RESEARCH DOSSIER: HIV PREVENTION FOR GIRLS AND YOUNG WOMEN
Ethiopia
This Research Dossier supports the Report Card on HIV Prevention for Girls and Young Women in Ethiopia produced by the United Nations Global Coalition on Women and AIDS (GCWA). It documents the detailed research coordinated for the GCWA by the International Planned Parenthood Federation (IPPF), with the support of the United Nations Population Fund (UNFPA), United Nations Program on AIDS (UNAIDS) and Young Positives. The Report Card provides an ‘at a glance’ summary of the current status of HIV prevention strategies and services for girls and young women in Ethiopia. It focuses on five cross-cutting prevention components: 1. Legal provision 2. Policy context 3. Availability of services 4. Accessibility of services 5. Participation and rights The Report Card also includes background information about the HIV epidemic and key policy and programmatic recommendations to improve and increase action on this issue in Ethiopia. This Research Report is divided into two sections: PART 1: DESK RESEARCH: This documents the extensive desk research carried out for the Report Card by IPPF staff and consultants based in the United Kingdom. PART 2: IN-COUNTRY RESEARCH: This documents the participatory in-country research carried out for the Report Card by a local consultant in Ethiopia. This involved: Two focus group discussions with a total of 19 girls and young women aged 15-24 years. The participants included girls and young women who are: living with HIV; in/out-of/school; involved in sex work; living in urban and suburban areas; and working as peer activists. Five one-to-one interviews with representatives of organisations providing services, advocacy and/or funding for HIV prevention for girls and young women. The stakeholders were: a country representative of an international NGO; a nurse at a national NGO focusing on sexual and reproductive health; a counsellor at an NGO/government voluntary counselling and testing centre; a programme officer of a United Nations agency; and a Technical Adviser of an international donor agency. Additional fact-finding to address gaps in the desk research.
Contents: PART 1 Country profile Prevention component 1: Legal Provisions Prevention component 2: Policy Provisions Prevention component 3: Availability of services Prevention component 4: Accessibility of services Prevention component 5: Participation and Rights PART 2 Focus group discussion: 13-21 year olds, urban area Focus group discussion: 17-20 year olds, urban area Focus group discussion: 18-23 years, rural area One-to-one interview: Interview with Program Officer, Male, HIV/AIDS and ARH, UNFPA One-to-one interview: Interview with HIV/AIDS Program Division Head, Male, Family Guidance Association of Ethiopia (FGAE) One-to-one interview: Interview with Model Clinic Head, Male, Family Guidance Association of Ethiopia (FGAE) One-to-one interview: Interview with National Coordinator, Female, PLHIV Network National Association of Positive Women in Ethiopia. One-to-one interview: Interview with Youth Club Coordinator, Female, HIWOT Ethiopia(NGO)
Abbreviations ARVs CEDAW CIA CRC FGAE IEC IPPF MTCT PLHIV PMTCT PSI SRH STD STI UNAIDS UNFPA UNICEF VCT WHO
Antiretrovirals Convention on the Elimination of All Forms of Discrimination Against Women Central Intelligence Agency Convention on the Rights of the Child Family Guidance Association of Ethiopia Information, communication and education International Planned Parenthood Federation Mother-to-Child Transmission People living with HIV Prevention of Mother-to-Child Transmission Population Services International Sexual and Reproductive Health Sexually transmitted disease Sexually transmitted infection United Nations Program on AIDS United Nations Population Fund United Nations Children’s Fund Voluntary, Counseling and Testing World Health Organisation
For further information about this Research Report, or to receive a copy of the Report Card, please contact: HIV/AIDS Department, International Planned Parenthood Federation (IPPF) 4 Newhams Row, London, SE1 3UZ, United Kingdom Tel: +44 (0) 207 939 8200. Fax: +44 (0) 207 939 8306. Website: www.ippf.org
PART 1: DESK RESEARCH
COUNTRY PROFILE •
Size of population: 74,777,981. Note: estimate explicitly take into account the effects of excess mortality due to AIDS; this can result in lower life expectancy, higher infant mortality and death rates, lower population and growth rates, and changes in the distribution of population by age and sex than would otherwise be expected (CIA (2006) The World Factbook – Ethiopia, http://www.cia.gov/cia/publications/factbook/geos/et.html (date accessed 25/04/06))
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% of population under 15 (0 – 14 years): 43.7% male and female (CIA (2006) The World Factbook – Ethiopia, http://www.cia.gov/cia/publications/factbook/geos/et.html (date accessed 25/04/06))
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Population below income poverty line of $1 per day: 50% (2004 estimate) (CIA (2006) The World Factbook – Ethiopia, http://www.cia.gov/cia/publications/factbook/geos/et.html (Date accessed 25/04/06))
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Health expenditure per capita (2002): 40.5% (2001 estimate), WHO 2004, http://data.unaids.org/Publications/Fact-Sheets01/Ethiopia_EN.pdf (Date accessed 25/04/06))
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Contraceptive prevalence: 8% (1995-2003) (UNDP (2005) (http://hdr.undp.org/statistics/data/countries.cfm?c=ETH (Date accessed 25/04/06))
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Maternal mortality rate: 870 per 100,000 live births (1985-2003) (UNDP (2005) http://hdr.undp.org/statistics/data/countries.cfm?c=ETH (Date accessed 25/04/06))
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Ethnic groups: Oromo 40%, Amhara and Tigre 32%, Sidamo 9%, Shankella 6%, Somali 6%, Afar 4%, Gurage 2%, other 1% (CIA (2006) The World Factbook – Ethiopia, http://www.cia.gov/cia/publications/factbook/geos/et.html (Date accessed 25/04/06))
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Religions: Muslim 45%-50%, Ethiopian Orthodox 35%-40%, animist 12%, other 3%-8%” (CIA (2006) The World Factbook – Ethiopia, http://www.cia.gov/cia/publications/factbook/geos/et.html (Date accessed 25/04/06))
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Languages: Amharic, Tigrinya, Oromigna, Guaragigna, Somali, Arabic, other local languages, English(CIA (2006) The World Factbook – Ethiopia, http://www.cia.gov/cia/publications/factbook/geos/et.html (Date accessed 25/04/06))
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AIDS deaths (adults and children) in 2003: 120 000(range: 74 000-190 000) (UNAIDS – Ethiopia, http://www.unaids.org/en/Regions_Countries/Countries/ethiopia.asp (Date accessed 25/04/06))
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Adult (15-49) HIV prevalence rate (end of 2003): 1 400 000 (range: 890 000-2 100 000) (UNAIDS,03/01/06) http://www.unaids.org/en/Regions_Countries/Countries/ethiopia.asp (Date accessed 25/04/06))
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Number of women (15-49) living with HIV (end of 2003): 770 000 (range: 500 000-1 200 000) (UNAIDS (2004) Report on the Global AIDS Epidemic, http://www.unaids.org/en/Regions_Countries/Countries/ethiopia.asp (Date accessed 25/04/06))
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Number of children (0-15) living with HIV (ages 0-14 years, 2003): 120,000 (UNICEF (2003) (http://www.unicef.org/infobycountry/ethiopia_statistics.html (Date accessed 22/04/06))
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Estimated number of orphans (0-17 years): estimated 4 000 000 (UNICEF (2003) (http://www.unicef.org/infobycountry/ethiopia_statistics.html (Date accessed 22/04/06))
PREVENTION COMPONENT 1: LEGAL PROVISION (national laws, regulations, etc) Key questions: 1. What is the minimum legal age for marriage? “Unlike the previous version that permitted the marriage of women over 15 years of age, the revised code sets the minimum age for marriage at 18 years for both men and women.(Pg24)” (Women of the World: Laws and Policies Affecting Their Reproductive Lives Anglophone Africa Progress Report (2001), http://www.crlp.org/pdf/wowaaprethiopia.pdf (Date accessed 22/06/06)) 2. What is the minimum legal age for having an HIV test without parental and partner consent? “Guidelines on VCT for 13 Years of Age: “The rise in HIV infection affects children and almost no counseling services exist for them. HIV testing, for children usually occur with a parent’s consent, however, counselor needs to consider: • Future medical care of the child. • Emotional support, including dealing with his/her illness and parental illness or death. • Anxieties about other children in the family who may be infected. • What and when to tell the child. • Coping with stigma and discrimination in the community. • Provision for the child’s future, what to do if the child’s mother or father becomes ill dies. Management of records Managers and counselors should ensure availability of client cards and referral forms. Client records must be confidential and at a minimum should include: • • • • • • •
Unique client identifier code, Client characteristics, Reasons for seeking VCT and client risk behaviors, Date of pre-test counseling, Laboratory result, Date of notification of results and post-test counseling, and Any referral and follow-up. (Module 4-8 )” (Ethiopia Ministry of Health - Prevention of Mother to Child Transmission of HIV Reference Manual (2005) http://www.etharc.org/pmtct/resources/PMTCT_ReferenceManual.pdf (Date accessed 22/06/06)
3. What is the minimum legal age for accessing SRH services without parental and partner consent? “As of 1990,many family planning clinics did not offer services to women under the age of 18 .However, no explicit laws or policies prevent adolescents from obtaining family planning or maternal/child health services. While the Population Policy expressly sets forth a strategy for the establishment of reproductive health counselling for teenagers and youth. pg 25”…. “The current policy of the MOH’s Family Health Department is to provide complete access to contraceptives for every woman of reproductive age and at all socio-economic levels. pg.20”…. “In addition, one of the plan’s strategies involves amending all laws “impeding, in any way, the access of women to all social, economic
and cultural resources,” and amending relevant articles and sections of the civil code to remove unnecessary restrictions to the “advertisement, propagation and popularization of diverse contraception control methods.” Other strategies listed include: establishing teenage and youth reproductive health counselling, centres ;increasing research in reproductive health; promoting male involvement in family planning; and diversifying available contraceptive methods. (Pg19)” (Centre for Reproductive Rights (2003), Laws and policies affecting their reproductive Lives, http://reproductiverights.org/pdf/WOWAA02.pdf (Date accessed 27.04.06)) “This youth policy defines youth to include part of the society who are between 15-29 years. Major Policy Issues 5.4 Youth and Health Create favourable conditions for youth to have proper access to information, education, counselling and leadership services in the areas of reproductive health and related health issues and benefit therefrom. 5.5 Create favourable conditions for the youth to benefit appropriately from information, education and counselling services on HIV/AIDS and other sexually transmitted diseases in a coordinated, consolidated and sustained manner.” (Federal Democratic Republic of Ethiopia National Youth Policy. Ministry of Youth, Sports and Culture, Addis Ababa 2004.) Vision: To enhance reproductive health and well-being among young people in Ethiopia ages 10-24 so that they may be productive and empowered to fully access and utilize quality reproductive health information and services, to make voluntary informed choices over their RH lives, and to participate fully in the development of the country. Goals: To meet the immediate and long term RH needs of young people through increased access and quality of reproductive health services for adolescents and young people of Ethiopia. (National Adolescent and Youth Reproductive Health Strategy 2006-2015. Federal Democratic Republic of Ethiopia, Ministry of Health.) 4. What is the minimum legal age for accessing abortions without parental and partner consent? “Grounds on which abortion is permitted o o o o o o o
To save the life of the woman To preserve physical health To preserve mental health Rape or incest Foetal impairment Economic or social reasons Available on request
Yes Yes Yes Yes Yes No No
Additional requirements Except when impossible, the danger to the pregnant woman’s life or health must be certified in writing by a registered medical practitioner. A second doctor must provide a concurrent opinion. The pregnant woman, or, if she is incapable, her next of kin or legal representative, is required to give consent to the intervention.”
(Population Division of the United Nations Secretariat - Abortion Policies: A Global Review(2002) http://www.un.org/esa/population/publications/abortion/profiles.htm (Date Accessed 06/07/06) “A woman may obtain a legal abortion under defined circumstances only when several formalities have been completed. The requirements for terminating a pregnancy on “medical grounds” include the presentation of a written, certified diagnosis submitted by a registered medical practitioner after examination of the pregnant woman.157 the diagnosis must be approved by a second doctor who is a specialist in the diagnosed condition and is empowered to make an authorization. 158 In addition, the pregnant woman must give her consent, or, if she is incapable of granting that consent, her next of kin or legal representative must consent for her(pg21)” (Centre for Reproductive Rights (2003), Laws and policies affecting their reproductive Lives, http://reproductiverights.org/pdf/WOWAA02.pdf (Date accessed 27.04.06)) 5. Is HIV testing mandatory for any specific groups (e.g. pregnant women, military, migrant workers, and sex workers)? “Immigrants Seven countries (Argentina, Bulgaria, Jordan, the Kyrgyz Republic, Panama, Russia, and Turkmenistan) indicated a positive response to obligatory testing of all immigrants, both in law and practice. El Salvador and Ethiopia employed this practice despite the absence of a law.” (Hnin Hnin Pyne- The European Commission Development website, Confronting AIDS: Evidence from the developing World- International law and the rights of people living with HIV/AIDS, http://www.iaen.org/limelette/html/lim05.htm (Date accessed 07/07/06) “No person shall be forced to undergo a mandatory HIV screening test for job recruitment purposes unless the nature of the occupation (pilots-civil aviation and air force) requires them to do so.” (Government of Ethiopia and Ministry of Health - Strategic Framework for the National Response to HIV/AIDS, Ethiopia 2000-2004 http://www.aids.harvard.edu/africanow/pdfs/ethiopia.pdf (Date accessed 27/04/06)) 6. Is there any legislation that specifically addresses gender-based violence? A women policy was enacted in the country in 1993 with the objective of facilitating equality, equal access to services and eliminating prejudice against women. The national poverty reduction strategy papers also identify HIV/AIDS as focus area. The country has ratified the Universal Declaration of Human Rights (UDHR) and relevant treaties like the Convention of the Elimination of All Forms of Discrimination against Women (CEDAW) and The Convention on the Rights of Child. Various laws in the country, such as Laws of non discrimination and equality before law; participation in the economic, political and cultural life of society; the rights of women, children and other vulnerable or affected group; have helped strengthen protection of vulnerable (specifically women and children) and affected society groups. Barriers for implementation: Although the country has a number of positive policies, strategies and legal frameworks, pertinent to HIV/AIDS prevention and control, there are also serious structural and economic barriers to implementation. There is not enough integration between the legal framework and HIV/AIDS risks e.g. protection of girls/women and helping rape victims. The national strategy has not
specifically included women among the vulnerable groups. Rural areas are only to a limited degree benefiting from interventions including services like information, Voluntary Counseling and Testing and Anti Retroviral Treatment. There are also barriers of cultural and social norms and practices. Gender inequality is the most important. Stigma and discrimination and harmful traditional practices like female genital mutilation, early marriage, abduction and widow inheritance are also common. (DANChurchAid Ethiopia website, (24/05/06), http://www.dca.dk/sider_paa_hjemmesiden/where_we_work/africa/ethiopia/re ad_more/hiv_aids_programme_in_ethiopia (Date accessed 09/11/06)) “Article 35 The Rights of Women: Women shall have equal rights with men in the enjoyment of the rights and protections guaranteed by this Constitution to all Ethiopians. ... 4. The State has the duty to guarantee the right of women to be free from the influence of harmful customary practices. All laws, stereotyped ideas and customs which oppress women or otherwise adversely affect their physical and mental well-being are prohibited. “ (Ethiopian Constitution (1994) http://www.africa.upenn.edu/Hornet/Ethiopian_Constitution.html (Date accessed 28/04/06)) Rape: “The Penal Code, pursuant to a section entitled “Injury to Sexual Liberty and Chastity,” defines rape as compelling “a woman to submit to sexual intercourse outside wedlock, whether by the use of violence or grave intimidation, or after having rendered her unconscious or, incapable of resistance.” 285 The punishment for such an offence is a maximum of 10 years of “rigorous imprisonment.”286 The punishment for rape can be extended to 15 years of rigorous imprisonment under the following circumstances: when the rape is committed against a child under the age of 15; against an institutionalized woman in the care of the offender; or by a number of persons acting in concert.287 The Penal Code thus recognizes statutory rape, but since it defines rape as occurring “outside wedlock,” it does not recognize marital rape as a crime.288.” (Centre for Reproductive Rights (2003), Laws and policies affecting their reproductive Lives, http://reproductiverights.org/pdf/WOWAA02.pdf ( Date accessed 09/11/06)) Domestic violence: “While the Penal Code assigns criminal penalties for willful injury289 and assault, 290 the laws do not specify the consequences of violence occurring between husband and wife. The Civil Code states, however, that “the spouses owe each other respect, support and assistance.”291 Moreover, as mentioned above, under the Civil Code, consent for marriage is invalid if obtained through violence.292 Article 558 of the Penal Code on “abduction” assigns a maximum of three years of rigorous imprisonment for “[w]hosoever carries off a woman by violence, or after having obtained her consent to abduction by intimidation or violence, trickry [sic] or deceit.”293There is no prosecution if the woman “freely contracts with her abductor a valid marriage”unless the marriage is later annulled by law.294 One who “carries off an insane, idiot or feeble minded woman, one not fully conscious” or unable to defend herself, is punishable with a maximum of five years of rigorous imprisonment.295” (Centre for Reproductive Rights (2003), Laws and policies affecting their reproductive Lives, http://reproductiverights.org/pdf/WOWAA02.pdf (Date accessed 09/11/06)) 7. Is there an AIDS Law – or equivalent – that legislates on issues such as confidentiality for testing, diagnosis, treatment, care and support? There is not enough integration between the legal framework and HIV/AIDS risks e.g.
protection of girls/women and helping rape victims. The national strategy has not specifically included women among the vulnerable groups. Rural areas are only to a limited degree benefiting from interventions including services like information, Voluntary Counseling and Testing and Anti Retroviral Treatment. There are also barriers of cultural and social norms and practices. Gender inequality is the most important. Stigma and discrimination and harmful traditional practices like female genital mutilation, early marriage, abduction and widow inheritance are also common. (DANChurchAid Ethiopia website, (24/05/06), http://www.dca.dk/sider_paa_hjemmesiden/where_we_work/africa/ethiopia/read_ more/hiv_aids_programme_in_ethiopia (Date accessed 09/11/06)) “Health Infrastructure: The lack of health infrastructures means that access to condoms is limited, STDs are not treated and drugs are not available to avoid mother-to-child transmission. Also, and especially in temporary health care facilities, there is a lack of trained staff, a lack of confidentiality and privacy and a lack of care and support for HIV infected persons. Furthermore, soldiers and uniformed services are more likely to be provided with health care and treatment than their families. (Example: 50% of beds in military hospitals in Ethiopia are allocated to AIDS cases which makes one wonder about the wives or partners of those soldiers and how they are being provided for) It is a fact that women have less access to health facilities and confront more public discrimination because of the absence of medical and social support.” (Ulf Kristoffersson- Humanitarian Coordinator Joint United Nations Programme on HIV/AIDS (Sweden), Expert Group Meeting on "The HIV/AIDS Pandemic and its Gender Implications" 13-17 November 2000 Windhoek, Namibia, http://www.un.org/womenwatch/daw/csw/hivaids/kristoffersson.htm (Date accessed 07/07/06)) 8. Is there any legislation that protects people living with HIV/AIDS, particularly girls and young women, from stigma and discrimination at home and in the workplace? “Policy, strategy and legal frameworks: The National AIDS Policy was drafted in 1991 and approved in 1998. A National Strategic Framework was formulated in 2002 with focus on reducing transmission. It was replaced by a strategic plan in December 2004 with focus on community mobilization of target groups including youth (15-29 years of age), rural communities and people living with HIV/AIDS. A women policy was enacted in the country in 1993 with the objective of facilitating equality, equal access to services and eliminating prejudice against women. The national poverty reduction strategy papers also identify HIV/AIDS as focus area. The country has ratified the Universal Declaration of Human Rights (UDHR) and relevant treaties like the Convention of the Elimination of All Forms of Discrimination against Women (CEDAW) and The Convention on the Rights of Child. Various laws in the country, such as Laws of non discrimination and equality before law; participation in the economic, political and cultural life of society; the rights of women, children and other vulnerable or affected group; have helped strengthen protection of vulnerable (specifically women and children) and affected society groups. Barriers for implementation: Although the country has a number of positive policies, strategies and legal frameworks, pertinent to HIV/AIDS prevention and control, there are also serious structural and economic barriers to implementation. There is not enough integration between the legal framework and HIV/AIDS risks e.g. protection of girls/women and helping rape victims. The national strategy has not specifically included women among the vulnerable groups. Rural areas are only to a limited degree benefiting from interventions including services like information, Voluntary Counseling and Testing and Anti Retroviral Treatment. There are also barriers of cultural and social norms and practices. Gender inequality is the most important. Stigma and
discrimination and harmful traditional practices like female genital mutilation, early marriage, abduction and widow inheritance are also common”. (DANChurchAid Ethiopia website, (24/05/06), http://www.dca.dk/sider_paa_hjemmesiden/where_we_work/africa/ethiopia/read_ more/hiv_aids_programme_in_ethiopia (Date accessed 09/11/06)) “The Justice Sector: Widespread abuse of human rights and fundamental freedom associated with HIV/AIDS infection has emerged since the start of the epidemic in the country. Respecting the rights of PLWHA is one of the essential conditions for an effective response to HIV/AIDS. An environment in which the rights of PLWHA are respected ensures that vulnerability is reduced, and helps victims live dignified lives, ensures that their special needs are progressively realized and the impact on the family and community is mitigated. Towards this end, the Sector has the responsibility for: • Periodically reviewing and modifying HIV/AIDS related legislation, • Facilitating legal services for the PLWHA and their families • Creating forum for dialogue on human right and other legal issues. (Pg50)” (ETHIOPIAN STRATEGIC PLAN FOR INTENSIFYING MULTI-SECTORAL HIV/AIDS RESPONSE (2004 - 2008)-Addis Ababa, Ethiopia (December 2004), http://etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 06/07/06)) “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 non-discriminatory 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.(pg10)” (Lisa Garbus, MPP AIDS Policy Research Center, University of California San Francisco, (April 2003)- Country AIDS Policy Analysis project) HIV/AIDS in Ethiopia, http://hivinsite.ucsf.edu/pdf/countries/ari-et.pdf (Date accessed 07/07/06)) 9. Are sex workers legally permitted to organise themselves, for example in unions or support groups? Commercial sex work is not a legally recognized ‘profession’ in Ethiopia. However, most of the establishments where the sex workers are based (hotels, bars/restaurants, night clubs etc.) operate legally with working licenses.” (Page 15). “3.5.1 Initiatives focusing on sex workers in red-light houses: A very small number of self-help initiatives had developed in a few kebeles. For example, a few years ago, about 200 sex workers in Wereda 21, Kebele 9 had established a ‘sisters’ self-help association. The current membership had decreased to only 25 but this group of women was running a shop and a restaurant. Each woman took her turn to work for the enterprise; the women did not receive salaries but were all beneficiaries of the project. Recently, Wereda 5, Kebele 7 also established a self-help association; however, at the time of the survey this was not fully operational.” (Page 45) (Mapping and Census of Female Sex Workers in Addis Ababa, Ethiopia, Family Health International (FHI)–Ethiopia in collaboration with the Addis Ababa City Administration Health Bureau (AACAHB), August 2002 - Addis Ababa, http://www.fhi.org/NR/rdonlyres/ekp62fa3kznvmsn4pqktuhrlkzgtuqwc57zx4piahrkhy3 6wm3jvmsbleve4f5pgtx6n7etyfpzmje/AAMappingofSWsFinal5Feb03.pdf (Date accessed 28/04/06)) 10. Are harm reduction methods for injecting drug users (such as needle exchange) legal?
“Nevertheless, "hard drugs" such as cocaine, heroin, LSD, and the like (e.g. morphine) may not be a problem of magnitude at present when compared to the Western Countries. Khat is very popular and is not an illicit drug in Ethiopia though regions like Tigray have started to make khat growing illegal. Khat, according to WHO classification, comes under "hard drugs" and occupies 6th place because of its active ingredient, cathinone" (pg7). (Mesfin Kassay1, Hassen Taha Sherief2, Ghimja Fissehaye3, Teshome Teklu1, Original article Knowledge of "drug" use and associated factors as perceived by health professionals, farmers, the youth and law enforcement agencies in Ethiopia” http://www.cih.uib.no/journals/EJHD/ejhd-v13/ejhd-v13-n2-141.htm (Date accessed 26/06/06) “There are no laws addressing harm reduction methods for injecting drug users (such as needle exchange.” (Abraham Habte Giorgis, Head, Planning, Drug Information Establishment and Distribution Department, Drugs Adminstration and Control Authority (DACA).)
Discussion questions: • •
Which areas of SRH and HIV/AIDS responses are legislated for? What are the biggest strengths, weaknesses and gaps in legislation in relation to HIV prevention for girls and young women? Is action taken if laws are broken (e.g. if a girl is married below the legal age)? Is there any specific legislation for marginalised and vulnerable groups1? If yes, is the legislation supportive or punitive? And what difference does it make to people’s behaviours and risk of HIV infection? To what extent are ‘qualitative’ issues – such as confidentiality around HIV testing – covered by legislation? How much do girls and young women know about relevant legislation and how it relates to them? Are there any initiatives to raise awareness about certain laws? Overall, how is relevant legislation applied in practice? What are the ‘real life’ experiences of girls and young women? What difference does it make to their vulnerability to HIV infection? How do the effects of legislation vary among different types of girls and young women, such as those in/out of school, married/unmarried, in rural/urban areas, living with HIV/not aware of their HIV status?
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PREVENTION COMPONENT 2: POLICY PROVISION (national policies, protocols, guidelines, etc) Key questions: 11. Does the current National AIDS Plan address the full continuum of HIV/AIDS strategies, including prevention, care, support and treatment? “A minimum package of services for targeted prevention, care and support has to be defined at the level of health post, health center and hospital and capacity building should occur at all levels. Universal coverage by the health extension program, coupled with capacity building from primary to tertiary levels, can ensure effectiveness and sustainability of the programs in the fight against HIV/AIDS” (Page 9). “Objective 1: Increase primary health service coverage from 60% to 80% and enable the facilities to 1
Examples include: people living with HIV/AIDS, sex workers, injecting drug users, migrant workers, refugees and displaced people, street children, school drop-outs, lesbians and ethnic minorities.
provide HIV/AIDS related preventive, care and treatment services. Selected Strategies: Construct and upgrade health institutions with emphasis on health posts and health centers. Furnish all health care facilities with improved diagnostic, medical equipment and supplies. Establish functional referral system. Strengthen the institutional capacity of health systems.”(Page 12) (Ethiopian Strategic Plan for Intensifying Multisectoral HIV/AIDS Response (2004-2008), , http://www.etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 28/04/06)) 12. Does the National AIDS Plan specifically address the HIV prevention and SRH needs of girls and young women? “The youth population between the ages of 15-29 years is highly affected by the epidemic. A large number from this age group are in schools, therefore, targeted behavioral change communication and integration of HIV/AIDS prevention issues in the curriculum and in civic education can effectively control the spread of HIV among the youth and the school community. In addition, youth out of school need to be targeted appropriately. Due to deep-rooted poverty, there is a rapid increase in the number of commercial sex workers, especially in urban settings, resulting in rapid transmission of the virus. Comprehensive and tailored packages of interventions should be in place to address their special need. Long distance truck drivers, migrant laborers, and uniformed people, should also be addressed with targeted interventions focusing on their mobile nature.” (ETHIOPIAN STRATEGIC PLAN FOR INTENSIFYING MULTI-SECTORAL HIV/AIDS RESPONSE (2004 – 2008)- Addis Ababa, Ethiopia (December 2004), http://etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 07/07/06)) “HIV/AIDS is gradually but steadily spreading into the rural areas where 85% of Ethiopia' s populations live, therefore mainstreaming of HIV/AIDS prevention and control programs in our rural development and the health extension programs is a strategic step to avoid the rapid spread of the epidemic in rural community. The active involvement of people living with HIV/AIDS has to be given a central place in our response. Orphans and other vulnerable children must and deserve to be targeted both from care and support point of view as well as prevention and reduction of vulnerability.( Pg11) Annex 2. Role of key implementing agencies and stakeholders This Strategic Plan provides a broad multi-sectoral plan for response to the epidemic. Each sector is expected to develop specific plans based on its role/mandate in the society and its capacity. The plans should focus on the sectors'comparative advantages in implementing the strategic plan. Each sector is expected to effectively mainstream HIV/AIDS in its sectoral policy and plan, to establish a focal taskforce/person responsible for advocating, managing and coordinating the implementation of HIV/AIDS activities within the sector and also to network with other sectors. .... 5. The Women's Affairs Bureau The gender inequality that has prevailed in rural and urban communities for years has fueled the vulnerability of and contributed to the spread of the virus among women. The Sector is responsible for addressing gender inequality and advocating for mainstreaming gender in all sectors of development and services. Its major areas of focus will include, among other, • Advocating for the empowerment of women and creating enabling environment to build their skills and thereby reduce risks • Promoting and expanding reproductive health services in rural areas • Enhancing the participation of women in all interventions mainly in prevention, HBC and support services, and PMTCT • Advocating for and promoting vulnerability and risk reduction programs against rape,
early marriage and harmful traditional practices” (Ethiopian Strategic Plan for Intensifying Multi-Sectoral HIV/AIDS Response (20042008), http://www.etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 28/04/06)) 13. Does the National AIDS Plan specifically address the HIV prevention and SRH needs of marginalised and vulnerable groups, including people who are living with HIV/AIDS? Policy, strategy and legal frameworks: The National AIDS Policy was drafted in 1991 and approved in 1998. A National Strategic Framework was formulated in 2002 with focus on reducing transmission. It was replaced by a strategic plan in December 2004 with focus on community mobilization of target groups including youth (15-29 years of age), rural communities and people living with HIV/AIDS. A women policy was enacted in the country in 1993 with the objective of facilitating equality, equal access to services and eliminating prejudice against women. The national poverty reduction strategy papers also identify HIV/AIDS as focus area. The country has ratified the Universal Declaration of Human Rights (UDHR) and relevant treaties like the Convention of the Elimination of All Forms of Discrimination against Women (CEDAW) and The Convention on the Rights of Child. Various laws in the country, such as Laws of non discrimination and equality before law; participation in the economic, political and cultural life of society; the rights of women, children and other vulnerable or affected group; have helped strengthen protection of vulnerable (specifically women and children) and affected society groups. Barriers for implementation: Although the country has a number of positive policies, strategies and legal frameworks, pertinent to HIV/AIDS prevention and control, there are also serious structural and economic barriers to implementation. There is not enough integration between the legal framework and HIV/AIDS risks e.g. protection of girls/women and helping rape victims. The national strategy has not specifically included women among the vulnerable groups. Rural areas are only to a limited degree benefiting from interventions including services like information, Voluntary Counseling and Testing and Anti Retroviral Treatment. There are also barriers of cultural and social norms and practices. Gender inequality is the most important. Stigma and discrimination and harmful traditional practices like female genital mutilation, early marriage, abduction and widow inheritance are also common. DANChurchAid Ethiopia website, (24/05/05), http://www.dca.dk/sider_paa_hjemmesiden/where_we_work/africa/ethiopia/re ad_more/hiv_aids_programme_in_ethiopia (Date accessed 09/11/06)) “4.6 Special target groups 4.6.1 Commercial Sex Workers, truckers, migrant laborers, uniformed people, teachers, students and out of school youth. “Objective 15: Reduce vulnerability to HIV infection among the identified targeted group. Strategies: • Promote VCT and other behavioral change interventions. • Promote the use of male and female condoms. • Provide user-friendly Reproductive Health and STI services. • Enhance bargaining and negotiations skills for safe sex where applicable. • Provide safe and alternative income generating and employment opportunities where applicable. • Strengthen and expand school anti AIDS clubs and mini Medias
• Integrate HIV/AIDS in life skill education and basic curriculum. • Develop youth centers and entertainment resorts. • Organize the youth on voluntary basis and provide peer education. 4.6.2 People living with HIV/AIDS, orphans and other vulnerable children Objective 16: Improve quality of life of people living with HIV/AIDS, orphans and other vulnerable children (OVC) Strategies: • Promote care within the family and mobilize the community to address and accommodate the issue of PLWHA/OVC through traditional and extended family mechanisms. • Provide counseling service, legal advice and protection to PLWHA/OVC. • Provide access to basic health, education and other social services to PLWHA/OVC • Provide vocational skill training and income generating opportunity for PLWHA/OVC • Develop acceptable social security models towards the special needs of PLWHA/OVC • Mobilize all stakeholders to address the needs of PLWHA/OVC in a sustainable manner.” (Ethiopian Strategic Plan for Intensifying Multi-Sectoral HIV/AIDS Response (20042008), http://www.etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 07/11/06)) 14. Does the National AIDS Plan emphasise confidentiality within HIV/AIDS services? Confidentiality is not mentioned in the Strategic Plan (Ethiopian Strategic Plan for Intensifying Multi-Sectoral HIV/AIDS Response (20042008), http://www.etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 28/04/06)) “Guiding Principles for Testing and Counseling for PMTCT. Confidentiality: Maintaining confidentiality is an important responsibility of all healthcare workers and is essential to establishing client trust. Information that is shared between healthcare workers and clients must be kept private. It is essential that a private venue/room be used for all discussions of HIV-related matters, particularly HIV diagnosis. Clients should be informed that personal and medical information, including HIV test results, might be disclosed” (Ethiopia Ministry of Health - Prevention of Mother to Child Transmission of HIV REFERENCE MANUAL (2005) – module 4-2 http://www.etharc.org/pmtct/resources/PMTCT_ReferenceManual.pdf (Date accessed 27/04/06)) 15. Does the national policy on VCT address the needs of girls and young women? “Guidelines on VCT for 13 Years of Age The rise in HIV infection affects children and almost no counseling services exist for them. HIV testing, for children usually occur with a parent’s consent, however, counselor needs to consider: • Future medical care of the child. • Emotional support, including dealing with his/her illness and parental illness or death. • Anxieties about other children in the family who may be infected. • What and when to tell the child. • Coping with stigma and discrimination in the community. • Provision for the child’s future, what to do if the child’s mother or father becomes ill or dies. • Management of records
Managers and counselors should ensure availability of client cards and referral forms. Client records must be confidential and at a minimum should include: • • • • • • •
Unique client identifier code, Client characteristics, Reasons for seeking VCT and client risk behaviors, Date of pre-test counseling, Laboratory result, Date of notification of results and post-test counseling, and Any referral and follow-up.” (Ethiopia Ministry of Health - Prevention of Mother to Child Transmission of HIV Reference Manual (2005) Subsection Ethiopia Policy on VCT - Module 4-8 http://www.etharc.org/pmtct/resources/PMTCT_ReferenceManual.pdf (Date accessed 27/04/06)
16. Does the national protocol for antenatal care include an optional HIV test? There is no national protocol for antenatal care. (Hiwot Mengistu, Head, Maternal and Child Health, Federal Ministry of Health.) “Counselling and testing. VCCT should be routine essential element of the management of HIV in pregnancy, with an informed right of refusal. In the event the woman refuses, she should be given the benefit of repeated VCCT throughout pregnancy”. (Ethiopia Ministry of Health - Prevention of Mother to Child Transmission of HIV Reference Manual (2005) – Module 3-8 http://www.etharc.org/pmtct/resources/PMTCT_ReferenceManual.pdf (Date accessed 07/11/06)) 17. Does the national protocol for antenatal care include a commitment that any girl or young woman testing HIV positive should be automatically offered PMTCT services? Appendix 4-E. Counseling is a relationship and provides an opportunity to connect with the client, answer questions, and make sure the client understands the information you are providing. o Greet the client. Establish rapport. o Make sure you have the client’s test results and inform the client that you have the result. o Ask whether the client has any questions that have come up since being tested. Answer questions and let client know counseling will continue to be available to help with important decisions. o Recap the pretest information/counseling session. Let the client know you are doing this to make sure he or she can recall the information. o Indicate that the HIV test result is ready and provide it in a straightforward manner. o State in a neutral tone: “Your test result is positive.” o Pause and wait for the client to respond before continuing. Give the client time to express any emotions. o Check the client’s understanding of the meaning of the result o Discuss and support the client’s feelings and emotions. o Normalize the client’s feelings and emotions o Inform the client of essential PMTCT issues. Discuss and support initial decisions on o Antiretroviral treatment/prophylaxis o Infant feeding options o Childbirth plans o Adequate nutrition Address positive living and provide referral for preventive health care services.
o o o
Prompt medical attention, prophylaxis, and treatment of opportunistic infections Ways to stay healthy Stress management and support systems.
Discuss the fact that the woman’s test result does not indicate whether her partner is infected and her partner will need to be tested. Discuss disclosure and support issues and subsequent counseling needs. Address risk reduction needed to protect her partner(s) and herself from re-infection o o
Condom use Reducing risk of infecting others and screening and treatment for sexually transmitted infections.
Identify sources of hope for the client, such as family, friends, community-based services, spiritual supports, and treatment options. Make referrals when appropriate. If client already has children, discuss and plan for testing of children. Ask whether the client has questions or concerns. Give the client contact information for the clinic should concerns arise. Remind mothers and families that counseling will be available throughout the pregnancy to help them plan for the future and obtain needed services.” (Ethiopia Ministry of Health - Prevention of Mother to Child Transmission of HIV Reference Manual (2005) – module 4-29 http://www.etharc.org/pmtct/resources/PMTCT_ReferenceManual.pdf (Date accessed 27/04/06)) 18. Is there a national policy that the protects the rights and needs - including HIV prevention, SRH services, employment opportunities and education - of young women or girls at risk or affected by early marriage? Policy, strategy and legal frameworks: The National AIDS Policy was drafted in 1991 and approved in 1998. A National Strategic Framework was formulated in 2002 with focus on reducing transmission. It was replaced by a strategic plan in December 2004 with focus on community mobilization of target groups including youth (15-29 years of age), rural communities and people living with HIV/AIDS. A women policy was enacted in the country in 1993 with the objective of facilitating equality, equal access to services and eliminating prejudice against women. The national poverty reduction strategy papers also identify HIV/AIDS as focus area. The country has ratified the Universal Declaration of Human Rights (UDHR) and relevant treaties like the Convention of the Elimination of All Forms of Discrimination against Women (CEDAW) and The Convention on the Rights of Child. Various laws in the country, such as Laws of non discrimination and equality before law; participation in the economic, political and cultural life of society; the rights of women, children and other vulnerable or affected group; have helped strengthen protection of vulnerable (specifically women and children) and affected society groups. Barriers for implementation: Although the country has a number of positive policies, strategies and legal frameworks, pertinent to HIV/AIDS prevention and control, there are also serious structural and economic barriers to implementation. There is not enough integration between the legal framework and HIV/AIDS risks e.g. protection of girls/women and helping rape victims. The national strategy has not specifically included women among the vulnerable groups. Rural areas are only to a limited degree benefiting from interventions including services like information, Voluntary Counseling and Testing and Anti Retroviral Treatment. There are also barriers of cultural and social norms and practices. Gender inequality is the most important.
Stigma and discrimination and harmful traditional practices like female genital mutilation, early marriage, abduction and widow inheritance are also common. DANChurchAid Ethiopia website, (24/05/05), http://www.dca.dk/sider_paa_hjemmesiden/where_we_work/africa/ethiopia/rea d_more/hiv_aids_programme_in_ethiopia (Date accessed 09/11/06)) "Article 35 The Rights of Women 2. Women shall, as prescribed by this Constitution, have equal rights with men in respect to marriage." ... "4. The State has the duty to guarantee the right of women to be free from the influence of harmful customary practices. All laws, stereotyped ideas and customs which oppress women or otherwise adversely affect their physical and mental wellbeing are prohibited." ... "8. Women shall have the right of access to education and information on family planning and the capability to benefit thereby so as to protect their good health and prevent health hazards resulting from child birth." ... "Article 36 The Rights of the Child 1. Every child shall be entitled to the rights enumerated hereunder:- " ... "d) the right to be protected against exploitative practices, and not to be permitted to engage in any employment which would prejudice its health, education or well-being; " ... "2. In all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration." (Ethiopian Constitution (1994) http://www.africa.upenn.edu/Hornet/Ethiopian_Constitution.html (Date accessed 28/04/06)) 19. Is HIV prevention within the official national curriculum for both girls and boys? “4.1.2 Education Sector Objective 3: Integrate HIV/AIDS education into the curriculum of all levels of schools. Selected Strategies: • Include HIV/AIDS education in teaching curricula • Promote peer education • Use effective communication and appropriate technology • Strengthen civic education Pg12”. (Mainstream HIV/AIDS into education” (Ethiopian Strategic Plan for Intensifying Multi-Sectoral HIV/AIDS Response (2004 - 2008) http://www.etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 28/04/06)) Biology Curriculum Guide Grade 7 7.5.7. HIV/AIDS Definition, cause, blood cells attacked by HIV, transmission, blood transfusion, traditional practices, prevention., Life skills activities on, HIV/AIDS, decision making, assertiveness, problem solving
Grade 8. 1.4.5. Reproductive health STDs, Illegal abortion Harmful traditional practices (e.g. female Circumcision), HIV and AIDS global distribution, Local distribution, Projection, Impact on society, Care and support for PLWHA, life skills activities (assertiveness, decision making, problem solving) Grade 9 4.5 HIV and white blood cells How does HIV affect WBC, Opportunistic infections associated with HIV, HIV Testing and counselling, Responsible behavior to prevent HIV, Life skills activities to learn responsible behavior. 4.6 Group project on how HIV/AIDS affects rural development programs and the recommended solutions. Grade 10 j) HIV and AIDS History of HIV and AIDS, major and minor symptoms, Incubation period of HIV, HIV and Immunity, Treatment of HIV/AIDS, Living with HIV/AIDS, HIV/AIDS life skills Grade 11 1.4 Biology and HIV and AIDS Contribution of biology to the fight against AIDS, students’ contribution to the fight against AIDS (community participation; love, care and protection of PLWHA; etc.), responsible sexual behaviour, life skills (decision making; problem solving; assertiveness; self - esteem; communication; etc.) Grade 12 2.6 HIV and AIDS HIV structures and functions, HIV multiplication, HIV and immunity, HIV testing and counselling, responsible sexual behaviour, life skills (Institute of Curriculum Development and Research (ICDR) (2004-2006)) 20. Is key national data about HIV/AIDS, such as HIV prevalence, routinely disaggregated by age and gender? Yes. (WHO, Country Health indicators, http://www3.who.int/whosis/country/indicators.cfm?country=eth (Date accessed 02/05/06)) Discussion questions: •
To what extent are relevant bodies – such as the Ministry of Education, NGO networks, religious organisations, etc – engaged in policy-making around HIV prevention for girls and young women?
•
To what extent do those bodies work in partnership or in isolation? What areas of HIV prevention responses (e.g. behaviour change, counselling, treatment, home-based care) have national protocols or guidelines?
•
To what extent do those protocols address the needs of girls and young women, including those that are marginalised and vulnerable?
•
What does school-based sex education cover? Does it help to build young people’s confidence and skills, as well as knowledge?
•
To what extent do policies help to reduce stigma and discrimination? For example, do they encourage people to stop using derogatory language or ‘blaming’ specific groups for HIV/AIDS? o To what extent are different areas of policy provision – such as for HIV/AIDS and antenatal care – integrated or isolated? o What policy measures exist in relation to consent, approval and confidentiality? For example, can girls and young women access services such as VCT without having to notify their parents and/or partner? And are they informed of their right to confidentiality?
• •
•
Overall, how are relevant policies applied in practice? What are the ‘real life’ experiences of girls and young women? How much do they know about them and how they relate to them? What difference do these policies make to their vulnerability to HIV infection?
•
How do the effects of policies vary among different types of girls and young women, such as those in/out of school, married/unmarried, in rural/urban areas, living with HIV/not aware of their HIV status?
PREVENTION COMPONENT 3: AVAILABILITY OF SERVICES2 (number of programmes, scale, range, etc) Key questions: 21. Is there a national database or directory of SRH and HIV/AIDS services for young people? Yes. (Family Health International, HIV Care and Support Addis Ababa Service Directory 2003, http://www.fhi.org/NR/rdonlyres/ehpnly6ybupaib7vpapa3dy26y6nk5l32xlj2oxc2e2zh aiebxvlw6xr4arxatxwokzkalvbs3gtbp/AADirectory.pdf (Date accessed 27/04/06)) 22. How many SRH clinics or outlets are there in the country? Government hospitals, health centers and health stations offer SRH services: 7. Health Infrastructure 7.1 Potential Health Service Coverage, 2004/05 Total Number of Government Health facilities – Hospitals - 131, Health Centers - 600, Health Stations – 1,662. Private Clinics – 1,578. (Health and Health Related Indicators 2004/05, Planning and Programming 2
(Refers to the full range of SRH and HIV/AIDS services relevant to girls and young women. These include antenatal care, STI information and treatment, HIV prevention, condoms, VCT and other counseling, positive prevention, treatment of opportunistic infections, care and support, treatment (including ARVs), skills building, economic development, etc).
Department, Federal Ministry of Health.) “The Family Guidance Association of Ethiopia (FGAE) operates 18 clinics, 24 youth service centers, 671 community-based reproductive health care sites, and hundreds of other health care facilities. The global gag rule has cost it more than $500,000, even though abortion is illegal in Ethiopia and the FGAE doesn' t provide abortion services. It does, however, seek to educate local policymakers about the role that unsafe abortion plays in Ethiopia' s staggering maternal mortality rate. The result is a loss of services to 301,054 women and 229,947 men in urban areas.” (Planned Parenthood Federation USA (2005), http://www.plannedparenthood.org/pp2/portal/files/portal/webzine/globaldispatc h/gd-050119-globalgag.xml (Date accessed 02/05/06)) Marie Stopes International Ethiopia operates 17 SRH clinics in the country. (Marie Stopes staff.) 23. At how many service points is VCT available, including for young women and girls? "Youth Prevention: Partnerships with youth clubs throughout the country to increase youth participation and leadership in HIV/AIDS programs, including adaptation of the "community conversation" methodology for youth. Launching of the National Youth Task Force to increase leadership and co-ordination. Initiation of youth-friendly VCT services in six youth centre sites. Engagement of university students in HIV/AIDS prevention and peer education." (Unicef website, http://www.unicef.org/ethiopia/hiv_aids_464.html (Date accessed 22/06/06) "20 sites.(Pg20-26)" (Frances Stuer-Country Director, Family Health International-Ethiopia, HIV Care and Support Addis Ababa service Directory(2003), http://www.fhi.org/NR/rdonlyres/ehpnly6ybupaib7vpapa3dy26y6nk5l32xlj2oxc2e2zh aiebxvlw6xr4arxatxwokzkalvbs3gtbp/AADirectory.pdf ( Date accessed 07/11/06) “Tigray National Region (37 Centers), Afar National Region (15 Centers), Amhara National Region (82 Centers), Oromiya National Region (113 Centers), Somale National Region (2 Centers), Benshangul Gumuz National Region (5 Centers), SNNPR (115 Centers), Gambela National Region (1 Centers), Harrari People National Region (6 Centers), Addis Ababa City Region (108 Centers), Dire Dawa Region (4 Centers)” (Ethiopian AIDS Resource Center Website, Voluntary counseling and testing (VCT) Centers by Region: http://www.etharc.org/vct/vctbyregion.cfm (Date accessed 22/06/06)) There are tremendous differences in the number and availability of VCT sites between urban and rural sites. In rural areas, VCT services are few and far between, at best often located in district capitals. (Key Informant Interviews with officers from UNFPA, FGAE and the national coordinator of the National Association of HIV Positive Women.) 24. Are male and female condoms available in the country? "LAW AND POLICY RELATED TO HIV PREVENTION Ethiopia plans to promote the use of both male and female condoms among targeted groups,including commercial sex workers, truckers, migrant laborers, uniformed
persons, teachers, and students.In order to reduce vulnerability among these groups, the country plans to make condoms available for free in “relevant sites.(Pg40)" (Siecus P E P FA R COUNTRY PRO F I L E S : FOCUSING IN ON PREVENTION AND YOUTH, http://www.siecus.org/inter/pepfar/Ethiopia.pdf (Date accessed 22/06/06) “Objective 15: Avail free supply of condoms in relevant sites. (Pg31)" (ETHIOPIAN STRATEGIC PLAN FOR INTENSIFYING MULTI-SECTORAL HIV/AIDS RESPONSE (2004 - 2008) Addis Ababa, Ethiopia December 2004, http://etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 22/06/06) 25. Is a free HIV test available to all pregnant girls and young women who wish to have one? “Expand VCT centers in all hospitals and health centers Establish free standing and mobile VCT (Pg31)” (ETHIOPIAN STRATEGIC PLAN FOR INTENSIFYING MULTI-SECTORAL HIV/AIDS RESPONSE (2004 - 2008)-Addis Ababa, Ethiopia (December 2004), http://etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 07/07/06)) 26.At how many service points are PMTCT services (such as nevirapine) available for pregnant girls or young women who are HIV positive? There are 128 PMTCT sites. (Ethiopian AIDS Resource Center Website : http://www.etharc.org/pmtct/pmtsite.htm (Date accessed 28/04/06) 27. At how many service points are harm reduction services for injecting drug users available? There are no harm reduction services for injecting drug users in Ethiopia. (Abraham Habte Giorgis, Head, Planning, Drug Information Establishment and Distribution Department, Drugs Adminstration and Control Authority (DACA).) 28. Are there any specific national projects (such as camps, conferences, and training courses) for boys/girls and young people living with HIV/AIDS? “Support for International Partnership against AIDS in Africa (SIPAA) supported several PLWHAs to attend study tours and conferences, train in planning, management, leadership and networking,which has facilitated their competence in advocacy, lobbying and public education. For example the DH-E conducted a 12-day training course in leadership for elected executives of PLWHA associations with support from SIPAA, which has improved their leadership role regarding HIV/AIDS. The Dawn of Hope Ethiopia (DH-E), Tilla, Addis Mieraf and Tesfa Brehan have organized themselves and identified part-time legal advisors who provide advise to members whenever it is needed.(Pg19)” (Akalewold Bantirgu, Stephen K. Kiirya, Tesfalidet Debesay, Alemu Aberra- SUPPORT TO INTERNATIONAL PARTNERSHIP AGAINST AIDS IN AFRICA (SIPAA)- ETHIOPIA PARTICIPATORY COUNTRY REVIEW REPORT- (February 2005) http://www.intellibiz.biz/ReviewEthiopia.pdf (Date accessed 06/07/06)) “Highlight of planned activities for 1997 EFY (2004-2005) o Short term training on developing literature, drama and music focusing on HIV/AIDS
o Provision of relevant materials for local IEC material production o Production and dissemination of messages focusing on stigma and discrimination o Training of animators on local level thematic and targeted IEC material production for 20 youth o Train 20 youth living with the virus on positive living.” (UNICEF, For Every Child Health, Education, Equality, Protection Advance Humanity http://www.etharc.org/amhara/About%20us/Programs/UNICEF.htm (Date accessed 02/05/06)) 29. At how many service points are ARVs available to people living with HIV/AIDS? "Reporting Facilities Number of treatment sites opened in the month 10 o o
Number of treatment sites operational 225 Number of reporting treatment sites 205"
(MOH - HAPCO, Monthly HIV Care and ART Update- Update as of end of Tahsas 25, 1999 (Jan 3, 2007), http://www.etharc.org/arvinfo/artupdate/ART Hid1998 Dec. 2006.pdf (date accessed 15/01/06)) “56 “ ((National AIDS Commission, UNAIDS, The Global Fund, The World Bank, updated October 2005, http://www.plusnews.org/aids/treatment/Ethiopia.asp (Date accessed 28/04/06)) 30. Are there specific positive prevention services, including support groups, for young women and girls living with HIV/AIDS? “The Women's Affairs Bureau: The gender inequality that has prevailed in rural and urban communities for years has fueled the vulnerability of and contributed to the spread of the virus among women. The Sector is responsible for addressing gender inequality and advocating for mainstreaming gender in all sectors of development and services. Its major areas of focus will include, among other, • Advocating for the empowerment of women and creating enabling environment to build their skills and thereby reduce risks • Promoting and expanding reproductive health services in rural areas • Enhancing the participation of women in all interventions mainly in prevention, HBC and support services, and PMTCT • Advocating for and promoting vulnerability and risk reduction programs against rape, early marriage and harmful traditional practices. (Pg49)” (ETHIOPIAN STRATEGIC PLAN FOR INTENSIFYING MULTI-SECTORAL HIV/AIDS RESPONSE (2004 - 2008)-Addis Ababa, Ethiopia (December 2004), http://etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 06/07/06)) (USAID, ICW and Global Network of People Living with HIV/AIDS, Directory of Associations of People Living with HIV/AIDS July 2004) http://www.usaid.gov/our_work/global_health/aids/Publications/docs/hivaidsdirect ory.pdf (Date accessed 05/05/06))
Discussion questions: •
What scale and range of HIV prevention services is available for girls and young women? For example, do programmes go beyond ‘ABC’ strategies? Do programmes cover social issues (e.g. early marriage)?
•
To what extent are SRH, HIV/AIDS and broader community services integrated and able/willing to provide referrals to each other? For example, could most SRH clinics refer a girl testing HIV positive to a support group for people living with HIV/AIDS?
•
To what extent are HIV prevention services available through ‘non-traditional’ outlets (e.g. religious organisations, youth clubs)?
•
Are there community programmes on gender awareness/dialogue for girls/boys and young women/men? Do they explore power differences and social ‘norms’ for sexual behaviour? Is there mentoring, peer support and economic development that targets females? “1.6. Conduct Youth Dialogue PSPs or trained CCF will conduct a minimum of two sessions of youth dialogue per year to reach 880 youth. 3.3 Undertake job oriented skill training for young people Job oriented skill training will be organized for selected 173 unemployed young boys and girls. …. Hair dressing, welding, carpentry, drama and music are some of the possible training types. 3.4 Organize girls’ club review meeting In all youth centers there is a girl’s club. Members of the clubs will conduct regular quarterly meetings …. which will enhance their involvement and allow them to disseminate correct ASRH information and education to their peers. 3.5 Conduct Assertiveness training Two hundred and twenty five young girls will be trained for 2-3 days on different issues of assertiveness with the main objective of empowering and protecting them from unsafe sexual practices and its consequences such as unwanted pregnancy, unsafe abortion, HIV/AIDS.” (Annual Work Program Budget 2007. Gender and Youth Program, Family Guidance Association of Ethiopia.) 2.4 “Description of main activities • Establish youth clubs including girls’-focussed clubs. strengthen girls forum in 12 existing youth clubs and establish 8 new girls focussed clubs • Advocacy project will carry out community level advocacy on selected girls focussed RH issues targeting mainly parents, community leaders, religious leaders, health workers, youth leaders to minimize harmful traditional practices like early marriage, FGM, menstrual taboos and other RH issues.” (Project Title - Creating Space for Girls, Awassa Area, SNNPR, 2005, DSW, German Foundation for World Population)
o
How available is prevention information and support for girls and young women living with HIV/AIDS?
o
How available are HIV prevention ‘commodities’ (e.g. condoms)? How are they distributed? •
How much do girls and young women know about the availability of services, such as where to get condoms or ARVs?
•
Overall, what does the availability of HIV prevention services mean in practice? What are the ‘real life’ experiences of girls and young women? What difference do these services make to their vulnerability to HIV infection?
•
How do the effects of availability vary among different types of girls and young women, such as those in/out of school, married/unmarried, in rural/urban areas, living with HIV/not aware of their HIV status?
PREVENTION COMPONENT 4: ACCESSIBILITY OF SERVICES (location, user-friendliness, affordability, etc) Key questions: 31. Are all government HIV prevention and SRH services equally open to married and unmarried girls and young women? “The youth population between the ages of 15-29 years is highly affected by the epidemic. A large number from this age group are in schools, therefore, targeted behavioral change communication and integration of HIV/AIDS prevention issues in the curriculum and in civic education can effectively control the spread of HIV among the youth and the school community. In addition, youth out of school need to be targeted appropriately. Due to deep-rooted poverty, there is a rapid increase in the number of commercial sex workers, especially in urban settings, resulting in rapid transmission of the virus. Comprehensive and tailored packages of interventions should be in place to address their special need. Long distance truck drivers, migrant laborers, and uniformed people, should also be addressed with targeted interventions focusing on their mobile nature. HIV/AIDS is gradually but steadily spreading into the rural areas where 85% of Ethiopia' s populations live, therefore mainstreaming of HIV/AIDS prevention and control programs in our rural development and the health extension programs is a strategic step to avoid the rapid spread of the epidemic in rural community. The active involvement of people living with HIV/AIDS has to be given a central place in our response. Orphans and other vulnerable children must and deserve to be targeted both from care and support point of view as well as prevention and reduction of vulnerability.( Pg11)” (ETHIOPIAN STRATEGIC PLAN FOR INTENSIFYING MULTI-SECTORAL HIV/AIDS RESPONSE (2004 - 2008)-Addis Ababa, Ethiopia (December 2004), http://etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 06/07/06)) 32. Are all government HIV prevention and SRH services equally open to girls and young women who are HIV positive, negative or untested? “To respond to the challenge of HIV/AIDS, the new Ethiopian Ministry of Youth, Sports and Culture decided to involve young people from all over the country in the process of formulating policy and planning action. The program is based on a methodology called “Participatory Learning and Action,” or PLA. The process began with an in-depth training program and the selection of 51 youth leaders by regional HIV/AIDS Prevention and Control Offices and Youth Bureaus in all 11 regions of the country. The youth leaders proceeded to: Implement peer education initiatives with more than 800 other young people from throughout the country. Conduct participatory assessments with youth and adult stakeholders in both rural and urban settings nationwide. Analyze the resulting data. Lead workshops, validate assessment findings, and synthesize findings in their youth charter and action plan. Several tools were key to the youth leaders’ activities. One tool employed during training was “body mapping,” a learning method in which participants draw representations of the human body. This tool demonstrates participants’ basic knowledge about the human reproductive system and other health
functions, as well as highlighting gaps in knowledge and distorted information. The body-mapping tool served as a significant opportunity for youth leaders to discuss issues related to sexuality. Youth leaders also learned to use a “universe-mapping” tool, whereby they schematically depicted their family and community networks, and examined sexual and reproductive health issues from a variety of perspectives. Other important tools included assessments of youth-friendliness, cost, and accessibility of existing reproductive health and HIV/AIDS services. After youth leaders learned to use these participatory methods, they were able to lead assessments among their peers, in collaboration with adult advisors. After training, assessments, data collection, and data analysis were complete, the youth leaders validated their findings with larger groups of young people during a series of regional consultations. They then reconvened in Addis Ababa for the first National Youth Consultation on Sexual and Reproductive Health and HIV/AIDS to present the results of their work. The consultation served as a forum for the young leaders to develop a national youth charter and a three-year action plan to mobilize youth for improved sexual health and HIV/AIDS preventive behavior. An important benefit of the process was the creation of a dynamic network of young people committed to the health and future of Ethiopia. Lessons Learned The Participatory Learning and Action process undertaken by the Ethiopian youth leaders points to a number of lessons for future work on young people and HIV/AIDS: Participatory learning tools such as body and universe mapping can help young people understand how their sexuality relates to HIV infection. Tools such as charters and action plans, with young people as key participants and catalysts, can serve to channel local energy and knowledge into a national arena. The participatory process can help adults overcome stereotypes of youth and reinforce ideas for a broader array of programs.Adult advisors need to embrace a long-term commitment to nurture youth networks for future action. Information adapted from the website of the Global Health Council “ (Reproductive Health outlook website, Program Examples, http://www.rho.org/html/hiv_aids_progexamples.htm( Date accessed 09/1/06) 33. Are VCT services free for girls and young women? Pro Pride promotes rights-based approach, encourages the involvement of the community and other concerned bodies’ in addressing gender issues. HIV/AIDS related activities include community sensitization on HIV/AIDS and STD, condom promotion and distribution, peer education, counseling, care and support. Activities Implemented • Encouraged STI positive clients to take VCT services • Encouraged HIV positive clients to test for STIs • Offered free STI and VCT services to all clients (previously these services were charged)" (International Council on Management of Population Programmes website, Increasing Institutional Capacity of RH and HIV/AIDS NGOs for Linked Response, http://www.icomp.org.my/Inno_prog/inno-LR-ethiopia.htm ( Date accessed 05/07/06) 34. Are approximately equal numbers of females and males accessing VCT services? “HIV in VCT clients: ( Year 2003/04)
o o
Female: 11.531 Male: 14,824, (N.B. All the Years are in G.C)” (Ethiopia Ministry of Health, Disease Prevention and Control Department, 2004. AIDS in Ethiopia, Fifth Report, Addis Ababa: Ministry of Health - AIDS in Ethiopia Fifth Report, (June 2004), http://www.etharc.org/plwha/resources/nationalfact.htm (Date accessed 05/07/06))
35. Are STI treatment and counseling services free for all girls and young women? “2.2 The Package for STI Prevention and Control The following are components of the public health package for STI prevention and care. • Integration of STI prevention and care facilities into PHC, RH core facilities, private core facilities, private clinics and others. • Specific services for populations at risk such as CSWs, adolescents, truck drivers, military personnel and prisoners.” (National Guideline for the Management of STIs using the Syndromic Approach, MOH, 2001.) “Formerly drugs for STI were funded by MSF and were therefore free. But since the funding has since been terminated, patients now have to purchase the drugs from private sources. Diagnosis and counselling for STIs however is offered free at government facilities”. (Dr. Aseged Woldu, Head, Program Evaluation, Operational Research and Capacity Building. Federal HIV/AIDS Prevention and Control Office.) "Pro Pride promotes rights-based approach, encourages the involvement of the community and other concerned bodies’ in addressing gender issues. HIV/AIDS related activities include community sensitization on HIV/AIDS and STD, condom promotion and distribution, peer education, counseling, care and support. Activities Implemented o o o o
Encouraged STI positive clients to take VCT services Encouraged HIV positive clients to test for STIs Offered free STI and VCT services to all clients (previously these services were charged) Provided STI and HIV/AIDS counseling to all FP/MCH clients" (International Council on Mangement of Population Programmes website, Increasing Institutional Capacity of RH and HIV/AIDS NGOs for Linked Response, http://www.icomp.org.my/Inno_prog/inno-LR-ethiopia.htm (Date accessed 07/11/06)
36. Are condoms free for girls and young women within government SRH services? “Avail free supply of condoms in relevant sites, Provide user friendly RH/STI services” (pg31) (ETHIOPIAN STRATEGIC PLAN FOR INTENSIFYING MULTI-SECTORAL HIV/AIDS RESPONSE (2004 - 2008)-Addis Ababa, Ethiopia (December 2004), http://etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 06/07/06) “Standard 2: Appropriate health services that cater to the reproductive and sexual health needs of the youth are available and accessible.
2.3 Criteria: SRH services for the youth should be provided at an affordable cost for those who cannot pay for free. ……each health facility should provide a range of services “included in the minimum service delivery package” for the youth, i.e. -
Information and Counseling on RSH issues, HIV testing and other services including PMTCT, Syndromic management of STIs, Pregnancy Testing, Antenatal care, Delivery Service and PNC, Abortion and Post abortion care, Family Planning Information, Counseling and Methods, Condom Promotion and Provision, Counseling and other related services should give emphasis to victims of sexual violence/abuse and other special groups. (Standards on Youth Friendly Reproductive Health Services, Service Delivery Guideline and Minimum Service Delivery Package YFRH Services. First Draft. September 2006.)
“Condoms are offered free in government health facilities but usually for family planning clients.” (Dr. Aseged Woldu, Head, Program Evaluation, Operational Research and Capacity Building. Federal HIV/AIDS Prevention and Control Office.) 37. Are ARVs free for all girls and young women living with HIV/AIDS? “Their Excelencies, the President and the Prime Minister of The Federal Democratic Republic of Ethiopia, launched the Free ART for Ethiopia on 24 January 2005”. (Ministry of Health, Accelerating Access to HIV/AIDS Treatment in Ethiopia, Road Map for (2004-2006), http://www.etharc.org/publications/moh/acceleratingtreatment.pdf (Date Accessed 02/04/06)) 38. Are issues relating to HIV/AIDS stigma and discrimination included in the training curriculum of key health care workers at SRH clinics? Combating stigma, isolation and marginalization Nurses and midwives have a responsibility to care for all people, regardless of their health or social status (Fact Sheet 6). They can act as role models to others in helping combat stigma, discrimination and isolation of PLHA. Prevention strategies will be more successful if HIV is treated like any other chronic illness.(pg281) (MaryAnn Vitiello, APRN-BC,ACRN, Debbie Winters, APRN-BC,AACRN Pat Daoust, MSN International Training and Education Center on HIV - Participant Handbook Basic HIV/ARV Training Course for Ethiopian Nurses (July 2004), http://go2itech.org/pdf/p06-db/db-50690.pdf (date accessed 26/06/06)) 39. Are issues relating to young people included in the training curriculum of key health care workers at SRH clinics? "Voluntary Counselling and Testing Models in Ethiopia Integrated within existing health care services, generalized and specialized: • •
ANC,TB, STI Free standing sites
• • • •
Mobile outreach Private Youth-friendly Work place.(slides 2-6) (MaryAnn Vitiello, APRN-BC,ACRN, Debbie Winters, APRN-BC,AACRN Pat Daoust, MSN International Training and Education Center on HIV - Participant Handbook Basic HIV/ARV Training Course for Ethiopian Nurses (July 2004), http://go2itech.org/pdf/p06-db/db-50690.pdf (date accessed 26/06/06))
Module 7, pg13 (Disease Prevention and Control Department Federal Ministry of Health, Ethiopia (April 2005), Prevention of Mother to Child Transmission of HIV, Training guide, http://www.go2itech.org/pdf/p06-db/db-50919-01.pdf (Date accessed 05/05/06)) 40. Are there any government media campaigns (e.g. television commercials and newspaper advertisements) about HIV/AIDS that specifically address prevention among girls and young women? “ADDIS ABABA — The President of Ethiopia this week declared September 10 as National Voluntary Counseling and Testing (VCT) Day in Ethiopia to demonstrate the country' s strong commitment to fighting the war against HIV and AIDS. Agencies working in HIV/AIDS prevention, control, treatment, and care and support were pleased with the move and said strong leadership is what is needed to stop the spread of HIV and mitigate the impact it is having in Ethiopia . “VCT is important as an entry point in HIV prevention and for early access to treatment, care and support and this campaign is geared towards not only empowering our community to access VCT services but also targeting service providers to strive towards the provision of quality Voluntary Counseling and Testing Services,” said Ato Negatu Mereke, Head of HIV/AIDS Prevention and Control Office (HAPCO). The observance of the first National VCT Day featured Ethiopian President Girma WoldeGiorgis unveiling a billboard that depicts three top Ethiopian world class athletes. The athletes — Tirunesh Dibaba, Meseret Defar, and Sileshi Sihen — were appointed VCT Ambassadors by President Wolde-Giorgis. Also present at the unveiling ceremony were State Minister of Health, Dr. Tedros Adhanom; HAPCO Head Ato Negatu Mereke; U.S. Acting Deputy Chief of Mission, Dr. Brian Moran; Country Director of U.S. Department of Health and Human Service' s Centers for Disease Control and Prevention (HHS/CDCEthiopia), Dr. Tadesse Wuhib, Heads of Health Bureau and HAPCO of the capital and other dignitaries and representatives of youth, women, religious and other organizations” (Centre for Communication Programs (September 2005), Ethiopia Observes First National HIV Voluntary Counseling and Testing Day, Three Ethiopian World Class Athletes Named VCT Ambassadors http://www.jhuccp.org/pressroom/2005/09-15.shtml (Date accessed 09/11/06) “The Ministry of Information, the Media and Information Sector The Sector has the comparative advantage of guiding and developing the use of the mass media in disseminating HIV/AIDS related information and messages to the general public and special target groups in different languages. Besides intensifying specific workplace interventions it has the mandate/role for: • Establishing a network of private and public media, promoting media campaigns, and inciting public dialogue on the epidemic • producing and regularly updating the natural glossary of terms related to HIV/AIDS • Developing and facilitating the expansion of edutainment programs through the mass media, etc. • Developing guidelines for the involvement of the media in the fight against HIV/AIDS.(Pg49-50)
(ETHIOPIAN STRATEGIC PLAN FOR INTENSIFYING MULTI-SECTORAL HIV/AIDS RESPONSE (2004 - 2008) Addis Ababa, Ethiopia December 2004, http://etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 22/06/06))
Discussion questions: Are HIV prevention services truly accessible to girls and young women, including those that are marginalised and vulnerable? For example, are they: safe? Affordable? Reachable by public transport? in appropriate languages? Non-stigmatising? open at convenient times? What are the cultural norms around prioritizing females and males for health care? To what extent are informed and supportive SRH services accessible for girls or young women living with HIV/AIDS? What are the client/service provider ratios in different types of HIV prevention services? What is the gender ratio for staff in those services? Do services make proactive efforts to attract girls and young women? For example, do SRH clinics have separate rooms for young women so that they do not risk seeing family members or familiar adults? What are the attitudes of service providers to girls and young women, including those who are marginalised and vulnerable? Are they kind, non-judgemental and realistic (for example about young people’s sexual pressures and desires)? Can they encourage girls/boys to assess their risks of HIV infection and change their behaviour? Are attitudes generally getting better or worse? Do HIV prevention information campaigns, etc, target girls and young women? For example, are they culturally and linguistically appropriate? Are materials distributed through appropriate media and outlets? Is there a national monitoring and evaluation framework? Does it encourage data to be disaggregated (according to gender and age) – to help assess the extent to which girls and young women are accessing programmes and services? Are referrals and follow-up provided during HIV/AIDS, SRH and antenatal care services for young women and girls? Overall, what difference does accessibility to services mean in practice? What are the ‘real life’ experiences of girls and young women? What difference is made to their vulnerability to HIV infection? How do the effects of accessibility vary among different types of girls and young women, such as those in/out of school, married/unmarried, in rural/urban areas, living with HIV/not aware of their HIV status?
PREVENTION COMPONENT 5: PARTICIPATION AND RIGHTS (human rights, representation, advocacy, participation in decision-making, etc) Key questions: 41. Has the country signed the Convention on the Rights of the Child (CRC)?
Yes, on 13th June 1991. (Office of the United Nations High Commissioner for Human Rights - status of ratifications of the principal International Human Rights Treaties As of 09 June 2004 http://www.unhchr.ch/pdf/report.pdf (Date accessed 25/04/06) 42. Has the country signed the Convention on the Elimination of all Forms of Discrimination against Women (DECAW) and the Convention on Consent Marriage, Minimum Age of Marriage and Registration of Marriages (CCM)? CEDAW – Yes, on 10th October 1981. (Office of the United Nations High Commissioner for Human Rights – Status of Ratification of the Principal International Human Rights Treaties (As of 09 June 2004) http://www.unhchr.ch/pdf/report.pdf (Date accessed 25/04/06)) CCM – no. (United Nations Treaty Collection [As of 5 February 2002] 3. Convention on Consent to Marriage, Minimum Age for Marriage and Registration of Marriages New York, 10 December 1962 http://www.unhchr.ch/html/menu3/b/treaty3_.htm (Date accessed 22/04/06) 43. In the National AIDS Council (or equivalent), is there an individual or organisation that represents the interests of girls and young women? Forging partnerships “Governments, policy makers, law enforcement agencies, health and social service agency personnel, nongovernmental organizations (NGOs), religious leaders and religious groups should join together in preventing HIV transmission. Nurses and midwives can play a central role in advocating for, and creating and participating in, such partnerships.(pg280)” (MaryAnn Vitiello, APRN-BC,ACRN, Debbie Winters, APRN-BC,AACRN Pat Daoust, MSN International Training and Education Center on HIV - Participant Handbook Basic HIV/ARV Training Course for Ethiopian Nurses (July 2004), http://go2itech.org/pdf/p06-db/db-50690.pdf (Date accessed 09/11/06)) “The consultation developed a national youth consensus on possible points for the proposed National Youth Charter and Plan of Action through an iterative process facilitated by the 51 youth facilitators. This iterative consensus-building consultation to contribute to or influence national policy might be considered a modified Delphi Consultation, a process developed and used in a number of settings for consensus building as the basis for health policy.(Pgiii)” (Kathy Attawell, Going to Scale in Ethiopia: Mobilizing Youth Participation in a National HIV/AIDS Program (July 2004), http://www.synergyaids.com/documents/GoingToScaleInEthiopia.pdf (Date accessed 26/06/06)) 44. In the National AIDS Council, is there an individual or organisation that represents the interests of people living with HIV/AIDS? Associations of Persons Living with HIV/AIDS (PLWHA) PLWHA are the key actors of the
national response. they are expected to organize themselves in as many associations and at all levels as they find it fit and form a joint forum. They are expected to focus on: • Protecting the rights of their members • Educating the public at large through sharing their life experiences • Promoting and participating in the provision of compassionate home based care • Fighting stigma and discrimination • Advocating for responsible behavior among their members • Advocating for access to ART and policy formulation and legislation Information Education Centre/Behavioral Change Communication IEC/BCC (Pg52)” (ETHIOPIAN STRATEGIC PLAN FOR INTENSIFYING MULTI-SECTORAL HIV/AIDS RESPONSE (2004 - 2008)-Addis Ababa, Ethiopia (December 2004), http://etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 06/07/06)) “The review also established that by supporting the members of Dawn of Hope Ethiopia (DH-E) to participate in regional Anti Stigma Tour of 2004, there has been a growth in the momentum of the organization to address Stigma, Denial and Discrimination (SDD) issues and participate in public education and sensitization campaigns. This has facilitated disclosure of the HIV status the organization has planned to undertake similar tours particularly in the remote areas where Stigma, Denial and Discrimination (SDD) is still widespread. . There is also an increase in the population of PLWHAs covered by sensitization activities organized by PLWHA associations. For example Tilla alone has so far sensitized about 107,867 people (54,082 males and 53,785 females) about SDD associated with the epidemic in and outside Awassa . Addis Mieraf has also initiated public debates on the rights of PLWHA, which has helped to break silence about the epidemic.(Pg19)” (Akalewold Bantirgu, Stephen K. Kiirya, Tesfalidet Debesay, Alemu Aberra- SUPPORT TO INTERNATIONAL PARTNERSHIP AGAINST AIDS IN AFRICA (SIPAA)- ETHIOPIA PARTICIPATORY COUNTRY REVIEW REPORT- (February 2005) http://www.intellibiz.biz/ReviewEthiopia.pdf (Date accessed 06/07/06)) “Association of PLWHA RHAPCOs Implementing Stakeholders (Pg23)” (ETHIOPIAN STRATEGIC PLAN FOR INTENSIFYING MULTI-SECTORAL HIV/AIDS RESPONSE (2004 - 2008) Addis Ababa, Ethiopia December 2004, http://www.etharc.org/arvinfo/HIVStrategicPlan.pdf (Date acceesed 26/06/06)) 45. Was the current National AIDS Plan developed through a participatory process, including input from girls and young women? “The Ministry of Youth, Culture and Sports Affairs Youth: Both in and out of school, and in both rural and urban settings, are amongst the most vulnerable groups. The Sector has the responsibility to develop, promote and expand innovative vulnerability reduction approaches that can provide for better life alternatives for the youth. Towards this end, the sector is expected to play pivotal role in: • Advocating and facilitating for the productive engagement of the youth • Developing strategies to establish comprehensive youth centers and edutainment facilities. • Advocating for the expansion of youth friendly health services • Enhancing youth focused IEC and Care and support activities. (Pg50)” (ETHIOPIAN STRATEGIC PLAN FOR INTENSIFYING MULTI-SECTORAL HIV/AIDS RESPONSE (2004 - 2008)-Addis Ababa, Ethiopia (December 2004), http://etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 06/07/06)) “Successful implementation was made possible by the enthusiastic participation of 51 young women and men facilitators at the grassroots level through regional meetings and, finally, a national plenary.(Pgiii)”
(Kathy Attawell, Going to Scale in Ethiopia: Mobilizing Youth Participation in a National HIV/AIDS Program (July 2004), http://www.synergyaids.com/documents/GoingToScaleInEthiopia.pdf (Date accessed 26/06/06)) “Apart from the FBOs and PLWHA associations, Action Aid Ethiopia- Support for International Partnership against AIDS in Africa (AAE-SIPAA) targeted other strategically important organizations to reach and mobilize their constituents for HIV/AIDS prevention, care and support, and anti-Stigma, Denial and Discrimination (SDD) campaigns. This includes the Addis Ababa Youth Association (AAYA), National Coalition for Women against AIDS (NCWA), Information and Development for Persons with Disabilities Association (IDPDA) and Afar Pastoralists Development Association (APDA), the Ethiopian Business Coalition - (EBC) and Ethiopian Employers Federation –(EEF).(Pg21)” (Akalewold Bantirgu, Stephen K. Kiirya, Tesfalidet Debesay, Alemu Aberra - SUPPORT TO INTERNATIONAL PARTNERSHIP AGAINST AIDS IN AFRICA (SIPAA)- ETHIOPIA PARTICIPATORY COUNTRY REVIEW REPORTFebruary 2005 http://www.intellibiz.biz/ReviewEthiopia.pdf (Date accessed 06/07/06)) 46. Is there any type of group/coalition actively promoting the HIV prevention and SRH needs and rights of girls and young women? Combining resources The combination of counselling, education, support, care services, and resources is necessary to provide a holistic continuum of prevention and care (Fact Sheet 3). For example, STD, antenatal, family planning, home care, hospital care, and community care, as well as other resources and services, can be combined to provide a comprehensive programme. In this way, programmes and services can be combined that address the various modes of HIV transmission without the stigma and discrimination often associated with HIV specific programs. Forging partnerships “Governments, policy makers, law enforcement agencies, health and social service agency personnel, nongovernmental organizations (NGOs), religious leaders and religious groups should join together in preventing HIV transmission. Nurses and midwives can play a central role in advocating for, and creating and participating in, such partnerships.(pg280)” (MaryAnn Vitiello, APRN-BC,ACRN, Debbie Winters, APRN-BC,AACRN Pat Daoust, MSN International Training and Education Center on HIV - Participant Handbook Basic HIV/ARV Training Course for Ethiopian Nurses (July 2004), http://go2itech.org/pdf/p06-db/db-50690.pdf (Date accessed 09/11/06)) The Women's Affairs Bureau: The gender inequality that has prevailed in rural and urban communities for years has fueled the vulnerability of and contributed to the spread of the virus among women. The Sector is responsible for addressing gender inequality and advocating for mainstreaming gender in all sectors of development and services. Its major areas of focus will include, among other, • Advocating for the empowerment of women and creating enabling environment to build their skills and thereby reduce risks • Promoting and expanding reproductive health services in rural areas • Enhancing the participation of women in all interventions mainly in prevention, HBC and support services, and PMTCT • Advocating for and promoting vulnerability and risk reduction programs against rape, early marriage and harmful traditional practices. (Pg49) (ETHIOPIAN STRATEGIC PLAN FOR INTENSIFYING MULTI-SECTORAL HIV/AIDS RESPONSE
(2004 - 2008)-Addis Ababa, Ethiopia (December 2004), http://etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 06/07/06)) “The use of PLA in a consultative process facilitated by young people is an effective model for building youth capacity to respond effectively to HIV/AIDS, as well as a good practice for addressing the holistic sexual and reproductive health needs of young people. (Kathy Attawell, Going to Scale in Ethiopia: Mobilizing Youth Participation in a National HIV/AIDS Program (July 2004), http://www.synergyaids.com/documents/GoingToScaleInEthiopia.pdf (Date accessed 26/06/06)) “The clients of Hiwot include HIV positive persons, orphans, in-school youths and dropouts. Hiwot provides financial, material and technical support to 15 youth clubs for them to deliver SRH information and services to young people age 10-24. Hiwot runs different awareness raising programs through seminars, coffee ceremony, IEC materials etc. It also works with parents, community leaders, government officials, and policy makers to encourage them to participate in youth RH program Activities Implemented Behavior change communication through o
Discussion sessions on PMTCT and FP with the community members during 4 coffee ceremonies
o
Drama and music group
o
Provision of FP counseling and referral for VCT and FP services
o
Referral linkages for FP and VCT services
Youth dialogues on male involvement in FP access, HIV/AIDS prevention, and being supportive of their partners o
o
Public discussions on ‘male involvement on issues of women’s reproductive health’
o
Public discussion session to advocate for the ‘Sexual and Reproductive Health (SRH) including HIV/AIDS rights and needs of HIV positive women’
o
Young boys group was formed to advocate for females’ SRHR”
(International Council on Management of Population Programmes website, Increasing Institutional Capacity of RH and HIV/AIDS NGOs for Linked Response, http://www.icomp.org.my/Inno_prog/innoLR-ethiopia.htm (Date accessed 05/07/06) 47. Is there any type of national group/coalition advocating for HIV prevention (including positive prevention) for girls and young women? “Forging partnerships “Governments, policy makers, law enforcement agencies, health and social service agency personnel, nongovernmental organizations (NGOs), religious leaders and religious groups should join together in preventing HIV transmission. Nurses and midwives can play a central role in advocating for, and creating and participating in, such partnerships.(pg280)”
(MaryAnn Vitiello, APRN-BC,ACRN, Debbie Winters, APRN-BC,AACRN Pat Daoust, MSN International Training and Education Center on HIV - Participant Handbook Basic HIV/ARV Training Course for Ethiopian Nurses (July 2004), http://go2itech.org/pdf/p06-db/db-50690.pdf (Date accessed 09/11/06)) “The Women's Affairs Bureau: The gender inequality that has prevailed in rural and urban communities for years has fueled the vulnerability of and contributed to the spread of the virus among women. The Sector is responsible for addressing gender inequality and advocating for mainstreaming gender in all sectors of development and services. Its major areas of focus will include, among other, • Advocating for the empowerment of women and creating enabling environment to build their skills and thereby reduce risks • Promoting and expanding reproductive health services in rural areas • Enhancing the participation of women in all interventions mainly in prevention, HBC and support services, and PMTCT • Advocating for and promoting vulnerability and risk reduction programs against rape, early marriage and harmful traditional practices. (Pg49)” (ETHIOPIAN STRATEGIC PLAN FOR INTENSIFYING MULTI-SECTORAL HIV/AIDS RESPONSE (2004 - 2008)-Addis Ababa, Ethiopia (December 2004), http://etharc.org/arvinfo/HIVStrategicPlan.pdf (Date accessed 06/07/06)) "Box 3. Recommendations from the Ethiopian National Youth Charter Promote prevention of unwanted pregnancy, sexually transmitted nfections, and HIV infection (e.g., promote choice of preventive options, including delayed sexual debut, abstinence, dual protection, consistent and correct use of male and female condoms; low-cost or free, easy-to-access condom provision).(Pg11)" (Kathy Attawell, Going to Scale in Ethiopia: Mobilizing Youth Participation in a National HIV/AIDS Program (July 2004), http://www.synergyaids.com/documents/GoingToScaleInEthiopia.pdf (Date accessed 26/06/06)) “In Ethiopia, teens who have volunteered to become “advocates of hope” are demonstrating what World AIDS Day really means by making a difference in their communities. Fourteen teens were given digital cameras for a week in August and asked to document their lives and ways they were keeping the promise of fighting AIDS by caring for one another, their families, their communities and themselves”. (Save the Children USA,) http://www.savethechildren.org/health/hiv_aids/world_aids_day05.asp# accessed 05/05/06))
(Date
48. Is the membership of the main network(s) for people living with HIV/AIDS open to young people, including girls and young women? Mekdim Ethiopia is a national association established in 1997 by people living with HIV/AIDS (PLWHA) and AIDS orphans. Mekdim believes that PLWHA and AIDS orphans should play an active role in the fight against HIV/AIDS. Their mission is to promote human rights for PLWHAs and AIDS orphans; to provide care and support to those infected and affected by the epidemic; and to educate and promote behaviour change among the public at large”. (Mekdim Ethiopia http://www.mekdim.org/ (Date accessed 02/05/06) “Dawn of Hope is one of earliest association of people living with HIV/AIDS, including orphans due to HIV/AIDS in Ethiopia. It was founded in 1998 by a group of eleven HIVpositive people with the purpose of educating the people and getting the rights of HIVpositive persons respected. Now Dawn of Hope counts more than 10,000 members and
it has twelve branch offices in Addis Ababa, Nazreth, Debre Zeyt, Debre Birhan, Awasa, Shashemene, Dilla, Harar, Bahir Dar and Humera implementing the Dawn of Hope program of education, care and support, and advocacy throughout the country.” (Dawn of Hope, http://www.dawn-of-hope.org/ (Date accessed 02/05/06) 49. Are there any programmes to build the capacity of people living with HIV/AIDS (e.g. in networking, advocacy, etc)? “Mekdim Ethiopia is a national association established in 1997 by people living with HIV/AIDS (PLWHA) and AIDS orphans. Mekdim believes that PLWHA and AIDS orphans should play an active role in the fight against HIV/AIDS. Their mission is to promote human rights for PLWHAs and AIDS orphans; to provide care and support to those infected and affected by the epidemic; and to educate and promote behaviour change among the public at large”. (Mekdim Ethiopia website, http://www.mekdim.org/ , (Date accessed 02/05.06) “Dawn of Hope is one of earliest association of people living with HIV/AIDS, including orphans due to HIV/AIDS in Ethiopia. It was founded in 1998 by a group of eleven HIVpositive people with the purpose of educating the people and getting the rights of HIVpositive persons respected. Now Dawn of Hope counts more than 10,000 members and it has twelve branch offices in Addis Ababa, Nazreth, Debre Zeyt, Debre Birhan, Awasa, Shashemene, Dilla, Harar, Bahir Dar and Humera implementing the Dawn of Hope program of education, care and support, and advocacy throughout the country.” (Dawn of Hope website, http://www.dawn-of-hope.org/ (Date accessed 02/05/ 50. Are there any girls or young women living with HIV/AIDS who speak openly about their HIV status (e.g. on television or at conferences)? “We would like to thank gratefully the members of Tilla Association of Women Living with HIV who have come forward and share their true life story. It is a sacrifice they pay to save the generation." (People Living with HIV/AIDS in Ethiopiawebsite, http://www.etharc.org/plwha/index.htm (Date accessed 05/07/06) "Summary: The second part in our series on health problems in the Horn of Africa: the problem of HIV-AIDS among a growing number of young girls living in the Ethiopian capital as prostitutes. The Science Unit’s Pauline Newman visits a drop-in centre in Addis Ababa run by the Forum on Street Children Ethiopia, set up for young prostitutes." (Ethiopa: HIV AIDS among child prostitutes Broadcast Monday (20 August 2001) with Norman Swan , http://www.abc.net.au/rn/talks/8.30/helthrpt/stories/s349705.hm (Date accessed 05/07/06)) “ADDIS ABABA, Dec 1 (IPS) - Aster tested positive for HIV/AIDS eight years ago, but she has yet to summon the courage to tell her family, for fear of being rejected by them. Her predicament is typical of HIV-positive Ethiopians. Health workers say the biggest obstacle to these people leading normal lives is the stigma associated with the disease. "I knew that I had the...virus in my blood in 1996. My husband died five years before that, and because his illness was very serious I decided to have an HIV/AIDS test," said Aster”. (Inter Press Services News agency, HEALTH-ETHIOPIA: Fighting the HIV/AIDS Stigma
Remains an Uphill Battle, http://precious-angel.org/uph/ (Date accessed 02/05/06)) Discussion questions: •
How are international commitments (e.g. CRC, CEDAW, and CCM) applied within the country?
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Is the national response to HIV/AIDS rights-based? For example, does it recognise the SRH rights of women living with HIV/AIDS?
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Do key decision-making bodies (e.g. the Country Coordinating Mechanism of the Global Fund to Fight AIDS, TB and Malaria) have a set number of seats for civil society? Are any of them specifically for representatives of girls and young women or people living with HIV/AIDS?
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Are HIV prevention programmes generally developed ‘for’ or ‘with’ girls and young women, including those who are marginalised and vulnerable? Are girls and young women seen as ‘implementers’ as well as ‘receivers’ of services?
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To what extent are girls and young women aware of decision-making processes? Are they encouraged to have a voice? Are they seen as an important constituency within committees, management groups, etc?
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How high are issues relating to HIV prevention for girls and young women (e.g. early marriage and stigma) on the agendas of local leaders and decision-making groups (e.g. district AIDS committees)? To what extent do girls and young women participate in those type of bodies?
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To what extent are people living with HIV/AIDS organised, for example in networks? Are girls and young women involved in those bodies?
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How are issues of participation affected by stigma? For example, is it safe for people living with HIV to speak openly about their HIV status?
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Overall, how are participation and rights applied in practice? What are the ‘real life’ experiences of girls and young women? What difference is made to their vulnerability to HIV infection?
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How do the effects of participation and rights vary among different types of girls and young women, such as those in/out of school, married/unmarried, in rural/urban areas, living with HIV/not aware of their HIV status?
PART 2: IN-COUNTRY RESEARCH
Focus group discussion with young women and girls Age group: 13-21 years Number of participants: 10 Profile of participants: included ou-of-school girls, sex workers and peer educators Place: Addis Ababa
Prevention component Availability of Services : 1. What sort of HIV prevention services are there for girls and young women in your community? Information and counseling on HIV is provided by a youth-oriented NGO and several AntiAids clubs. “Peed educators in Hiwot Ethiopia conduct coffee ceremonies and peer education activities to teach us about life skills, anatomy and peer pressure. There are also 4 Anti-AIDS clubs which teach us about HIV/AIDS.” The youth, including girls, get condoms from the health center and youth clubs as well as shops. Youth clubs, the local administration and World Vision counsel and refer youth to the health center for HIV tests and STI treatment. 2. How much do boys and young men know about HIV prevention services in your community? What is their role in supporting HIV prevention for girls and young women? Although boys and young men are aware of HIV prevention methods and services, they may not be willing to use them. “There is still a problem with men’s attitudes towards the HIV test. Women have more awareness about the importance of the HIV test and are willing to take the test”. Some men are reluctant to use condoms. But many are changing in that they encourage women to get treated for STDS. “Young men and women are not afraid of each other any more and freely talk about HIV/AIDS”. 3. What sort of HIV prevention services would you like more of in your community? How would that make a difference to your life? We need more HIV test centers because only the health center provides this service and and it may be too far for some. “In our area, there is no STI counseling center. The clubs also do not distribute contraceptives on a regular basis”. Prevention component: Accessibility of services 4. What are your experiences of using HIV prevention services in your community? In what way have those experiences been good or bad? Service providers do not maintain a flexible schedule to accommodate the needs of the youth. They are also very inquisitive when giving birth control, which discourages girls from going to them. “When people go for an HIV test, the health workers give group counseling rather than individual counseling. Many of them are too bored to provide careful counseling”. 5. What are the main barriers that you have faced when trying to use HIV prevention services in your community? Health workers do not have a good attitude towards girls and young women who come to them. Because a large number of people go to them for an HIV test, they prefer to conduct pre-test counseling on a group basis. The youth are afraid of testing positive for HIV. “I always wonder if I am found to be HIV positive, what my family’s and community’s attitude towards me would be. Since I see how they treat my friend who is positive, how can I have the courage to take the test?” Although the HIV test is free, the Family Guidance clinic charges 10 birr, which discourages some youth from using the service. 6. In what ways are HIV prevention services easier or harder for particular types of girls and young women to use?
Married women are too busy trying to make a living, which prevents them from having access to information on HIV. Also, “married women think they are safe because they are married and fail to use protection. Unmarried women however use condoms because their relationship with their partner is more casual”. Out-of-school girls have less access to information, so they are less likely to want to test for HIV. Prevention component: Participation and rights 7. In what ways and to what extent are girls and young women involved in HIV prevention in your community? The girls’ clubs prepare coffee ceremonies for the community and conduct discussions, drama and poetry on HIV and other reproductive health issues. Although there are as many as 20 female members in youth clubs, girls’ and young women’s overall participation in HIV prevention is not enough. 8. Have there been any projects in your community to bring together girls and boys or young women and young men to talk about HIV prevention? A youth club brings together girls and boys on a monthly basis to discuss various issues. “We discuss issues such as marriage and reproductive health. The youth like the program very much. It improves their decision-making skills and helps them develop confidence in themselves”. 9. What would encourage you to get more involved in HIV prevention in your community? The coffee ceremonies should be held more regularly. If parents receive information through ‘idirs’ or the burial association and home-to-home visits, they will be encouraged to discuss HIV with their children freely and allow them to participate in Anti-AIDS clubs. Prevention component: Legal provision: 10. What do you know about laws in Ethiopia that might affect how girls or young women can protect themselves from HIV? There are laws prohibiting the harassment of women, rape, wife inheritance, female circumcision and abortion. These can help protect girls and young against HIV. 11. To what extent do these laws affect HIV prevention for girls and young women? Although such laws exist, their enforcement is often weak. This is partly because the community’s awareness of these laws is low. Rapists are often freed on bail or for lack of evidence. “In our area, a 40 year old man got married to a 13 year old girl. The police arrested him but later freed him. He subsequently abducted the girl and took her to another city”. Although abortion is prohibited by law, backs street abortions still take place. Prevention component: Policy provision: 12. What type of education have you received about issues such as relationships, sex and AIDS? For example, what have you been taught about your sexual and reproductive health in school? The school curriculum does not cover reproductive health issues. “In biology class, the teachers teach us about our bodies and menstruation, but do not give detailed instruction on HIV or sex”. The school Anti-AIDS clubs and mini-media deal with these topics however. The health center holds instruction sessions and TV shows on HIV, STDs and condoms for people who go there for medical assistance. Dramas are also shown. 13. What could the government of Ethiopia do to fight fear about AIDS in your community? Information on HIV should be provided to the public through the media and other institutions. It should be given in an attractive and easily understandable way. The government should also allow expansion in the number of NGOs which provide information on HIV. Summary Question:
14. What are the 2-3 most important changes that could be made to help girls and young women in Ethiopia protect themselves from HIV? Girls and young women should be provided with better education and employment. Women should be placed in decision-making positions so that they can help other women. The enforcement of the laws on rape, early marriage and abduction should be strengthened. “Support should be given to open job opportunities for prostitutes and to expand the numbers and coverage of girls’ clubs”.
Focus group discussion with young women and girls Age group: 17-20 years Number of participants: 10 Profile of participants: included in-school girls, mostly peer educators Place: Addis Ababa
Prevention component: Availability of services 1. What sorts of HIV prevention services are there for girls and young women in your community? Youth clubs, an NGO and a health center offer information and condoms to the community. The latter, however, offers condoms only when they run out of other contraceptives. Condoms are also available in shops and pharmacies. The NGO provides HIV testing services for free. ARVs are provided by the health center. “The youth clubs distribute newspapers and leaflets, conduct peer education sessions and coffee ceremonies to teach people about HIV, and distribute condoms as well”. 2. How much do boys and young men know about HIV prevention services in your community? What is their role in supporting HIV prevention for girls and young women? Many boys and young men do not want to use condoms. “Men’s interest in using condoms is very low. Women are embarrassed to buy condoms so it would be good if the men become more interested in getting and using them”. Men are also often uninterested in taking the HIV test. “Neither the young men or women take the initiative to take the HIV test. The women take the test only when they are about to go abroad or when they are getting married. The girls’ club teaches women about HIV, but men have to be reached also. Otherwise, it is like clapping with one hand”. 3. What sort of HIV prevention services would you like more of in your community? How would that make a difference to your life? Provision of information on HIV should be expanded. More youth clubs should be established and more entertaining forms of transmitting information such as dramas and songs should be used. “Schools should include information on HIV in their curriculum. This is because students pay more attention to what their teachers say than to anyone else”. Prevention component: Accessibility of services 4. What are your experiences of using HIV prevention services in your community? In what way have those experiences been good or bad? Girls and young women are often reluctant to receive information on HIV and condoms because of embarrassment, negative attitudes towards youth clubs, or because they are tired of hearing about HIV. “When we invite girls to come to the girls’ club, they refuse to come, saying they have heard enough from the media. But we encourage them to come and listen to discussions of other issues, including reproductive health”. 5. What are the main barriers that you have faced when trying to use HIV prevention services in your community?
Health workers are not very welcoming to girls and young women who want to take the HIV test. “Once my friend and I went to a clinic for an HIV test. We told the nurse that we were 18 years old but she looked at us and said that we would not be allowed to take the test unless we brought our parents. The attitude of the health workers does not encourage people to take the HIV test. Sometimes, they go out for a tea break and make people wait”. The attitudes of community members are also discouraging. “The community does not have a good attitude towards people who want to take an HIV test. They often say, ‘why does she doubt herself? She must have done something wrong’”. The cost of an HIV test can also discourage some from taking it, sometimes because they believe that tests which are offered without charge or for low prices are inadequate. 6. In what ways are HIV prevention services easier or harder for particular types of girls and young women to use? Married women are usually less likely to test for HIV because they believe that they are safe. On the other hand, their chances of taking the test become higher when they become pregnant. Out of school girls and married women also have less access to information on HIV. “Married women spend most of their time in the house. So they do not have access to places where they can get information”. Prevention component: Participation and rights 7. In what ways and to what extent are girls and young women involved in HIV prevention in your community? The person who handles HIV matters in our local administration is a woman. In the youth club, 40 out of 50 members are girls. However, “overall female participation in youth clubs is low because they are burdened by domestic chores”. 8. Have there been any projects in your community to bring together girls and boys or young women and young men to talk about HIV prevention? Anti-AIDS clubs prepare coffee ceremonies in which young men and women discuss HIV, RH, relationships and their life experiences. 9. What would encourage you to get more involved in HIV prevention in your community? Efforts to present messages in an attractive manner can promote girls’ involvement in HIV prevention. “We should reach out to parents to encourage them to allow their daughter to participate in Anti-AIDS clubs.”. Prevention component: Legal provision: 10. What do you know about laws in Ethiopia that might affect how girls or young women can protect themselves from HIV? The laws on rape, early marriage, circumcision, abduction and the right to have information on reproductive health help girls and young women protect themselves from HIV. 11. To what extent do these laws affect HIV prevention for girls and young women? Lack of enforcement of the laws on rape, abduction and early marriage weaken their role in preventing HIV for girls and young women. “There are some who say that they can commit rape and still be released from jail by paying 500 birr”. Prevention component: Policy provision: 12. What type of education have you received about issues such as relationships, sex and AIDS? For example, what have you been taught about your sexual and reproductive health in school?
We have not had lessons on HIV in our school. “In our biology class, we have been taught about the menstrual cycle and our anatomy, but very little on HIV”. 13. What could the government of Ethiopia do to fight fear about AIDS in your community? More counseling and information centers should be established. The government should encourage youth associations because they can bring about change. It would help if schools provide more instruction on HIV. Media messages on HIV should be monitored more closely. Summary Question: 14. What are the 2-3 most important changes that could be made to help girls and young women in Ethiopia protect themselves from HIV? Parent-child communication on reproductive health should be encouraged. Support should be provided to promote women’s involvement in decision-making positions. “The government should provide opportunities for greater female participation in combating HIV/AIDS. The government and NGOs should support girls’ clubs and women’s associations.”
Focus group discussion with rural, married young women Age group: 18-23 years Number of participants: 11 Profile of participants: Rural, married women Place: Soyoma Genji, Becho district, Oromia region – Rural area
Prevention component: Availability of services 1. What sorts of HIV prevention services are there for girls and young women in your community? The two Community-Based Reproductive Health Agents (CBRHAs) teach women about the modes of transmission and prevention of HIV during home visits and community meetings. The health center however does not provide information on HIV. “There is a community health worker who teaches us about HIV. He taught us to remain with only one partner, and to encourage our husbands to use condoms”. Condoms are distributed to the men by the CBRHAs. The HIV test is offered by health centers in the rural town of Tulo Bolo 10 km away and in Weliso town, 15 km away. Not many people were aware of the existence of this service nor did they use it however. “I took the HIV test at the Weliso health center when I got married three years ago. We started to take the test before marriage after we got information on it from the CBRHAs but some people still get married without getting tested.” Treatment for STDs is offerred at the health center and private clinics in Tulo Bolo. The women believed that ARVs for pregnant women were given only in Addis Ababa, while it was probably given in Weliso. 2. How much do boys and young men know about HIV prevention services in your community? What is their role in supporting HIV prevention for girls and young women? Men learn about HIV and HIV prevention services from the CBRHAs during community meetings and when they go to health centers with their wives. Most had received such information. “They know about it but we do not know whether they use it or not”. After receiving information on HIV from the CBRHAs, the men had started to change their behavior and also to advise women on protecting themselves. “Previously, the men used to go to town and spend 2 to 3 days drinking. But they have stopped doing this after they received the information on HIV. I even know a man who uses condoms because he is not sure about his health status”.
3. What sort of HIV prevention services would you like more of in your community? How would that make a difference to your life? Provision of information on HIV by the Community-Based Reproductive Health Agents should be expanded to reach remote localities, males and elders. “Elderly men are giving their daughters in marriage to men without asking them to take the HIV test. So, it is important to teach them about the disease since they are the decisionmakers about marriage”. It was considered desirable to have a health facility built nearby, because trips to the health center in town gave men the opportunity to spend more time drinking and engaging in sexual liaisons. Prevention component: Accessibility of services 4. What are your experiences of using HIV prevention services in your community? In what way have those experiences been good or bad? The women felt that the provision of information and services by the community-based reproductive health agents was very accessible and useful. The health centers however did not teach about HIV and were less accessible and receptive. 5. What are the main barriers that you have faced when trying to use HIV prevention services in your community? The barriers to using condoms and taking the HIV test are mainly attitudinal. “Our husbands say that condoms reduce sexual satisfaction and do not want to use them”. “People are too embarrassed to take condoms from health workers and health centers”. “People do not take the HIV test because if they were found to be HIV positive they are afraid they will be stigmatized by the community”. 6. In what ways are HIV prevention services easier or harder for particular types of girls and young women to use? Married women are able to get access to HIV information and services when they go to health facilities to get various MCH services. While in-school girls can get information about HIV from schools, their awareness can be lower than that of out-of-school girls because the former are often focused only on their education. Prevention component: Participation and rights 7. In what ways and to what extent are girls and young women involved in HIV prevention in your community? Girls and young women who are more aware about HIV prevention discuss their knowledge with others on an informal basis, at markets and social occasions. But they do not engage in other formal or planned HIV prevention activities. 8. Have there been any projects in your community to bring together girls and boys or young women and young men to talk about HIV prevention? Although the community-based reproductive health agents give instruction on HIV to males and females together, discussions among them have not taken place. 9. What would encourage you to get more involved in HIV prevention in your community? The formation of a woman’s association, which can be involved in teaching the community about HIV, and sensitizing men to allow women to participate in such work were suggested ways of increasing women’s involvement in HIV prevention. Prevention component: Legal provision: 10. What do you know about laws in Ethiopia that might affect how girls or young women can protect themselves from HIV?
Laws that protect girls and young women from HIV are those which prohibit early marriage, abduction, harassment of women and harmful traditional practices such as cutting of tonsils and scraping gums. 11. To what extent do these laws affect HIV prevention for girls and young women? Early marriage and rape, which make girls and young women vulnerable to HIV, have declined because of the laws against them. “Previously, it was difficult to send girls to school or the market because rape was common. But rape rarely occurs now because people have heard through the media that it is punishable with 15 to 20 years in prison”. Prevention component: Policy provision: 12. What type of education have you received about issues such as relationships, sex and AIDS? The school curriculum deals with subjects like human anatomy but not about such issues as relationships and sex. The provision of information on the modes of transmission and prevention of HIV was either lacking or limited, according to participants. The Anti-AIDS clubs though, discuss HIV, faithfulness and relationships. 13. What could the government of Ethiopia do to fight fear about AIDS in your community? Strengthened education about HIV and stigma as well as increased availability of ARVs were suggested as mechanisms which could reduce fear about AIDS in the community. “It would be better if we could get the medicine in the nearest health center. This would encourage people to take the HIV test”. “The government should teach about HIV so that the stigma against people living with the virus will be reduced. Many people want to take the test but they are afraid that the community may stigmatize them if they are found to be positive”. Summary Question: 14. What are the 2-3 most important changes that could be made to help girls and young women in Ethiopia to protect themselves from HIV? Strengthen enforcement of the laws which prohibit early marriage and harmful traditional practices such as tonsillectomy, uvulectomy and female genital circumcision. This should be supplemented with “education for elders who are the main decision-makers on their children’s marriage”. Introduce a law that requires tests for HIV before marriage.
Interview with Program Officer, Male, HIV/AIDS and ARH, UNFPA
1. What is your impression about the general situation of HIV prevention for girls and young women in Ethiopia? Are things getting better or worse, and why? The National HIV/AIDS Strategic Plan creates a good policy environment for HIV Prevention among girls and young women. It makes clear that they are the main target group for HIV prevention. Actual prevention activities are much stronger in urban areas where there are many Anti-AIDs clubs. There are few Anti-AIDs clubs in rural areas and HIV-related educational activities are directed mainly at married adults. Groups of women who are particularly inaccessible to HIV prevention services and information are girls within marriage in rural areas – the average age of marriage for girls in Amhara region for instance is 14.4 – and domestic workers. The Adolescent and Youth Policy is expected to come out in January. This policy gives substantial attention to HIV in addition to reproductive health generally as well as gender. The Community Conversations initiated by UNDP have significant potential in involving urban and rural communities in discussions and action related to HIV prevention. Although they would ideally involve young women, girls may be less involved. The conversations are also held in a limited number of areas in the country.
2. In your opinion, what laws in Ethiopia are making HIV prevention for girls and young women better or worse? The legal minimum age of marriage is now 18 years. This has raised the actual age of marriage in many communities, which will reduce girls’ vulnerability to HIV arising from this practice. However, the reality remains that a large proportion of girls still get married at younger ages to males who are as much as ten years older. This will make some of them vulnerable to HIV infection. Stronger efforts are needed to build the capacity of judicial and enforcement agencies with respect to the age of marriage. The new Family Law has liberalized abortion rights, especially for women who have experienced rape or incestuous intercourse. This may protect some girls and young women from HIV/AIDS infection due to back-street abortions. There are no legal prohibitions on the use of HIV prevention and STI treatment services for girls and young women. Girls under 18 years of age are presently restricted from using VCT services however. A new provision that is being developed expands access to VCT services to those who are 15 years and older. 3. How does legislation affect different types of girls and young women and their vulnerability to HIV? The legal restrictions on abortions as well as the recent changes have a more significant impact on urban and unmarried girls who are more likely to be exposed to unwanted pregnancy. The right to use SRH services is more likely to be beneficial for in-school girls who are more informed about these services. 4. Overall, what laws could the government change to bring the greatest improvements to HIV prevention for girls and young women? Strengthened implementation of laws on early marriage and abortion rights is needed to improve HIV prevention. The proposed provision of access to VCT for girls over 15 years of age is positive but needs to be supplemented with appropriate counseling. 5. What types of government policies or protocols makes HIV prevention for girls and young people in Ethiopia better or worse? The national HIV/AIDS strategy stresses expanded availability of male and female condoms. The policy on ART makes it widely available free of charge. It does not include directions on nutritional interventions and livelihoods support however, which should be addressed. While the previous policy on VCT services stresses self-initiated requests for this service, the proposed HCT urges health workers to encourage clients to undertake counseling and testing. The policy on mainstreaming HIV is helpful in directing line ministries to allocate 2% of their budget to HIV prevention. 6. Do girls and young women – and also boys and young men - receive any type of official sex education? The Ministry of Education has incorporated Life Skills in the national curriculum, which includes attention to SRH issues such as HIV and STI prevention. However, there is substantial variation in the extent to which the different regional administrations have adopted it in their regional curriculums. 7. Overall, what policies or protocols could the government change to bring the greatest improvements to HIV prevention for girls and young women? Potential improvement to policy should involve “giving more attention to strengthening livelihoods and nutrition, which are sources of vulnerability to HIV and AIDS”. 8. What type and scale of HIV prevention services are available for girls and young women in Ethiopia? The availability of HIV prevention services is generally inadequate. With respect to condom availability, he said, “In a recent study trip to the north of the country, we found that the availability of condoms per person allowed for the use of only 4 condoms a year, which is highly inadequate in relation to the estimated average coital frequency of 80 times a year”. Female condoms are unavailable in most areas. UNFPA has plans to expand the availability of female condoms in 2007. Although there are 700 VCT sites and 112 ARV sites, they are
seriously inadequate in relation to the need for them, especially in rural areas where information about them is also minimal. 9. What type and scale of HIV prevention services are available for particular types of girls and young women? HIV prevention services are least available for rural women. Lack of information makes it more difficult for out-of-school girls to make use of available services. Married women are less able to request condoms without their husbands’ permission. 10. What type and extent of HIV prevention services and information are available for boys and young men? How does this affect the situation for girls and young women? Availability and access to ARVs, STI treatment and information on HIV is greater for boys and young men who are more knowledgeable about them. 11. Overall, what types of services most urgently need to be increased to improve HIV prevention for girls and young women? To improve service availability, HIV services should be integrated with ANC. The availability of YFS should be expanded. Support for livelihood skills will transform the lives of girls and young women and enable them to avoid multiple partners and sex work. Q 12-15. Skipped for lack of time on the part of respondent. 16. How are international commitments applied in Ethiopia? The protection of the human rights of girls and young women is not strong. The CRC and CEDAW lack reporting mechanisms, which makes it difficult to assess implementation. Implementation is likely to be limited given low awareness of them and the prevalence of early marriage, abduction, FGM and violence. 17. To what extent is the national response to AIDS ‘rights-based’? The national AIDS policy is not formulated on the basis of ‘rights’. It places the burden of responsibility on ‘duty bearers’ or service providers rather than giving recognition to clients’ rights. 18. To what extent are girls and young women involved in decision-making about AIDS at the national level? The respondents’ knowledge of female participation in national-level decision-making on AIDS prevention was limited. 19. Overall, what priority actions could be taken to support girls and young women to be more involved in national level decision-making about AIDS? Women’s representation on national and regional HIV/AIDS councils and the CCM should be ensured. There is a need to strengthen capacity in the Women’s Affairs Ministry on Gender and HIV, to improve their ability to address HIV prevention and strategic issues. HIV should be mainstreamed in the National Gender Action Plan. 20. In summary, what are the 3-4 key actions that would bring the biggest improvements to HIV prevention for girls and young women in Ethiopia? To improve HIV prevention for girls and young women, he stressed that “focused interventions targeting specific geographic areas and women and youth should be emphasized. For instance, youth involvement in HIV prevention should be strengthened by supporting Anti-AIDS clubs. Integration of HIV prevention services with the health system, such as in the expansion of YFS, can be a significant opportunity”. He added that underlying causes for the expansion of the epidemic could be addressed by supporting economic self-reliance among women. Access to male and female condoms should be expanded. Greater attention should be given to gender issues such as early marriage, violence and harmful traditional practices such as abduction and FGM.
Interview with HIV/AIDS Program Division Head, Male, Family Guidance Association of Ethiopia (FGAE) 1. What is your impression about the general situation of HIV prevention for girls and young women in Ethiopia? Are things getting better or worse, and why? HIV prevention programmes for girls and young women have been limited and not as effective. They are usually directed at the whole population and do not target them specifically. But we see some improvements among this group in that they are more likely to use services freely. The number of girls’ anti-AIDS clubs is increasing and more girls are involved in post-test clubs and as peer promoters. 2. In your opinion, what laws in Ethiopia are making HIV prevention for girls and young women better or worse? The new legal provision on abortion allows victims of rape to get an abortion based on their own testimony in contrast to the previous situation in which they had to go through an extended process. The law prohibiting marriage under the age of 18 years will also contribute significantly to HIV prevention. Girls are not required to get parental consent in order to use HIV prevention services. 3. How does legislation affect different types of girls and young women and their vulnerability to HIV? The abortion law is more likely to benefit unmarried and out of schoolgirls who are more vulnerable to rape and unwanted pregnancy. The law on early marriage will strengthen HIV prevention especially among rural and out-of-school girls. 4. Overall, what laws could the government change to bring the greatest improvements to HIV prevention for girls and young women? The government should introduce a law that restricts commercial sex work. The absence of such a law denies the women involved any protection and exposes them to HIV. 5. What types of government policies or protocols make HIV prevention for girls and young people in Ethiopia better or worse? The proposed VCT policy, which allows service providers to take the initiative to suggest testing, is beneficial, and will increase the number of VCT clients. It also allows for group counseling for ANC clients who may then undertake testing and individual post-test counseling. Vulnerable girls and young women, including CSWs, who come for other services, will be able to benefit from this. 6. Do girls and young women – and also boys and young men - receive any type of official sex education? The respondent believed that family life education was being given in schools but was uncertain about its contents. 7. Overall, what policies or protocols could the government change to bring the greatest improvements to HIV prevention for girls and young women? He did not suggest any changes to current policy that could improve HIV prevention 8. What type and scale of HIV prevention services are available for girls and young women in Ethiopia? HIV prevention services are generally quite available in urban areas. Male condoms, and STI, VCT and ARV services are available in hospitals and health centers. Two hundred health centers now offer PMTCT services. But since the number of such facilities is limited in rural areas, condoms, STI, VCT and ARV services are unavailable to most of the rural population. RH agents are often the only source of condoms but they may not be present in many localities however. Unreliable supplies, lack of awareness and biases against condoms also restrict condom use in rural areas. Female condoms are generally unavailable in both urban and rural areas however.
9. What type and scale of HIV prevention services are available for particular types of girls and young women? In addition to rural girls, HIV prevention services are less available to out-of-school girls who are less informed about them. CSWs visit health centers to get treatment for STIs and are often offered condoms through outreach activities. Orphaned girls with HIV who are involved in HBC are able to get ARVs. Positive prevention among PLWAs has been strengthened considerably as a result of ‘the increasing number of and support for post-test clubs which have allowed them to discuss their concerns and promoted a positive environment for them.” 10. What type and extent of HIV prevention services and information are available for boys and young men? How does this affect the situation for girls and young women? The availability of services for males is similar to that for females. Males are more likely to request condoms and STI and VCT services. They face less social restrictions. 11. Overall, what types of services most urgently need to be increased to improve HIV prevention for girls and young women? To improve HIV prevention among girls and young women, availability of information and VCT services in rural areas and for those out of school should be strengthened. 12. What are the main barriers to girls and young women using HIV prevention services in Ethiopia? The barriers to girls and young women using HIV prevention services include the cost of VCT services. The location of services is more of an obstacle for rural girls and women. Lack of privacy is a strong concern in the case of VCT sites, which often do not have visual privacy. ART sites, which are often newly built, are more isolated. The attitudes of health workers, who may sometimes be judgmental of ARV clients, can be quite discouraging. “We have also observed that counseling services are not ideal since some health workers who work as counselors are sometimes disinterested and even hostile.” Cultural norms can also be severe constraints on the use of HIV prevention services. A common comment made about those who want to take up VCT for instance, is “why does she want to get tested? She must have engaged in illicit sex.” 13. Are HIV prevention services easier or harder for particular types of girls and young women to access? The costs of VCT services can still be prohibitive for those who are unmarried and out of school. Condoms are more accessible to CSW and unmarried girls however. 14. What role do boys and young men have in making HIV prevention services easier and better for girls and young women? Men play both negative and positive roles. Married men, for instance, are commonly disinterested in using condoms. On the other hand, men are often instrumental in bringing their partners to undertake VCT or STI treatment. Many are less willing to use these services in response the their partners’ request however. 15. Overall, what priority actions could be taken to make HIV prevention services more accessible to girls and young women? “Priority should be given to the expansion of VCT services in rural areas where there is great demand for them. Many rural people now have to come to urban centers to get tested in preparation for marriage. It would be beneficial if VCT services are offered free of charge to rural, unmarried and out-of-school girls and young women. Similarly, condoms should be promoted among rural and out-of-school girls.” 16. How are international commitments applied in Ethiopia? International commitments such as the CRC and CEDAW are not well implemented. This is apparent from rampant persistence of child labor and continued lack of decision-making power and low status of women in the country. 17. To what extent is the national response to AIDS ‘rights-based’?
The national AIDS policy is theoretically rights-based but these rights are not well implemented. For example, “SRH rights such as the right to confidentiality, safe services and information are not guaranteed”. The respondent was not aware that SRH rights of female PLWA were mentioned in the AIDS policy 18. To what extent are girls and young women involved in decision-making about AIDS at the national level? The respondent was not aware of the participation of girls and young women in national decision-making on HIV/AIDS. 19. Overall, what priority actions could be taken to support girls and young women to be more involved in national level decision-making about AIDS? “The development of plans, policies and guidelines on HIV prevention should involve girls and young women”. 20. In summary, what are the 3-4 key actions that would bring the biggest improvements to HIV prevention for girls and young women in Ethiopia? Expand the presence and awareness of VCT, ART and PMTCT services in rural health centers and clinics. Legal processes for victims of rape should be facilitated. The respondent underlined that “women living with HIV/AIDS should be supported by giving them special employment and educational privileges. This will also encourage many girls and young women to get tested for HIV”. To reduce the many cultural constraints on HIV prevention, there is a need to involve community leaders in encouraging people to use condoms and VCT and STI services.
Interview with Model Clinic Head, Male, Family Guidance Association of Ethiopia (FGAE)
1. What is your impression about the general situation of HIV prevention for girls and young women in Ethiopia? Are things getting better or worse, and why? HIV/AIDS has been recognized as a major problem at the national level. As a result, the government and the Ministry of Health as well as NGOs have given great attention to it. Major activities have been concerned with information provision and advocacy. Substantial efforts have been made to promote VCT. NGOs have been a significant source of support for orphans and the elderly who have been affected by the epidemic. There are weaknesses in the overall effort however. Seekers of HIV prevention services are not able to find them whenever they are need. The resources available for NGOs and the government are not adequate which lead to fluctuation in the services that they provide. 2. In your opinion, what laws in Ethiopia are making HIV prevention for girls and young women better or worse? The legal environment for the prevention of HIV/AIDS among girls and young women has been improving. A new law has been introduced to penalize those who knowingly spread the virus. Strengthened sanctions and enforcement on rape will protect those who are vulnerable to HIV/AIDS as a result of rape. The law prohibiting early marriage is being implemented by some of the regions. Parents are now penalized for marrying off girls who are less than 18 years old. Legal measures have also been introduced to restrict harmful traditional practices such as wife inheritance, FGM and tattooing. The new law on abortion permits those who have experienced rape and incestuous sexual relations to have an abortion based on the victims’ testimony only. This may be beneficial but it can also promote risky sexual behavior and the spread of HIV and STDs. It would be better to stress the use of condoms and contraceptives. Generally, these laws can play a strong role in preventing HIV among girls and young women if supplemented with education. 3. How does legislation affect different types of girls and young women and their vulnerability to HIV?
The laws on rape, early marriage and abortion are especially beneficial to unmarried girls and both in school and out-of-school girls. 4. Overall, what laws could the government change to bring the greatest improvements to HIV prevention for girls and young women? The enforcement of these laws should be strengthened in order to better prevent HIV among girls and young women.
5. What types of government policies or protocols makes HIV prevention for girls and young people in Ethiopia better or worse? The policy environment around HIV prevention is generally good. The National HIV/AIDS policy emphasizes HIV prevention, promotes utilization of VCT and discourages stigma and discrimination against PLWAs. The Women’s and Youth Policies also complement it. However, implementation of the policy is weak. 6. Do girls and young women – and also boys and young men - receive any type of official sex education? The respondent was not aware of the inclusion of sex education in the school curriculum. 7. Overall, what policies or protocols could the government change to bring the greatest improvements to HIV prevention for girls and young women? “The policy on VCT should be supplemented with strengthened community sensitization and mobilization if it is to be effective. This policy can also be improved by allowing for the provision of proof of status after testing as well as obligatory testing for rapists”. 8. What type and scale of HIV prevention services are available for girls and young women in Ethiopia? HIV prevention services, including condoms, VCT and STI treatment, are available in most health facilities. However, the respondent emphasized that: “Since VCT and STI services are often subsidized or offered by donors or NGOs their future availability and affordability is in question. Since the youth do not tell their parents that they are about to test for HIV, they may find VCT increasingly unaffordable.” ARV treatment is also not available in many places, including in Addis Ababa. 9. What type and scale of HIV prevention services are available for particular types of girls and young women? The relative availability of HIV prevention services to different types of girls however is similar. PLWAs receive messages on positive prevention during VCT sessions. 10. What type and extent of HIV prevention services and information are available for boys and young men? How does this affect the situation for girls and young women? The availability of HIV prevention services for boys and young men is similar to that of girls and young women, except that the latter are more likely to be offered such services when they come for family planning services. 11. Overall, what types of services most urgently need to be increased to improve HIV prevention for girls and young women? The availability of services such as VCT, STI treatment and ART should be expanded. This requires investment in human resources, drugs and equipment. 12. What are the main barriers to girls and young women using HIV prevention services in Ethiopia? There are cultural norms that sanction male dominance and discourage women from expressing their needs. Thus, “women are not encouraged to look for care. While males have many excuses – such as their involvement in games – that allow them to use RH services, females are restricted to the home. Girls who experience rape therefore cannot get emergency contraceptives or treatment for STDs. Because they are often economically
dependent, they may not be able to get treated for STD, also because they are unable to inform their partner about their condition.” In rural areas, the location of HIV prevention services and lack of transport constrains many women from using health services. The respondent also believed that available services are usually not very youth friendly; “Health workers may not be receptive to the youth. Since other entertainment services are absent, the youth do not have a cover if they come into contact with family members at the health facility.” 13. Are HIV prevention services easier or harder for particular types of girls and young women to access? Among the female population, unemployed, unmarried and in-school girls are least likely to have the financial resources to pay for such services. Rural women are also constrained cultural norms and lack of awareness. While in-school girls have greater access to information, they may have less access to condoms which are not offered in schools. 14. What role do boys and young men have in making HIV prevention services easier and better for girls and young women? Many males may restrict women’s and girls’ use of services. For instance, we commonly hear girls saying “If I ask him to use a condom, he refuses saying ‘you must have had sex with others. I know my status’”. 15. Overall, what priority actions could be taken to make HIV prevention services more accessible to girls and young women? There is a need to raise their awareness of their rights and available services 16. How are international commitments applied in Ethiopia? Not discussed – lack of time 17. To what extent is the national response to AIDS ‘rights-based’? Not discussed. 18. To what extent are girls and young women involved in decision-making about AIDS at the national level? Respondent not informed about women’s participation in decision-making on HIV/AIDS at the national level, he noted that women held many key positions in the health ministry. 19.
Overall, what priority actions could be taken to support girls and young women to be more involved in national level decision-making about AIDS? It is important to increase the involvement of women in the National HIV/AIDS Office.
20. In summary, what are the 3-4 key actions that would bring the biggest improvements to HIV prevention for girls and young women in Ethiopia? “Steps should first be taken to enhance their overall awareness and education. Secondly, female participation in positions of authority and decision-making should be increased, which will allow them to stand for their own rights without waiting for the good will of others. Thirdly, their economic self-reliance should be strengthened by supporting them in gaining employment and generating income. Fourth, legal provisions concerned with practices that contribute to the spread of HIV among girls and young women, which include rape, knowingly spreading HIV, early marriage, wife inheritance and abduction, should be strengthened and enforced better.”
Interview with National Coordinator, Female, PLHIV Network National Association of Positive Women in Ethiopia.
1. What is your impression about the general situation of HIV prevention for girls and young women in Ethiopia? Are things getting better or worse, and why? An assessment of the general situation of HIV prevention for girls and young women in Ethiopia has to consider the extent to which the rural population has been reached, since that is the majority. In this respect, the work done is not adequate in terms of raising awareness and addressing harmful traditional practices such as abduction, rape, FGM and the spread of HIV. Media programs, which are transmitted in only several languages, do not reach communities who speak the many other languages. The media is especially inaccessible to young girls. For sure, health workers, youth and PLWAs have done strong educational work. But their impact is weakened by the lack of open parent-child communication, which makes girls vulnerable due to the clandestine sex they engage in, and the lack of awareness about condom use. Religious leaders urge abstinence as a mode of prevention but this is considered unrealistic by the youth. They also advocate ‘one to one’ relationships which may be difficult to achieve for the many youth who have to migrate to urban areas due to the lack of enough land in the rural areas. Practices such as early marriage and wife inheritance also put girls and women at risk. The work done in promoting VCT is quite good however. Although things are getting better, much more needs to be done. She explained: “Programmes are directed at the general population and do not give special attention to females. For instance, when girls are raped, they face biased judges. They are also not able to communicate their complaints out of fear and the humiliation that results. Girls themselves do not have the education and skills to protect themselves. I myself had 3 children in 5 years after being abducted by husband. He died subsequently after exposing me to HIV. Change has been slow in the twenty years since I got married.” 2. In your opinion, what laws in Ethiopia are making HIV prevention for girls and young women better or worse? Laws which protect women exist but their implementation is weak. The community does not cooperate in enforcing the laws. For instance, “when a girl is raped, it is often settled through mediators and bribes. People also lack awareness of the laws. They keep quiet when FGM occurs, claiming that it is none of their business”. The law also does not adequately protect HIV positive women from evictions and property losses. 3. How does legislation affect different types of girls and young women and their vulnerability to HIV? Out-of-school girls are vulnerable to rape but they do not press charges because they lack awareness about the law. If they became infected with HIV, they fail to go to court out of shame. Married women are not protected from physical and sexual violence within their marriage. 4. Overall, what laws could the government change to bring the greatest improvements to HIV prevention for girls and young women? Strengthened enforcement of laws on violence, rape and abduction will contribute to HIV prevention. 5. What types of government policies or protocols makes HIV prevention for girls and young people in Ethiopia better or worse? Policies on HIV also do not target women specifically. She said that they plan to work for an increased focus on women in the revised HIV policy expected to come out in 2008. HIV positive women also have to be involved in the development of policies on HIV. 6. Do girls and young women – and also boys and young men - receive any type of official sex education? Don’t know. 7. Overall, what policies or protocols could the government change to bring the greatest improvements to HIV prevention for girls and young women? Don’t know.
8. What type and scale of HIV prevention services are available for girls and young women in Ethiopia? The availability of HIV prevention related services such as ART and VCT is fairly adequate in urban centers where they are found in most hospitals and in a growing number of health centers. Nurses have now started to administer ART. These are good developments but the services are still concentrated in urban centers where they are inaccessible to much of the rural population. But the supply of CD4 count and viral load measurements machines and second line drugs are severely short and highly variable, which result in 3 month long waiting periods. PMTCT is mainly available in hospitals. Home-based care is provided by NGOs, which mostly work in urban areas, so HBC is not really available in rural areas. Female condoms are unavailable generally and awareness regarding them is low. Male condoms are mostly available in urban areas. 9. What type and scale of HIV prevention services are available for particular types of girls and young women? Beyond urban and rural differences, the availability of HIV prevention services is similar for different categories of women, including migrants. Till recently, appropriate ARVs were not available for AIDS orphans, but this may have improved. 10. What type and extent of HIV prevention services and information are available for boys and young men? How does this affect the situation for girls and young women? The availability of HIV prevention services for boys and young men is similar to that of females, but their access to information is higher because their opportunities to listen to the media and join Anti-AIDS clubs are greater. 11. Overall, what types of services most urgently need to be increased to improve HIV prevention for girls and young women? “We have to bring information and advocacy about these services to their homes, similar to the way we promote sanitation and mosquito nets�.
12. What are the main barriers to girls and young women using HIV prevention services in Ethiopia? One of the obstacles to girls and young women using HIV prevention services are men who restrict their mobility. Parental control can also make it difficult for girls to access and use these services. Once they reached the health facilities, they did not face significant barriers to their use of services. The shortage of health workers could result in long waits however. She believed that VCT, STD and ART services were available free of charge for those who needed them, although some drugs for STDs had to be bought from private sources, which often made them inaccessible. She felt that the attitudes of health workers were generally good. Fears about confidentiality were also less important these days. 13. Are HIV prevention services easier or harder for particular types of girls and young women to access? Access to HIV prevention services is obviously much more restricted for rural women due to the location of the services. The accessibility of VCT services is somewhat better for married women than for unmarried women. This is because the latter were often unwilling to get tested because of fears that they may be vilified for loose behavior if found positive. 14. What role do boys and young men have in making HIV prevention services easier and better for girls and young women? Males are often not interested in using condoms. They also make use of STI treatment and ARVs without telling their partners or wives, because they are afraid to do so. 15. Overall, what priority actions could be taken to make HIV prevention services more accessible to girls and young women? ARVs should be made more accessible to rural women by making them available in rural health facilities and increasing women’s awareness of their availability. 16. How are international commitments applied in Ethiopia?
No information. 17. To what extent is the national response to AIDS ‘rights-based’? The National AIDS Policy does recognize the reproductive rights of women living with HIV. However, the problem is that implementation is weak. She explained, “Many men do not permit their wives to reveal their positive status. These women therefore cannot get any care or assistance. Some men also force such women to have children”. On the other hand, counselors do provide information on reproductive and sexual health during post-test counseling sessions. 18. To what extent are girls and young women involved in decision-making about AIDS at the national level? Female involvement in policy development is generally low. The millennium campaign (according to the Ethiopian Calendar), which seeks to raise awareness levels and use of VCT and ART service, is expected to involve women significantly. 19. Overall, what priority actions could be taken to support girls and young women to be more involved in national level decision-making about AIDS? They should be appointed to government and decision-making positions.
20. In summary, what are the 3-4 key actions that would bring the biggest improvements to HIV prevention for girls and young women in Ethiopia? Enable HIV positive girls and young women to provide peer-to-peer education. Integrate sex education in the school curriculum. Strengthen women’s involvement in including decision-making bodies, including those addressing HIV/AIDS. Support income generation for girls and young women. Executive Director, Female, NGO providing HIV Prevention and Support Services. 1. What is your impression about the general situation of HIV prevention for girls and young women in Ethiopia? Are things getting better or worse, and why? HIV prevention for girls and young women is generally stronger in urban areas, where a lot of information on HIV/AIDS is disseminated through TV and the radio and school and community programmes. Health facilities, which provide information and counseling, are more accessible in urban areas. Rural girls often even lack access to radio programmes because they are burdened by domestic work. Their access to information on HIV is therefore limited. But the dissemination of information is getting stronger. Religious bodies are getting involved in teaching about HIV. The Community Conversations Programme is also strengthening knowledge about HIV. Many youth are involved in using rural markets and holidays to conduct edutainment activities. 1. In your opinion, what laws in Ethiopia are making HIV prevention for girls and young women better or worse? One of the laws that help prevent HIV among girls and young women is the one on rape, which penalizes perpetrators. Victims are increasingly beginning to bring rapists to the courts. Enforcement of this law is stronger in some regions. The law on abduction has also reduced its incidence. Because of fears about HIV, families are now less likely to come to a settlement when it occurs. 2. How does legislation affect different types of girls and young women and their vulnerability to HIV? Among different categories of girls, “it is those who are informed about their rights and HIV/AIDS who are able to seek legal help when they experience rape.” Urban girls are more likely to be assertive about their rights.
3. Overall, what laws could the government change to bring the greatest improvements to HIV prevention for girls and young women? “Their enforcement needs to be strengthened. Educational activities should be conducted to support victims in becoming more assertive and knowledgeable with respect to the law. Community awareness of the law should also be promoted.” 4. What types of government policies or protocols makes HIV prevention for girls and young people in Ethiopia better or worse? There are sound policies relating to HIV prevention for girl and young women such as the HIV/AIDS and the Youth and Women’s policies. She said however, “Are they being implemented properly? This needs an informed and empowered public. It is only then that weaknesses in the policies can be assessed.” Although the educational policy is expanding girls’ enrollment in schools, they do not receive much information on HIV/AIDS. 5. Do girls and young women – and also boys and young men - receive any type of official sex education? The school curriculum does not give much attention to sex education, except in biology class where they may learn about STIs and HIV. 6. Overall, what policies or protocols could the government change to bring the greatest improvements to HIV prevention for girls and young women? “Policies should promote male involvement in HIV/AIDS and RH issues and activities. This is because both males and females are involved in the occurrence and effect of RH problems”. 7. What type and scale of HIV prevention services are available for girls and young women in Ethiopia? HIV prevention services are mainly provided by health facilities. However, “Youth-friendly services are uncommon although some NGOs have started to set them up in health facilities. Since the whole community goes to these health facilities, the youth do not have youth-oriented facilities that they can go to confidently. VCT services are attached to health facilities too. Stand-alone or drop-in VCT centers are uncommon. Since health workers are burdened by other work, the quality of counseling provided is lowered.” Health facilities, NGOs, shops, peer educators and reproductive health agents have made condoms fairly available. Information on HIV prevention is widely disseminated, from such places as markets. Surveys indicate that “most of the population receives information from the radio and TV”. 8. What type and scale of HIV prevention services are available for particular types of girls and young women? Among different categories of girls, “the provision of services to young and unmarried girls is very inadequate in relation to their needs because the services are not designed to target them specifically”. Otherwise, the degree of service availability for in and out-of schoolgirls is similar. Sex workers also no longer need identification cards to get free services. Refugee camps often have UN funded clinics which also provide VCT services. PLWA associations, which have regional branches, provide positive prevention services. 9. What type and extent of HIV prevention services and information are available for boys and young men? How does this affect the situation for girls and young women? Although the availability of HIV prevention services is not differentiated by gender, women are given special attention due to their reproductive roles and enhanced vulnerability. “Men are not targeted by health services. Since many of them do not come to health facilities, they are not able to get information nor services”. 11. Overall, what types of services most urgently need to be increased to improve HIV prevention for girls and young women? Mobile services should be introduced to serve rural girls and women who have to travel long distances to get health care. The provision of reproductive and sexual information in the curriculum and extra-curricular activities should be strengthened as well.
12. What are the main barriers to girls and young women using HIV prevention services in Ethiopia? An important barrier to the use of HIV prevention services by girls and young women is “the lack of openness regarding RSH within the family. Parents do not talk to their children about RSH. Therefore, if a girl experiences a problem, she is not able to talk to her parents and to make use of services”. Health institutions are not oriented to serve the youth who do not feel that they are there to serve them. The location of services is a major barrier to rural women. A barrier to the use of VCT services by the youth is their uncertainties about the confidentiality of their discussions with counselors. 13. Are HIV prevention services easier or harder for particular types of girls and young women to access? Unmarried adolescent girls have less access to services due to their fear of disapproval.
14. What role do boys and young men have in making HIV prevention services easier and better for girls and young women? Young males who are open and aware support their partners in using HIV prevention services. But this is not always the case. 15. Overall, what priority actions could be taken to make HIV prevention services more accessible to girls and young women? Community awareness has to be raised regarding HIV/AIDs, reproductive health and the problems of the youth. NGOs and private institutions need to be involved in establishing youth-friendly services in health institutions. 16. How are international commitments applied in Ethiopia? The public is not aware of international conventions related to children’s and women’s rights. As a result, implementation of or claims to these rights are weak. Abuses against children also remain hidden. 17. To what extent is the national response to AIDS ‘rights-based’? The National AIDS policy is not really ‘rights based’ because PLWAs were not involved when it was being developed. “There are PLWAs who have suffered a lot and they should participate in revising the AIDS policy in order to make it more ‘rights based’”. 18. To what extent are girls and young women involved in decision-making about AIDS at the national level? Girls and young women participate in regional level youth associations which may be involved in HIV related activities. But their participation in the development of the HIV/AIDS policy nor in the Nationals AIDS Committee is not very apparent. 19. Overall, what priority actions could be taken to support girls and young women to be more involved in national level decision-making about AIDS? “Strong women’s associations have to be established at the regional and national level. The HIV/AIDS and ‘rights’ component of already existing women’s associations have to be strengthened. Girls should be more involved in school student councils and girls’ clubs in every school have to be supported. Generally, specific mechanisms have to be established to give voice to girls and young women”. 19. In summary, what are the 3-4 key actions that would bring the biggest improvements to HIV prevention for girls and young women in Ethiopia? Enhanced political commitment is needed at all levels. Public awareness of policies has to be raised to insure their implementation. Donors have to design long-term school projects that provide education on HIV to adolescents throughout high school. HIV projects have to have a livelihoods component in order to reduce female vulnerability to HIV. For instance, daughters of CSWs are neglected and have to be targeted with income generating or educational programmes.
Interview with Youth Club Coordinator, Female, HIWOT Ethiopia (NGO) 1. What is your impression about the general situation of HIV prevention for girls and young women in Ethiopia? Are things getting better or worse, and why? The situation of HIV prevention for girls and young women in Ethiopia can be divided into two categories. In urban areas, the work done has been good. There are many youth associations, NGOs and school programs which have provided a lot of information on HIV/AIDs and preventing pregnancy. People are therefore very aware. In rural areas however, the level of activity and information provision is very low. Rural people do not have much access to the media. The situation is improving though because the development of infrastructure is allowing NGOs to start HIV related activities there. 2. In your opinion, what laws in Ethiopia are making HIV prevention for girls and young women better or worse? Some laws which may affect HIV prevention have been strengthened. These include the laws on rape, incestuous marriage and the purposeful sexual transmission of HIV. 3. How does legislation affect different types of girls and young women and their vulnerability to HIV? The laws on rape are especially likely to protect out-of-school girls who are vulnerable to rape. The laws on early marriage, abduction and wife inheritance are especially beneficial to rural girls. 4. Overall, what laws could the government change to bring the greatest improvements to HIV prevention for girls and young women? “Awareness of the laws, which is very low, has to be increased. The legal documents should be made available everywhere so everybody can get them. I myself don’t know much about the laws, so it is hard for me to comment on changes to them”. 5. What types of government policies or protocols makes HIV prevention for girls and young people in Ethiopia better or worse? She supported the policies relating to HIV prevention to a certain extent. Their shortcoming however was that “the youth are not involved in the design of the policies. For instance, in attending a discussion forum on the youth policy, I was surprised to see that only a few youth were present. And they were mainly talking about how to establish offices and the like. The policies would be much more effective if the youth, who are most affected by the problems, are more involved in their design”. The policies are also not well implemented. For example, “The youth supposedly have a right to VCT. But we see that counselors are much older people. This discourages the youth from using the services because it is much easier for them to talk about their problems to those who are their own age. It would be much better to make peer to peer counseling more available”. 6. Do girls and young women – and also boys and young men - receive any type of official sex education? During the time she was in school, not much attention was given to sex education. A class touched on such issues as menstruation very briefly. She did not think that there was much coverage of reproductive health in the current curriculum either. 7. Overall, what policies or protocols could the government change to bring the greatest improvements to HIV prevention for girls and young women? “The capacity of implementers has to be strengthened. “Just because a someone is a nurse, it does not mean she can be a counselor, which requires special training. Let me give you an example from my own experience. When I went to get counseling, I saw the results of my test on the table of my counselor even before we started talking. I thought, ‘what if I had been positive, what would I have felt?’”.
8. What type and scale of HIV prevention services are available for girls and young women in Ethiopia? The availability of HIV prevention services is fairly adequate. In towns, youth clubs, associations, NGOs and local administrations provide information. Information provision in rural areas is inadequate however. While the availability of male condoms is fairly adequate in both urban and rural areas, female condoms are unavailable. Government and private health facilities offer VCT and STI treatment, so their availability is generally adequate. The budget this NGO has in its referral system for STI is limited however. 9. What type and scale of HIV prevention services are available for particular types of girls and young women? The availability of HIV prevention services to different categories of girls is quite similar. ‘Positive prevention’ services are very inadequate however, due to the high scarcity of specialized counselors who provide this type of counseling. 10. What type and extent of HIV prevention services and information are available for boys and young men? How does this affect the situation for girls and young women? HIV prevention services such as information and condoms are fairly available to males. Girls are more likely to use STI treatment and family planning. There is a need to offer programmes that are of interest to young males, such as educational services. The lack of variety in the types of condoms offered to young males is also a serious problem because many of them do not want to use the type that is commonly available. 11. Overall, what types of services most urgently need to be increased to improve HIV prevention for girls and young women? Improvements in HIV prevention services should include, “expanded availability of female condoms. It is something that increases their control and girls could carry them around easily and use them in case of rape. There are also anti-AIDs creams which are now only available in certain hospitals which should be more widely available”. 12. What are the main barriers to girls and young women using HIV prevention services in Ethiopia? “The barriers to girls and young women using HIV prevention services that were mentioned were mainly attitudinal. “Many in-school girls are afraid to receive condoms because they think they may be discovered by their families or friends who may consider them sexually loose. Many girls also place the responsibility to get and use condoms on males. Some are afraid to ask males to use a condom”. Girls are less likely to use STI services because they are often afraid to tell service providers or other people if they are having a problem with STIs and because of their limited awareness of available services. Many are reluctant to use VCT services because they think they may die soon if they turn out to be positive. “The youth, including girls and young women, are also discouraged by health workers who are not qualified to counsel. Some counselors lack ethical principles, commonly tell others about the status of their clients”. 13. Are HIV prevention services easier or harder for particular types of girls and young women to access? HIV prevention services are more accessible to more educated and aware girls and young women, whereas “rural and out-of-school females may fail to use VCT services because they don’t want the community to hear about it. Similarly, in-school girls are afraid they may have to stop going to school or having to leave their homes if they happen to be HIV positive. Whereas married women can say that they got the virus from their partners, unmarried girls are asked ‘where did you bring it from? Aren’t you a virgin’”. 14. What role do boys and young men have in making HIV prevention services easier and better for girls and young women? “The role of male in preventing HIV among females is limited. In our work, girls tell us that their partners rejected them when they became pregnant. In addition, “girls are more interested in taking test for HIV. The males are often not willing to take the test”.
15. Overall, what priority actions could be taken to make HIV prevention services more accessible to girls and young women? “It is important to reduce the shortage of trained counselors who are ethical and know that girls have a right to confidentiality. Girls should be informed that such services are available, in places such as schools. Girls should also know that it is their right to get information and to talk to professionals”. 20. How are international commitments applied in Ethiopia? Although the protection of children’s and women’s rights is improving, many AIDS orphans suffer from stigmatization. Care should therefore be taken in using children in ads about AIDS orphans. Commercial ads also often perpetuate gender stereotypes. 21. To what extent is the national response to AIDS ‘rights-based’? SRH rights are well recognized in national policy. Recognition of the rights of PLWAs is also improving in that many offices now have PLWA associations and testing is encouraged. Implementation of these rights is weakened by lack of trained counselors. 22. To what extent are girls and young women involved in decision-making about AIDS at the national level? Female involvement in national associations and local youth associations, policies and NGOs which address HIV is growing. 19. Overall, what priority actions could be taken to support girls and young women to be more involved in national level decision-making about AIDS? “Girls should be made aware of their rights and the law through training and discussion forums”. 20. In summary, what are the 3-4 key actions that would bring the biggest improvements to HIV prevention for girls and young women in Ethiopia? To improve HIV prevention for girls and young women, the availability of referral and counseling services should be expanded. Variety in the types of condoms available should be increased. The rights of children who appear in advocacy campaigns on HIV should be protected. Greater attention should be given to reduce child trafficking.