial and human resources.330 National HIV/AIDS Policy In August 1989, the MOH drafted a four-point policy statement on AIDS prevention. The minister of health convened a 13-member policy drafting committee on HIV/AIDS to create a comprehensive national policy. The committee produced the first draft of the national policy in 1991 and forwarded it to the MOH. Between 1992 and 1993, there were numerous revisions. However, between 1993 and 1996, there was little progress on the policy, largely because the Ethiopian government was engaged in significant decentralization of many of its activities, including health. The decentralization led to a drastic reduction in HIV/AIDS technical staff at the MOH; moreover, the momentum to produce an HIV/AIDS policy declined. In August 1998, after further revisions and review, a national HIV/AIDS policy was finally approved by the Council of Ministers. 331 The policy has the overall objective of providing an enabling environment for the prevention and mitigation of HIV/AIDS. Its specific objectives are to: * establish effective HIV/AIDS prevention and mitigation strategies to curb the spread of the epidemic * promote a broad, multisectoral response to HIV/AIDS, including more effective coordination and resource mobilization by government, NGOs, the private sector, and communities * encourage government sectors, NGOs, the private sector, and communities to take measures to alleviate the social and economic impact of HIV/AIDS * support a proper institutional, home-, and community-based health care and psychological environment for PWHA, orphans, and surviving dependents * safeguard the human rights of PWHA and avoid discrimination against them * empower women, youth, and other vulnerable groups to take action to protect themselves against HIV * promote and encourage research activities targeted toward preventive, curative, and rehabilitative aspects of HIV/AIDS332 The policy states that PWHA should be involved in all these efforts through education, counseling, and peer groups to "help themselves live with HIV/AIDS and to communicate to the community the dangers of risky behaviors." 333 The priority prevention and control measures called for in the policy include: * encourage people to maintain faithful sexual relationships with one partner * promote the use of condoms in situations where there may be the risk of HIV transmission * minimize other unsafe practices such as illegal injections, harmful traditional procedures, and drug addiction * ensure safe medical practices to protect against HIV transmission * ensure the human rights of people with AIDS334 Strategic Framework for the National Response to HIV/AIDS in Ethiopia for 2000-2004 As the HIV/AIDS policy framework was being developed, the Ministry of Health coordinated a process of strategic planning and program development in Ethiopia's nine regions and two city administrations. This process involved national and regional governmental institutions, the major regional sector NGOs and religious organizations, and other key stakeholders. The result was the five-year Federal Level Multisectoral HIV/AIDS Strategic Plan 2000-2004 (costed at US$11 million) and accompanying Regional Multisectoral HIV/AIDS Strategic Plans 2000-2004 (costed at US$45 million). Together, these plans were synthesized into the Strategic Framework for the National Response to HIV/AIDS in Ethiopia for 2000-2004. The framework focuses on reducing the transmission of HIV and associated morbidity and mortality, and its impact on individuals, families, and society at large. The strategy is built on four issues: multisectoralism, participation, leadership, and efficient management (including adequate monitoring and evaluation). 335 The strategy highlights the following priority areas for action: Prevention * improve access to and quality of STI, TB, and HIV/AIDS prevention, care, and support services to meet the needs of groups at increased risk of HIV infection * increase the provision of comprehensive STI/TB management in health care facilities * increase access to education in general and to HIV/AIDS education and communication in particular * increase accessibility and availability of condoms * promote information, education, and communication messages that are continuous, appropriate, acceptable, and effective in inducing behavior change * contribute to national and local initiatives to alleviate poverty and increase employment opportunities, particularly for youth and women * empower women and girls to reduce their risk of HIV infection * prevent HIV transmission in hospital settings336 Care and Support * provide clinical and home- and community-based care for PWHA * increase social support to PWHA and their families * establish an ethical, legal, and human rights framework for PWHA * expand and accelerate sector-specific interventions to mitigate impact * increase HIV/AIDS research and surveillance. 337 The National AIDS Prevention Council The National AIDS Prevention and Control Council and its secretariat were established in April 2000. The council is chaired by the president of Ethiopia and comprises members from government, NGOs, religious bodies, and civil society. The council oversees the implementation of the Strategic Framework for the National Response to HIV/AIDS in Ethiopia for 2000-2004, examines and approves annual plans and budgets, and monitors plan performance and impact.338 At its fourth regular session in June 2001, the council declared HIV/AIDS a national emergency.339 The council has appointed the National HIV/AIDS Board of Advisors, which meet monthly.340 The National HIV/AIDS Prevention and Control Office (HAPCO, formerly the National AIDS Council Secretariat) was reestablished by Proclamation No. 276/2002 in July 2002 as the executive arm of the council. HAPCO is led by an executive board comprising eight ministers and several representatives of civil society and the private sector.341 There are also HIV/AIDS focal persons at regional level. At district level, the focal person for disease prevention and control covers this function. With the decentralization process, AIDS committees have been established in all woredas.342 As discussed in the Donor section below, the World Bank is providing Ethiopia with US$63.4 million (concessional loan) for a three-year project to help implement the Strategic Framework for the National Response to HIV/AIDS in Ethiopia for 2000-2004. The Bank project also created an Emergency HIV/AIDS Fund to channel grants directly to community organizations (kebeles), NGOs, and the private sector.343 , 344 Ministries outside Health * The Ministry of Education has yet to provide clear guidelines for a comprehensive HIV education curriculum. Although there are several hundred anti-HIV/AIDS clubs in high schools, their goals vary widely and they do not promote HIV prevention skills.345 * Despite that the agricultural and livestock sectors account for over 85 percent of the labor force, 346 the Ministry of Agriculture is not actively involved in HIV prevention. 347 , 348 * The Ethiopian Ministry of Youth, Sports, and Culture is using a youth-based participatory process to develop an HIV/AIDS and sexual health program. Young people developed a national youth charter and a three-year action plan to mobilize youth for improved sexual health and HIV preventive behavior. The participatory process involved in-depth training for 51 youth leaders from all regions.349 * Ethiopian Airlines, a parastatal, conducts mandatory HIV testing of all staff every six months. Those who test positive are counseled by in-house medical staff. All HIV-positive cockpit crew are grounded and given other jobs. Some HIV-positive personnel take advantage of free air tickets to visit South Africa or Thailand regularly for treatment.350 Assessment of Current Response Although Ethiopia began the HIV/AIDS policy process in 1989 ¾ far earlier than most other countries ¾ it took nine years to complete, much longer than in other countries. Moreover, the process involved almost no participation by actors outside government. 351 According to a 2002 report from the U.S. National Intelligence Council, the Ethiopian Government "does not appear focused on AIDS, despite occasional statements on the issue." Although the government has focused heavily on the conflict with Eritrea (and drought), this NIC assessment does not seem entirely fair. For example, David Shinn, who served as U.S. ambassador to Ethiopia during 1996-99 (and who contributed to the NIC study) reports that when he assumed his post in 1996, "virtually no one in Ethiopia was taking the HIV/AIDS problem seriously." However, by 1999, "President Negasso Gidada had become an active governmental spokesman for HIV/AIDS....The issue finally and belatedly reached critical mass in 1999."352 In October 2002, as he opened Parliament, Ethiopian President Girma Woldegiorgis stated: The alarming spread of the disease which is attacking our youngsters could be a great deterrent to the efforts of the nation in achieving sustainable development and democratic order....Needless to say the epidemic is badly affecting the main working force of the nation in urban and rural areas.353 (Some heads of state in hard-hit African countries omit any mention of AIDS in their major speeches.) After a 2001 return to the country, Shinn noted that constraints to the response included that the "bureaucracy has not yet organized itself in a way to take maximum advantage of growing financial resources. The Ministry of Health has traditionally been one of the weakest ministries in Ethiopia. Also, the one-year-old National HIV/AIDS Council has not yet become an effective coordinator of the many disparate efforts to counter the problem." 354 A report from the U.N. Office for the Coordination of Humanitarian Affairs in June 2002 stated that: The anti-HIV/AIDS campaign is being spearheaded by the National AIDS Council Secretariat (NACS). However, the World Bank, which has contributed US $59.7 million to fighting HIV/AIDS in Ethiopia, has criticized NACS as lacking the capability to combat the virus. The Bank said it was "seriously concerned" by its failure to improve the capacity of those participating in the campaign. A team of World Bank inspectors noted "serious shortcomings" requiring urgent rectification in order to enhance the effectiveness of anti-AIDS projects. Almost half the NACS proposals submitted for funding to fight HIV/AIDS are still "pending" while a further 26 percent have been rejected.355 A report in November 2002 raised concerns that NACS had spent only one-fifth of the Bank funds in the last two years. 356 In an interview in November 2002, Negatu Mereke, head of the National AIDS Secretariat, commented on the Bank's criticism: We did not adequately establish the institutional arrangements that enabled effective absorption of funds of that size when the loan of US $59.7 million was secured two years back. Institutionally, we did not have that capacity to deal with the funds that came to the country. The absorption of funds of this size was strange for us. Even if the government and other stakeholders were very cognizant of the magnitude of the problem, and committed to fight the spread of the pandemic and mitigate its impact, they lacked experience and capacity to handle it in terms of funds of this size for HIV/AIDS. In the last year, we have seen unprecedented levels of political and institutional interest in reversing the cause of the HIV/AIDS pandemic. In fact, in the last few months or so we were highly engaged in addressing basic policies and organizational issues. We believe this will accelerate the implementation of HIV/AIDS prevention and control. With our legal status proclamation [reference to HAPCO], political leadership has improved significantly, providing a more enabling environment for the fight against the pandemic and its effects on development. Effective institutional arrangements have been put in place from federal level to the smallest community. We have cleared the organizational confusion that impaired the speedy implementation of the three-year World Bank loan. Absorption of funds has accelerated. From the first year of the loan, less than US $1.5 million was disbursed. The following year, the amount rose to US $12 million. Some 292 organizations and 25 government bodies have secured funds out of 350 applications.357 Ethiopia's response is constrained by extremely limited human, financial, technical, material, and management capacities. The country's health care infrastructure is, as David Shinn puts it: shockingly ill equipped to carry out a national anti-HIV/AIDS program, particularly outside Addis Ababa. The health care infrastructure is spread thin and poorly equipped. Equipment is often broken and no repair program is established. 358 Although much more funding is required, building additional human capacity in the health sector, improving coordination, and using existing funds efficiently and effectively are paramount. 359 That the HIV/AIDS program is so highly dependent on donors also raises concerns about its future sustainability. The tensions with Eritrea persist, such that there is concern that the peace accord may fall apart. The country is also contending with a major drought. Certainly, these factors lessen the government's focus on HIV/AIDS, as well as divert resources that could be used to address it. With regard to the war with Eritrea, Carol Bellamy, executive director of UNICEF, recently stated that: [Ethiopia] is a poor country, and those limited resources could probably have been better spent on health and education and other kinds of productive investments; investing in conflict does not produce a return.360 A major concern is that behavior change is seriously lagging behind knowledge. The BSS preliminary findings indicate that behaviors that put people at risk of acquiring HIV are more widespread than the 2000 EDHS suggests. Yet dissemination of behavior change messages is impeded by the fact that 86.4 percent of women and 72.6 percent of men have no exposure to the mass media. In rural areas, these figures are 93.7 and 80.3 percent, respectively. Only 20.7 percent of all Ethiopian household have a radio; only 12.8 percent of rural households have a radio.361 Moreover, as Shinn highlights: Ethiopia is not only populous, but it is geographically large - the size of Texas and California combined. Improvement of the transportation infrastructure has made significant stride, but reaching all parts of the country in a timely way remains difficult, especially so during the rainy season when some areas are completely cut off for short periods of time. Even if it was a wealthy country, the inadequate transportation infrastructure and difficult topography would pose a major challenge to an effective health care system generally and a program to combat HIV/AIDS in particular....The war on HIV/AIDS would be aided enormously if Ethiopian universities' medical departments and major research institutions and counterpart organizations outside the country had point-to-point satellite connections. 362 Researchers from Addis Ababa University and the Ethio-Netherlands AIDS Research Project also underscore transport constraints faced by staff at both the federal and regional health bureaus.363 Shinn believes that Ethiopia's policy of ethnic federalism, adopted soon after the 1991 overthrow of Mengistu Haile Mariam, is "both a blessing and a curse" with regard to addressing HIV/AIDS. Although the 85-member National HIV/AIDS Council is charged with coordinating the overall effort, responsibility for implementing the program rests with the regional HIV/AIDS councils. These, in turn, work through the zones, woredas, and kebeles. In the long term, this system is likely to enhance delivery of HIV/AIDS interventions. In the short term, however, it is expensive, requires large numbers of qualified staff to carry out programs at the different levels of government, and renders coordination difficult. 364 Human Rights The national HIV/AIDS policy and strategic framework both address human rights and HIV/AIDS, though in a very general manner. The National HIV/AIDS Policy states that PWHA "shall not be subject to special restrictions on employment, education, access to public facilities, or housing."365 However, there are no specific laws to enforce the policy. Although Ethiopia's 1994 Constitution outlaws discrimination of any form, it does not address HIV/AIDS-related discrimination. A study undertaken in 1999 found that although existing laws are nondiscriminatory with regard to PWHA, there is evidence of discriminatory practices in the workplace, health care facilities, schools, and housing. Enforcement of current laws (including the National Policy for Women) is paramount. The need for new legislation to specifically address discrimination of PWHA, preemployment testing, orphan care, and other issues must also be examined. 366 , 367 Ethiopia's June 2002 proposal to the GFATM stated that the "Ministry of Justice is currently reviewing legislation relevant to HIV/AIDS."368 Budgets Ethiopia's 2002 GFATM proposal indicated that the government is annually allocating US$1 million to HAPCO to coordinate the national response (more detail on the timeframe was not included). In 2001, the government earmarked US$8.5 million to HIV/AIDS; this included financing from external donors. Data on the 2002 earmark for malaria were included in the GFATM proposal, though not for HIV/AIDS. 369 In June 2002, Abebe Kebede of the Addis Ababa Metropolitan HIV/AIDS Secretariat reported that the country required at least US$166 million annually for HIV/AIDS prevention and care (this figure does not include ART).370 Ethiopia's 2002 GFATM proposal stated that the HIV/AIDS "national funding gap identified through the federal and regional implementation plans stands at US$120 million." 371 Donors The 2002 GFATM proposal provided the following information on the main donor support for HIV/AIDS in Ethiopia: * Christian Relief and Development Agency: HIV/AIDS interventions, NGO capacity building, advocacy: US$233,400 for 2001-2003 * WHO: Technical support to health sector HIV/AIDS interventions: US$1.75 million for 2002-2003 * UNICEF: Support to multisectoral HIV/AIDS interventions, PMTCT, youth prevention: US$3.4 million for 2001 -2002 * UNAIDS: Support to HAPCO, support MOH in VCT: US$486,000 for 2002-2003 * UNDP: Leadership, advocacy & communication, mainstreaming in planning, human rights, socioeconomic research: US$3 million for 2002-2006 * World Bank: Funding for the Ethiopian Multisectoral AIDS Program: US$13.36 million for 2001-2002 * USAID: Prevention, care and support, BSS: no amount provided in the GFATM proposal (USAID provided US$8.2 million in HIV/AIDS assistance to Ethiopia in FY2001, up from $7.6 million in FY2000372) * Ireland Aid: Support to MOH in strengthening VCT and OI management: US$34,000 for 2002 * DFID: Support to multisectoral response: US$35,000 for 2002 * Netherlands: Ethio-Netherlands AIDS Research Project (ENARP), WHO-Netherlands support: over US$1 million for 2002-2003 * Norway: Support channeled through UNICEF, UNFPA and HAPCO: US$1.3 million for 2002 * CDC: Surveillance, STI, VCT: US$10 million for 2002-2003 (more on further CDC funding to reach military personnel below) * GTZ: Support to Amhara, Tigray, and Oromiya Regions: US$120,000 for 2002373 Japan and Italian Cooperation are also funding HIV/AIDS activates in Ethiopia. In general, Ethiopia's largest bilateral donors are Germany, Sweden, the European Union, Italy, and the United States. The U.N., particularly UNICEF, has an extensive program in Ethiopia, with a major focus on girls' education. Ethiopia is one of the World Bank's International Development Association's (IDA) largest clients in Africa, with a portfolio of 20 projects totaling over US$1.9 billion.374 (IDA lends money to the world's poorest countries at zero interest with a 10-year grace period and maturities of 35 to 40 years.) Ethiopia was one of the first countries to receive funding from the Bank's Multicountry HIV/AIDS Program for Africa (MAP). To quality for MAP, Ethiopia had to meet the following criteria: 1. satisfactory evidence of a strategic approach to HIV/AIDS, developed in a participatory manner 2. existence of a high-level HIV/AIDS coordinating body, with broad representation of key stakeholders from all sectors, including people living with HIV/AIDS 3. government commitment to quick implementation arrangements, including channeling grant funds for HIV/AIDS activities directly to communities, civil society, and the private sector 4. agreement by the government to use multiple implementation agencies, especially NGOs and CBOs375 As mentioned above, the US$64.3 million MAP project is meant to finance a portion of the government's 2000-2004 HIV/AIDS strategic plan. Almost half of the loan is earmarked for community-based activity at the woreda and kebele level. The goal is to provide funding to 165 woredas during the three-year period of the loan. The money can be used to provide training for district coordinators and help create a financial system for accountability purposes. Once a district government has shown that it has an adequate financial system in place, it is eligible to draw funds from the loan and forward that money to kebeles for implementation.376 By the end of the project period, the Bank expects that: * Access to treatment for OIs will increase from 30 to 50 percent. * The number of national surveillance sites will increase by 10 percent. * The number of blood banks will increase by 25 percent.377 Other objectives: * At least 70 percent of the participating woredas will have implemented their agreed action plans. * The Emergency AIDS Fund disbursements will be at least 70 percent of plan level. * The number of affordable VCT services incorporated into ANC, TB, and STI clinics will have increased by 10 percent.378 More information on donors is found in the Links section. Global Fund to Fight AIDS, Tuberculosis & Malaria When the first round of GFATM grants was announced in April 2002, Ethiopia was approved to receive US$26,980,649, for its five-year TB proposal. In the second round, announced in January 2003, the fund approved US$139,403,241 for Ethiopia's HIV/AIDS proposal and US$76,875,212 for malaria (again, for a five-year implementation timeframe.) (Both second-round grants were approved pending further clarifications by the Ethiopia Global Fund Coordinating Committee [i.e., the country coordinating mechanism].) 379 As of March 2003, no funds from either the first or second round had yet been released. The 2002 proposal was drafted by Ethiopia's Global Fund Coordinating Committee, which comprises 12 members and is chaired by the minister of health. Members include representatives from the Ministry of Finance and Economic Development, HAPCO, WHO, Christian Relief and Development Association, USAID, Norwegian Embassy, Ethiopian Health and Nutrition Research Institute, Ethiopian Public Health Association, and Dawn of Hope (a major PWHA association). 380 The overarching objectives of the GFATM proposal are to reduce HIV infection by 25 percent by 2007 and scale up baseline coverage of national strategic interventions in all regions. In addition to the organizations already mentioned in the Donors section, other major actors with responsibility for implementing Ethiopia's GFATM proposal include: * Family Health International * Medical Faculty of Addis Ababa University, as well as other teaching hospitals/medical schools * CARE Ethiopia * Ethiopian Red Cross Society-Blood Transfusion Service * Johns Hopkins University * Action AID * DKT/Population Services International (social marketing of the Hiwot condom brand; also works closely with the Ministry of Defense on training programs on HIV awareness and proper and consistent use of condoms for military personnel posted in border areas. Worked with military to produce a film on protecting their families from HIV/AIDS)381 NGOs Given years of centralized power, civil society in Ethiopia remains weak and underdeveloped. Since the country has moved toward a multiparty democracy, civil society is becoming increasingly crucial to the country's socioeconomic development; however, compared to other African countries, Ethiopia's NGO sector is small and has limited capacity. Most NGOs are located in Addis Ababa.382 Nevertheless, civil society has started mobilizing against HIV/AIDS. Most NGOs concentrate on HIV/AIDS awareness; few focus on VCT, community-based care, or social support. Activities are largely concentrated in and around major cities and, thus far, have had little impact on rural populations. They are also on a limited scale, reaching only a small fraction of the population in need of services. They are not inadequately funded and are often intermittent because of irregular and insufficient funding.383 The World Bank believes that there is considerable scope for strengthening civil society HIV/AIDS activities as local government (woreda, kebele) and community governance structures have a strong relationship in Ethiopia. Ethiopian society also features prominent traditional social groups such as the edir or mahaber, and religious committees, all of which can be mobilized in the fight against HIV/AIDS.384 Building on these strengths will be crucial. However, it is unclear how much local structures can take on, given their own pressures of poverty, drought, and AIDS morbidity and mortality. The two national PWHA associations in Ethiopia are Dawn of Hope and Mekdim Ethiopia HIV Positive Persons and AIDS Orphans National Association, both of which are providing an array of HIV/AIDS services. There are also local associations of PWHA. (See the Links section for a continually updated list of NGOs and CBOs.). Faith-based Organizations According to the 2000 EDHS, only 7.0 percent of women and 8.1 percent of men cited a mosque or church as an information source for HIV/AIDS.385 These data highlight a major "missed opportunity" in terms of HIV/AIDS education. There are, however, faith-based organizations in Ethiopia providing HIV/AIDS prevention, care, and support. For example, the Ethiopian Orthodox Church, Ethiopian Evangelical Church, and Ethiopian Islamic Affairs Supreme Council have received funding from USAID and are working with Pathfinder International to raise HIV awareness and extend care and support services. 386 Influential religious leaders appear to be publicly supporting action against HIV/AIDS (though not condom promotion and use). In 1999, the patriarch of the Ethiopian Orthodox Church launched a major HIV prevention campaign.387 In August 2002, a conference entitled "Sex, Stigma and HIV/AIDS: African Women Challenging Religion, Culture and Social Practices" was held in Addis Ababa and hosted by The Circle, a network of African women theologians. The conference was opened by Ethiopia's President Girma Wolde Giorgis and attended by high-ranking church leaders (though not by Muslim officials).388 In November 2002, Negatu Mereke, head of HAPCO, stated that: The issue of condoms is quite sensitive in Ethiopia. We are not forcing anyone, particularly those religious organizations. It is up to the religious organizations. We just tell them about the use of condoms. We leave them to tell their followers to use condoms. We have to be careful in using the faith-based organizations. The secular approach is working on condoms; the religious organizations are working against HIV/AIDS in their own way. We want them to complement [our efforts]. It is difficult for a religious organization to advocate condoms, because one of the Ten Commandments says 'Do not commit adultery.' If they advocate condoms they are directly violating that commandment. So they should do it their own way.389 Orphans Numerous NGOs and CBOs are providing support to AIDS orphans and other vulnerable children (see the Links section). In 1998, UNICEF launched a program for street children in six towns; it now operates the program in 14 towns, providing health education, vaccinations, and educational support. As of April 2002, about 1,800 children in the program had been enrolled in school. 390 Traditional Medicine Dr. Hareya Fassil of Oxford notes that about 80 percent of Ethiopians rely on traditional, plant-derived medicines for their basic health care needs. (Given the state of the health system discussed earlier, this figure is not surprising.) However, professional traditional health practitioners play a much less pronounced role in rural communities than has generally been presumed. Most ailments are diagnosed and treated at the household level. Very few informants report seeking professional traditional help on a regular basis. When professionals are consulted, it is often for their specialized traditional knowledge and skills pertaining to a relatively limited range of health problems.391 Given the above, however, one might infer that many Ethiopians with AIDS will use traditional medicine to alleviate symptoms of OIs. The MOH has encouraged the involvement of traditional healers in AIDS care and a national committee comprising scientists and traditional healers has been formed. The Department of Drug Research at the Ethiopian Health and Nutrition Research Institute is now working with traditional healers who claim to have cures for AIDS and some OIs.392 , 393 Blood (Also see the Epidemiology section.) The MOH has recently published a national blood service strategy that mandates the Ethiopian Red Cross Society (ERCS) to operate blood transfusion services throughout the country. GFATM funding will be used to increase the number of blood banks and initiate other improvements.394 Universal Precautions The MOH has prepared draft national guidelines on UP. GFATM funding will be used to implement it (e.g., training, supplies, and equipment). Post Exposure Prophylaxis The MOH has created a policy on PEP. This involves establishing an exposure surveillance system. Again, GFATM funding is expected to finance implementation of the strategy.395 PMTCT According to WHO, only 50 clients received PMTCT services in Ethiopia during 2001 (i.e., basic counseling, testing, and AZT or NVP treatment). There were three public/NGO sites providing basic PMTCT services in 2001, with no such services in the commercial sector. 396 In January 2002, national guidelines on PMTCT were released. In addition, the national policy on ART promotes improving the coverage of PMTCT in all parts of the country. With support from UNICEF and NVP donated by Boehringer-Ingelheim, the MOH has initiated a pilot PMTCT program. The MOH envisions using GFATM financing to scale up PMTCT to 50 sites spanning all regions. It is also planning to implement PMTCT+ services. Addis Ababa University's Medical Faculty is currently conducting a research project on the efficacy of a longer course of NVP among breastfeeding mothers in three sites.397 VCT According to the 2000 EDHS, only 2.2 percent of Ethiopian men had been tested for HIV. A much higher percentage of men living in Addis Ababa (16.5 percent) have been tested for HIV, as have urban men (9.3 percent) and men with at least secondary education (8.4 percent), than their counterparts. However, 64.8 percent of all men who have not been tested for AIDS want to be tested. Men under age 40, those never-married, those residing in urban areas and in Oromiya and Harari regions, and highly educated men are more likely to desire an HIV test. (The 2000 EDHS did not ask these questions of women.) According to WHO, during 2001, only 2,400 to 3,500 clients were seen at Ethiopia's 20 publicly funded/NGO VCT centers. (Twenty percent of VCT services were offered in the commercial sector.) 398 The 2002 GFATM proposal stated that in 2002, the country had 23 VCT centers, of which 3 were government, 12 private, and 8 NGO. It estimated that 10,000 clients were seen at these facilities in 2002. With GAFTM financing, this figure is projected to rise to 500,000 by year five.399 Almost all of the country's VCT services are located in Addis. Family Health International's IMPACT project, funded by USAID, has assisted the Addis Ababa Health Bureau to integrate VCT into the standard package of services in all public health centers in the city.400 There is a severe lack of trained HIV/AIDS counselors in the country. According to anecdotal evidence from Shinn, counseling done under the auspices of a church appears to be more effective, reportedly because infected individuals put greater trust in medical personnel associated with a church than with a governmental organization. 401 Care and Support The Ethiopian MOH and Addis Ababa University have developed national guidelines on HIV/AIDS care and support for adults and children. There are multiple care and support activities occurring in Ethiopia. However, there is great disparity with regard to resources for HIV/AIDS care and support between Addis and other regions of the country. Another constraint is that although there are numerous care and support training activities, they are not coordinated nor are their curricula standardized. There is a major lack of resources to coordinate the multiple training activities conducted by Ethiopian public health institutions and international partners. As such, there is no systematic process whereby health care providers can take advantage of these training opportunities to ensure that their knowledge and skills keep pace with emerging best practices. The MOH is working with CDC and HRSA through the International Training and Education Center on HIV (I-TECH) to strengthen care and support through the establishment of a national training center.402 Some NGOs have been providing home-based care since 1992. National guidelines on HBC were developed in 2001. Ethiopia's 2002 GFATM proposal outlines the need to disseminate these guidelines throughout the country, requiring substantial investment in translating the guidelines and related manuals into local languages and training several levels of trainers so as to reach most kebeles.403 ART According to the 2002 GFATM, although national guidelines on clinical management of HIV infection in adults and children have been in use for two years, they require updating.404 The World Bank loan mentioned above includes financing to help strengthen the health infrastructure in anticipation of ART.405 Ethiopia also plans to use GFATM funding to undertake preparatory work for large-scale introduction of ART. 406 According to WHO, no adults with HIV/AIDS received isoniazid prophylaxis during 2001. (Data on cotrimoxazole prophylaxis in Ethiopia were not included in the WHO report.)407 Access to HIV/AIDS-related care and support services in Addis, other urban areas, and rural areas is deemed minimal. WHO reported that there were no public/NGO nor private sites providing ART during 2001.408 In 2001, Shinn noted that: During the delegation's visit, limited amounts of antiretroviral drugs were available on the black market or purchased illegally in Ethiopian pharmacies. Within the past month, the government has legalized the importation of these drugs. A small number of wealthy individuals are taking them on an unsupervised or inadequately supervised basis. There is virtually no capacity now to monitor the use of these drugs and few individuals can afford them in any event. The drugs are unavailable in most of Ethiopia.409 Some researchers are exploring alternatives to the biologic markers used to determine initiation of ART in wealthy countries. For example, the Ethio-Netherlands AIDS Research Project has identified simple markers to replace CD4 counts and viral load. It notes, however, that the validity of these markers for monitoring patients' improvement following therapy remains to be evaluated.410 Military The Ethiopian National Defense Force (ENDF) has approximately 100,000 personnel, rendering it one of the largest military forces in Africa (though the number is significantly smaller than the 250,000 plus troops that existed during the Derg regime). Since the early 1990s, the ENDF has been in transition from a rebel force to a professional military organization with the aid of the U.S. and other countries. Training in demining, humanitarian and peacekeeping operations, professional military education, and military justice are among the major programs sponsored by the U.S. 411 Shinn notes that Ethiopian defense forces are often cited as being at the forefront of HIV prevention. The Ethiopian military has developed an extensive HIV/AIDS workplan that includes training at all levels, widespread distribution of condoms, information dissemination, surveillance, and research.412 A major initiative under way is deploying demobilized soldiers as HBC providers; a database has already been established to facilitate easy access to this group.413 In March 2003, CDC and the ENDF announced a joint HIV/AIDS project. CDC is providing about 2.8 million Ethiopian birr (about US$325,000) for the five-year project, which will focus on peer education. The project will also focus on the Ethio-Djibouti transportation corridor.414 Family Health International, the Civil-Military Alliance to Combat HIV & AIDS, the POLICY Project of The Futures Group International, the U.S. Naval Health Research Center, Population Services International, the U.S. Department of Defense, USAID, and UNAIDS are also participating in this project.415 The U.N. peacekeeping mission in Ethiopia and Eritrea (UNMEE) is training troops from both countries, as well as its own peacekeepers, to instruct fellow soldiers and civilians on HIV prevention. Troops that have graduated from the HIV training program have been trained to help educate their communities when they return home.416 Other Mobile Populations The World Food Program is working with local NGOs and transport companies to train over 2,000 WFP-employed truck drivers and their assistants in HIV/AIDS awareness and prevention. After a rapid baseline assessment of the truck drivers' needs, 12 trainers along with regional health officers offered three, two-hour daily sessions for 60 consecutive days. Sessions dealt with a range of risk-reducing behaviors and included time for participants to share personal experiences. T-shirts, cassette tapes of prevention songs, educational materials to share along their routes, and condom "starter kits" were offered to drivers at the end of the training. All participants received a card certifying their attendance. The project also involves follow-up support through the use of peer educators.417 The International Organization for Migration is deploying mobile units along the Ethio-Djibouti trucking route and in a gold mining area in Ethiopia. These units are seeking to address the needs of mobile populations such as truck drivers, merchants, gold miners, and sex workers. Each unit has four staff, two counselors and two nurses. The units provide free services and easy access to VCT and syndromic treatment of STIs. 418 Private Sector According to the 2000 EDHS, only 4.2 percent of men and 1.1 percent of women had heard about HIV/AIDS at their workplace. Note, however, that of "employed" women, 56.3 percent work in the agriculture sector, and of these women, 93.6 percent work on their own land. Among employed men, 83.9 percent work in agriculture (comparable data on landholding were not available from the 2000 EDHS). 419 Thus, reaching those in rural areas is crucial. Some workplace interventions are beginning to occur. For example, the Confederation of Ethiopian Trade Unions and the Addis Ababa Chamber of Commerce have received funding from USAID to implement HIV prevention programs in the workplace.420 Some of the projects mentioned in this paper that work with transport workers have also included transport company owners as key stakeholders. However, to what degree these companies are themselves initiating projects is unclear. Links Government * Ministry of Health * National HIV/AIDS Prevention and Control Office (HAPCO) <> * Regional AIDS Council Secretariats <> * AIDS Resource Center Addis Ababa. Ethiopia's premier source of AIDS information. Searchable databases of organizations, funders, and materials. Can also subscribe to newsletter . Managed by HAPCO with funding from CDC and technical assistance from the Johns Hopkins University Center for Communication Programs and Analytical Sciences, Inc. * Central Statistical Authority <> Academic and Research Institutes * Addis Ababa University * Gondar College of Medical Sciences * Jimma Institute of Health Sciences * Black-Lion Teaching Hospital <> Addis Ababa * Zewditu Hospital <> Addis Ababa * Balcha Hospital <> Addis Ababa * Tikur Anbesa Hospital <> * Ramo Institute <> Addis Ababa * Armed Forces Hospital <> Addis Ababa * Miz-Hasab Research Center <> Addis Ababa * Ethio-Netherlands AIDS Research Project (ENARP) * Ethio-Swedish Children's Hospital <> Addis Ababa * Tekle-Haymanot Health Center<> Addis Ababa * Ethiopian Health and Nutrition Research Institute (EHNRI) * Ethiopian Medical Association * Ethiopian Public Health Association * Ethiopian Economic Association * Ethiopian Economic Policy Research Institute (EEPRI) VCT Centers in Addis Ababa 1. Bethezata Higher Clinic 2. Blue Nile Higher Clinic 3. Arsho Electronic Laboratory 4. Tirat Higher Clinic 5. St. Gabriel Hospital 6. D' Afrique Higher Clinic 7. Addis Ababa Poly Clinic 8. Medical Missionary of St. Marry 9. Menaharia Higher Clinic 10. Global Medium Clinic 11. Tekle Haimanot Higher Clinic 12. Hayat Hospital 13. Haya hulet Mazoria Higher Clinic 14. Prime Higher Clinic 15. Tikur Anbesa Hospital 16. Balcha Hospital 17. Zewditu Hospital 18. CARE Ethiopia Kazanchis Health Center 19. OSSA 20. Rabie Higher Clinic International Partners * University of Amsterdam * Division of Public Health and Environment, Municipal Health Service, Amsterdam * Department of Public Health, Erasmus University, Rotterdam * AIDS Center, Department of Clinical Microbiology and Infectious Diseases, The Hebrew University-Hadassah Medical School, Jerusalem * Rambam Medical Center, Haifa, Israel * Haifa District Health Office, Ministry of Health, Israel * Clalit Health Services, Haifa & West Galilee District, Haifa, Israel * Karolinska Institute, Stockholm * Department of International Health, Institute of General Practice and Community Medicine, University of Oslo <> * University of Nottingham * Emerging Diseases Epidemiology Unit, Pasteur Institute <> Paris. * Institute of Development Studies, University of Sussex * Oxford University * McGill University AIDS Center * Harvard AIDS Institute * Johns Hopkins University Bloomberg School of Public Health * Boston University School of Public Health * Columbia University * Keck School of Medicine, University of Southern California * Ipas Sexual and reproductive health research. Based in Chapel Hill. * Population Council * International Center for Research on Women National NGOs and CBOs * Abyssinian Health * Addis Ababa Chamber of Commerce <> * Amhara Development Association Bahir Dah. * Bahir Dar Michael Orphanage <> Affiliated with the Ethiopian Orthodox Church. * Beza Lewegen <> * Consortium of Family Planning NGOs in Ethiopia (COFAP) <> * Dawn of Hope <> Association of PWHA. Provides pre- and posttest counseling and testing services; home-based care services; assistance to families; and education and training on HIV/AIDS prevention and management. P.O. Box 24378, Code 1000 Addis Ababa, Ethiopia; tel: (251) 1 560154; fax: (251) 1 560245. * Development Aid for Youth <> * Ethiopian Aid <> * Ethiopia AIDS Prevention Society <> * Ethiopian Trade Unions <> * Ethiopian Evangelical Church Mekane Yesus <> * Ethiopian Gemini Trust - Youth & Creative Arts * http://www.developmentgateway.org/pop/dg-contribute/item-detail?item_id=292112&version_id=171091&from=alert an unusual NGO which was set up in 1983 in response to the very high death rate among twin babies in Ethiopia. It is run by an Ethiopian staff under a Board of Trustees, and currently supports over 1,100 destitute families for whom ... * Ethiopian Islamic Affairs Supreme Council <> * Ethiopian Orthodox Church <> * Ethiopian Red Cross Society- Blood Transfusion Service <> * Family Guidance Association of Ethiopia <> Offices in Addis Ababa, Awassa, Bahirdar, Dessie, Nazareth * Fatumatu Zahara Aid Organization (FZAO) Offers a care and support program for AIDS orphans, primarily in urban areas of Amhara Region. * Fifty Lemons Works through partnership-based programming, including anti-AIDS club support, sponsorship and care of orphans, youth prevention education, and youth behavior research. * GOAL <> Works with street children. * Good Shepherd Family Care Services * Hope For Children <> Addis Ababa * Integrated Holistic Approach Urban Development Project * Integrated Service for AIDS Prevention and Support Organization (ISAPSO) <> Prevention and education, workplace programs (Ethio-Djibouti truck route, other transportation sites, factories, construction workers), orphan care, and vocational training. * Jerusalem Association Children's Home Found in 1985 as response to children orphaned by civil war, drought, and famine. * Love to Human Being * Mary Joy AIDS through Development <> Prevention and care. Outreach to street children, capacity building for CBOs, skills training, and microcredit programs. * Medical Missionaries of Mary Counseling & Social Services Center <> Addis. Support to PWHA, their families, and orphans and OVC. * Mekdim Ethiopia HIV Positive Persons and AIDS Orphans National Association HIV awareness raising for public at large; psychological support (counseling) and social support for HIV patients and AIDS orphans; home-based care services for critically ill AIDS patients and AIDS orphans. * Nazareth Children's Center for Integrated Development * Organization for Integrated Services for AIDS Prevention and Support (ISAPSO) * Organization for Social Services for AIDS in Ethiopia (OSSA) <> Addis Ababa. National scope. Home-based care, orphan and OVC care and support. Services iplemented through memeber organizations such as churches, mosques, other NGOs. * Save Your Generation * Tigray Development Association * YWCA of Ethiopia <> International NGOs * See InterAction for comprehensive list of (primarily U.S.-based) international NGOs working in Ethiopia: http://www.interaction.org/members * ActionAid * Adoption Advocates This is an international adoption agency site focusing on children from Ethiopia and several other countries. Most of the children up for adoption, though not HIV-positive themselves, have lost their mother or both parents to HIV/AIDS. * African Humanitarian Action Funded by USAID (through Pathfinder International) to manage a small-scale, community-level HIV prevention program. * African Partnership for Sexual and Reproductive Health and Rights of Women and Girls (Amanitare) Partnership to consolidate the skills, knowledge, and institutional resources of groups and individuals active in the field of sexual and reproductive health, gender equality, and women's rights. Coordinated by RAINBO (see below). * American Red Cross * Amnesty International * Association François-Xavier Bagnoud * Canadian Public Health Association * CARE International U.K. * CARE International U.S. * More CARE International affiliates * Catholic Agency for Overseas Development * Catholic Relief Services * Center for Reproductive Rights * Christian Aid U.K. * Christian Children's Fund <> * Christian Relief and Development Association (CRDA) * Civil-Military Alliance to Combat HIV & AIDS, Rolle, Switzerland * CONCERN-Ethiopia <> Irish-based NGO. Funds Mekdim Ethiopia HIV Positive Persons and AIDS Orphans National Association. * Concern Worldwide * Dan Church Aid <> * DKT International * Family Care International * German Foundation for World Population * A Glimmer of Hope * International HIV/AIDS Alliance * International Committee of the Red Cross * International Family Health * International Federation of Red Cross and Red Crescent Societies * International Food Policy Research Institute * International Organization for Migration <> * Marie Stopes International Reproductive health. * Médecins Sans Frontières (MSF) Belgium * Norwegian Church Aid * Oxfam Australia * Oxfam UK * Oxfam US * PACT * People to People, Inc. * PharmAccess International * Plan International * Population Communications International * Reseach Action and Information Network for the Bodily Integrity of Women (RAINBO) Promotes women's sexual and reproductive health and rights; focus on female circumcision/female genital mutilation and other forms of gender-based violence. * Rotary International * Save the Children Norway * Save the Children UK * Transparency International * Uniting Churches of the Netherlands <> * World Council of Churches * World Vision UN Agencies * UNAIDS * Global Fund to Fight AIDS, Tuberculosis & Malaria * WHO ? Roll Back Malaria Initiative * UNDP * World Food Program * UNFPA * UNICEF * United Nations High Commissioner for Refugees (UNHCR) * UNIFEM * UNDCP * ILO * U.N. Office for the Coordination of Humanitarian Affairs * FAO * International Fund for Agricultural Development (IFAD) * World Bank * International Finance Corporation (IFC) * IMF * African Development Bank (AFDB) Bilateral Donors * Canadian International Development Agency (CIDA) * Commonwealth * U.K. Department for International Development (DFID) ? The British Council * European Commission ? EC Food Security Network (RESAL) * Gesellschaft für technische Zusammenarbeit (GTZ) ? GTZ Backup Initiative Supports countries in obtaining funds for HIV/AIDS, TB, and malaria. * Ireland Aid * Japan International Cooperation Agency (JICA) * Norwegian Agency for Development Cooperation (NORAD) ? Royal Norwegian Embassy * SNV Netherlands Development Organization ? Royal Netherlands Embassy * Swedish Agency for International Development (SIDA) * USAID and Funds projects of: ? Academy for Educational Development http://www.aed.org/ ? Advance Africa Seeks to improve family planning and reproductive health services reaching underserved groups. ? Center for Development and Population Activities (CEDPA) www.cedpa.org ? Development Alternatives http://www.ecouncil.ac.cr/devalt ? Engender Health http://www.engenderhealth.org ? Family Health International/IMPACT Works to increase the capacity of Ethiopian government and NGOs to implement HIV/AIDS prevention, care, and support interventions among vulnerable populations. ? Famine Early Warning Systems Network (FEWS Net) ? The Futures Group International/POLICY Project Supports the MOH in sentinel surveillance data analysis. ? INTRAH ? John Snow, Inc. http://www.jsi.com or http://www.mothercare.jsi.com ? Macro International http://www.macroint.com/ ? NGO Networks for Health ? PACT Supports organizations working with street children and children affected by AIDS. Also addresses democracy and governance, including the rights of people living with HIV/AIDS and the rights of children orphaned due to AIDS. ? Pathfinder International Faith-based and workplace initiatives. ? Population Council/Horizons ? Population Services International/ DKT/AIDSMark ? Program for Appropriate Technology in Health (PATH) * Ethiopia is one of the countries identified for increased HIV/AIDS funding under the proposal laid out by President Bush in his January 2003 State of the Union address. As of March 2003, the actual amount of funding was still unclear. Major concerns have also been raised about the "gag rule" that will apply to any HIV/AIDS funding under this bill. * U.S. Centers for Disease Control and Prevention (CDC) Global AIDS Program Priorities include VCT; surveillance; information management; and care, support, and treatment. In December 2002, CDC and the Ethiopian MOH signed an agreement to formalize cooperation on improving HIV/AIDS prevention, care, and support, and strengthening capacity to address the national HIV/AIDS epidemic through financial and technical assistance in partnership with communities, government, and national and international organizations.421 * U.S. Centers for Disease Control and Prevention (CDC) National Prevention Information Network Works with ARC in Addis. * U.S. Naval Health Research Center San Diego. Working with Ethiopian military on HIV prevention and education. * U.S. Health Resources and Services Administration (HRSA), International Training and Education Center on HIV/AIDS (I-TECH) * U.S. National Alliance of State and Territorial AIDS Directors (NASTAD) Working in Addis Ababa to build capacity of government, civil society, and the private sector to respond to HIV/AIDS through exchange of information, resources, and experience. Foundations * Ford Foundation * Gates Foundation * Packard Foundation Subregional Organizations * InterAfrica Group (IAG) NGO that seeks to represent the voices of citizens in the Greater Horn of Africa. * Nile Basin Initiative Electronic Discussion Fora * HealthNet Ethiopia Partnership between Satellife and Addis Ababa University's School of Medicine. Provides access to a wide range of information services critical to health care delivery. * AF-AIDS Launched by the Fondation du Présent; moderated by Health & Development Networks, and hosted by Health Systems Trust, Durban, South Africa. * African Networks for Health Research & Development (AFRO-NETS) Hosted by SatelLife; includes links of partner organizations. Other Information Sources * Integrated Regional Information Networks (IRIN) News service of the UN Office for the Coordination of Humanitarian Affairs, in partnership with ReliefWeb. Reports on political, economic, and social issues affecting humanitarian efforts in Africa. Daily news organized by subregion and country. Includes PlusNews, an HIV/AIDS news service. * Abbyssinia Cyber Gateway Extensive links to Ethiopian websites. * AllAfrica.com: Ethiopia Compilation of daily news articles from a variety of media outlets. * Development Information Network on Ethiopia * University of Pennsylvania: Ethiopia Resources 1 Lester FT, Ayehune S, Zewdie D. "Aquired immunodeficiency: seven cases in Addis Ababa hospital." Ethiop Med J 1988;26:139-45. 2 Ethiopian Ministry of Health, Disease Prevention and Control Department. AIDS in Ethiopia: Background, Projections, Impacts, Interventions, Policy. 3rd edition. Addis Ababa: 2000 3 Ethiopian Ministry of Health, Disease Prevention and Control Department. AIDS in Ethiopia: Background, Projections, Impacts, Interventions, Policy. 3rd edition. Addis Ababa: 2000 4 Derege Kebede, Mathias Aklilu, Eduard Sanders. The Epidemiology of HIV/AIDS in Ethiopia: A Review. Report commissioned by UNAIDS/Ethiopia. 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The Epidemiology of HIV/AIDS in Ethiopia: A Review. Report commissioned by UNAIDS/Ethiopia. Addis Ababa: March 2000. 37 Derege Kebede, Mathias Aklilu, Eduard Sanders. The Epidemiology of HIV/AIDS in Ethiopia: A Review. Report commissioned by UNAIDS/Ethiopia. Addis Ababa: March 2000. 38 Fontanet AL, Messele T, Dejene A, et al. "Age-sex-specific HIV-1 prevalence in the urban community settings of Addis Ababa, Ethiopia." AIDS 1998 Feb;12(3):315-22. 39 Derege Kebede, Mathias Aklilu, Eduard Sanders. The Epidemiology of HIV/AIDS in Ethiopia: A Review. Report commissioned by UNAIDS/Ethiopia. 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