HIV/AIDS Behavioral Surveillance Survey (BSS) Ethiopia 2002 Round One Authors/investigators: Dr Getnet Mitike, Department of Community Health, AAU Dr Wuleta Lemma, Family Health International, Regional Senior Technical Officer Dr Frehiwot Berhane, BSS Project – Department of Community Health, AAU Dr Reta Ayele, Ministry of National Defense Ato Tamrat Assefa, Jimma University Dr Tewodros G/Michael, private consultant Ato Fikre Enqusellase, Department of Community Health, AAU Dr Atalay Alem, Department of Psychiatry, AAU Dr Yigeremu Abebe, Ministry of National Defense Professor Dereje Kebede, Department of Community Health, AAU Table of Contents Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv Definitions of terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv Operational definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Introduction and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Summary of findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii Female sex workers (FSWs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Between group comparisons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Overview of HIV/AIDS in Ethiopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.3 Introduction to behavioral surveillance survey (BSS). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.4 Objectives of BSS in Ethiopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 2 Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2.1 Quantitative survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2.1.1 Target groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2.1.2 Sample design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2.1.3 Sample size and sampling procedure for target groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 2.1.4 Data collection and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 2.2 Qualitative study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2.2.1 Purpose and objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2.2.2 Methods and target groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2.2.3 Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2.2.4 Tools and procedures for data collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2.2.5 Analysis and write up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2.2.6 Presentation of results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2.3 Ethical considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3 Quantitative Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 3.1 Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 3.1.1 Socio-demographic characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 3.1.2 STI/HIV/AIDS related knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 3.1.3 Alcohol and drug use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 3.1.4 Sexual behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 3.1.5 STI and treatment seeking behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 3.1.6 HIV testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 3.1.7 Exposure to interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 3.1.8 Relationship between knowledge, behavior, VCT and perception of risk . . . . . . . . . . . . . . . . . . . . . 26 3.2 Female sex workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 3.2.1 Socio-demographic characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 3.2.2 STI/HIV/AIDS and related knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 3.2.3 Alcohol and drug use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 v 3.2.4 Sexual behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 3.2.5 STIs and treatment seeking behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 3.2.6 HIV testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 3.2.7 Exposure to interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 3.2.8 Relationships of knowledge, behavior and perception of risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 3.3 Uniformed services, transport workers, the rural population and factory workers . . . . . . . . . . . . . . . . . . . 40 3.3.1 Uniformed services (ground forces and the air force) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 3.3.2 Transport workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 3.3.3 Rural population groups (farmers and pastoralists) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 3.3.4 Factory workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 3.3.5 Comparisons between the adult groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 4 Qualitative Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 4.1 In- and out–of-school youth in three regional cities (Dire Dawa, Bahir Dar and Jijiga) . . . . . . . . . . . . . . . 60 4.1.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS . . . . . . . . . . . . . . . 60 4.1.2 Relationship between HIV infection and other STIs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 4.1.3 Misconceptions about HIV/AIDS, its transmission, and condoms and their effects . . . . . . . . . . . . . . 60 4.1.4 Stigma and attitudes towards PLWHA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 4.1.5 Voluntary counseling and testing (VCT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 4.1.6 Influence of knowledge, education and religion on behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 4.1.7 Contribution of information sources to increased knowledge and behavioral change . . . . . . . . . . . . 63 4.1.8 Perception and behavior/practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 4.1.9 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex . . . . . . . . 65 4.1.10 Perceived risk behaviors and behavioral change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 4.1.11 Participation in anti-AIDS clubs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 4.1.12 Suggestions to avert the spread of HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 4.2 Akaki Textile Factory workers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 4.2.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS . . . . . . . . . . . . . . . 67 4.2.2 Relationship between HIV infection and other STIs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 4.2.3 Misconceptions about HIV/AIDS, HIV transmission and condom use . . . . . . . . . . . . . . . . . . . . . . . . 67 4.2.4 Stigma and attitudes towards PLWHA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 4.2.5 Voluntary counseling and testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 4.2.6 Influence of knowledge, educational status and religion on behavior . . . . . . . . . . . . . . . . . . . . . . . . 68 4.2.7 Contribution of information sources to increased knowledge and behavioral change . . . . . . . . . . . . 68 4.2.8 Perception and behavior/practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 4.2.9 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex . . . . . . . . 69 4.2.10 Perceived risk behaviors and behavioral change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 4.2.11 Suggestions to avert the spread of HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 4.3 Truckers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 4.3.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS . . . . . . . . . . . . . . . 70 4.3.2 Relationship between HIV and other STIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 4.3.3 Misconceptions about HIV/AIDS, HIV transmission and condom use . . . . . . . . . . . . . . . . . . . . . . . . 70 4.3.4 Stigma and attitudes towards PLWHA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 4.3.5 Voluntary counseling and testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 4.3.6 Influence of knowledge, educational status and religion on behavior . . . . . . . . . . . . . . . . . . . . . . . . 71 4.3.7 Contribution of information sources to increased knowledge and behavioral change . . . . . . . . . . . . 71 4.3.8 Perception and behavior/practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 4.3.9 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex . . . . . . . . 72 4.3.10 Perceived risk behaviors and behavioral change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 4.3.11 Participation in anti-AIDS clubs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 4.3.12 Suggestions to avert the spread of HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 4.4 Intercity bus drivers and minibus drivers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 4.4.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS . . . . . . . . . . . . . . . 72 4.4.2 Misconceptions about HIV/AIDS, HIV transmission and condom use . . . . . . . . . . . . . . . . . . . . . . . . 73 4.4.3 Stigma and attitudes towards PLWHA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 4.4.4 Voluntary counseling and testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 4.4.5 Influence of knowledge, educational status and religion on behavior . . . . . . . . . . . . . . . . . . . . . . . . 73 vi 4.4.6 Contribution of information sources to increased knowledge and behavioral change . . . . . . . . . . . . 73 4.4.7 Perception and behavior/practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 4.4.8 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex . . . . . . . . 74 4.4.9 Perceived risk behaviors and behavioral change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 4.4.10 Participation in anti-AIDS clubs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 4.4.11 Suggestions to avert the spread of HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 4.5 Pastoralists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 4.5.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS . . . . . . . . . . . . . . . 75 4.5.2 Relationship between HIV and other STIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 4.5.3 Misconceptions about HIV/AIDS, HIV transmission and condom use . . . . . . . . . . . . . . . . . . . . . . . . 75 4.5.4 Influence of knowledge, educational status and religion on behavior . . . . . . . . . . . . . . . . . . . . . . . . 75 4.5.5 Contribution of information to increased knowledge and behavioral change . . . . . . . . . . . . . . . . . . 76 4.5.6 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex . . . . . . . . 76 4.5.7 Voluntary counseling and testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 4.5.8 Perception and behavior/practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 4.6 Farmers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 4.6.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS . . . . . . . . . . . . . . . 77 4.6.2 Relationship between HIV and other STIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 4.6.3 Misconceptions about HIV/AIDS, HIV transmission and condom use . . . . . . . . . . . . . . . . . . . . . . . . 77 4.6.4 Stigma and attitudes towards PLWHA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 4.6.5 Voluntary counseling and testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 4.6.6 Influence of knowledge, educational status and religion on behavior . . . . . . . . . . . . . . . . . . . . . . . . 78 4.6.7 Contribution of information to increased knowledge and behavioral change . . . . . . . . . . . . . . . . . . 78 4.6.8 Perception and behavior/practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 4.6.9 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex . . . . . . . . 79 4.6.10 Factors and circumstances contributing to unprotected sex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 4.6.11 Perceived risk behavior and behavioral change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 4.6.12 Suggestions to avert the spread of HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 4.7 Female sex workers (bar-based, home-based and street-based). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 4.7.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS . . . . . . . . . . . . . . . 80 4.7.2 Relationship between HIV and other STIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 4.7.3 Misconceptions about HIV/AIDS, HIV transmission and condom use . . . . . . . . . . . . . . . . . . . . . . . . 80 4.7.4 Stigma and attitudes towards PLWHA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 4.7.5 Voluntary counseling and testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 4.7.6 Influence of knowledge, educational status and religion on behavior . . . . . . . . . . . . . . . . . . . . . . . . 81 4.7.7 Contribution of information to increased knowledge and behavioral change . . . . . . . . . . . . . . . . . . 81 4.7.8 Perception and behavior/practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 4.7.9 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex . . . . . . . . 82 4.7.10 Perceived risk behaviors and behavioral change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 4.7.11 Participation in anti-AIDS clubs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 4.7.12 Suggestions to avert the spread of HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 5 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 5.1 Knowledge about HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 5.1.1 Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 5.1.2 Preventive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 5.1.3 Misconceptions about HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 5.1.4 Comprehensive knowledge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 5.1.5 Stigma and discrimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 5.2 General risk and sexual behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 5.2.1 Drug and alcohol use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 5.2.2 Premarital sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 5.2.3 Non-commercial sex partners and numbers of sexual partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 5.2.4 Commercial sex partners and non-regular sex partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 5.2.5 Condom use and unprotected sex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 5.2.6 History of STIs and treatment seeking behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 5.3 HIV testing and exposure to interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 vii 5.3.1 HIV testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 5.3.2 Media interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 5.4 Relationships between knowledge, sexual behavior and perception of risk. . . . . . . . . . . . . . . . . . . . . . . . 87 5.5 Limitations to the study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 6 Conclusions and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 6.1 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 6.2 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 6.2.1 Policy and advocacy level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 6.2.2 Information, education and communication/behavioral change communication (IEC/BCC) . . . . . . . 90 6.2.3 Program level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Additional resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Annexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Annex 1. Sample sizes for study populations (respondents) and sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Annex 2A. BSS indicators for ISY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Annex 2B. BSS knowledge indicators and components for ISY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Annex 2C. BSS indicators for younger OSY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Annex 2D. BSS knowledge indicators and components for younger OSY . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Annex 2E. BSS indicators for older OSY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Annex 2F. BSS knowledge indicators and components for older OSY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Annex 3A. BSS indicators for FSWs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Annex 3B. BSS knowledge indicators and components for FSWs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Annex 4A. BSS indicators for uniformed services, transporter workers, factory workers and rural populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Annex 4B. BSS knowledge indicators and components for uniformed services, transport workers, factory workers and rural populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Annex 5A. Characteristics of the focus group discussants – youth in three regional cities, August 2002 . . . . 116 Annex 5B. Characteristics of the individual in-depth interviewees – youth in three regional cities, August 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Annex 5C. Characteristics of the focus group discussants – adult population groups and female sex workers (FSWs), August 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Annex 5D. Characteristics of the individual in-depth interviewees – adult population groups and female sex workers (FSWs), August 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Annex 6. Definitions of indicators used in Ethiopian BSS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 List of contributors to the BSS round I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 viii List of Tables Table 1.1 Percentage of pregnant women testing HIV positive by sentinel site (urban and rural) 1989-2001. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Table 3.1.1 ‘Ever use’ of specific types of drugs by the youth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Table 3.1.2 Percentage of sexually active respondents who reported having had STI symptoms in the previous 12 months – by target group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Table 3.2.1 Socio-demographic characteristics of FSW by city. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Table 3.2.2 Knowledge of STI symptoms amongst FSW who were aware of the existence of STIs. . . . . . . . . . 31 Table 3.2.3 ‘Ever use’ of specific types of drugs by FSW. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Table 3.2.4 Reasons commonly given by FSWs for non-use of condoms at last sexual encounters with paying clients and non-paying partners.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Table 3.2.5 Percentage of FSWs who reported having had an STI in the past 12 months by category. . . . . . . 37 Table 3.3.1 ‘Ever use’ of specific types of drugs by uniformed services respondents. . . . . . . . . . . . . . . . . . . . 42 Table 3.3.2 Proportion of uniformed services respondents who reported that they had experienced STI symptoms during the previous 12 months.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Table 3.3.3 ‘Ever use’ of specific types of drugs by transport workers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Table 3.3.4 Proportion of transport workers who reported that they had experienced STI symptoms during the previous 12 months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Table 3.3.5 ‘Ever use’ of specific types of drugs by factory workers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Table 3.3.6 Proportion of factory workers who reported that they had experienced STI symptoms during the previous 12 months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 ix List of Figures Figure 1.1 Map of Ethiopia showing administrative regions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Figure 3.1.1 Levels of literacy by age and gender – OSY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Figure 3.1.2 Percentage of ISY (15-19 years old) and OSY (15-24 years old) with commonly observed misconceptions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Figure 3.1.3 Percentage of OSY and ISY who, when prompted, voiced at least one misconception about HIV/AIDS transmission. (Note: ISY was surveyed only in the Amhara, Oromia, Somali, Harari and Addis Ababa regions and the Dire Dawa AC). . . . . . . . . . . . . . . . . . . . . . . . . 17 Figure 3.1.4 Locations where youth obtain male condoms.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Figure 3.1.5a Regular alcohol and khat use amongst ‘ever users’ by region – ISY.. . . . . . . . . . . . . . . . . . . . . . . 20 Figure 3.1.5b Regular alcohol and khat use amongst ‘ever users’ by region – OSY.. . . . . . . . . . . . . . . . . . . . . . 20 Figure 3.1.6a Percentage of OSY (15-19 years old) who had ever had sex – by region and gender.. . . . . . . . . . 21 Figure 3.1.6b Percentage of OSY (20-24 years old) who had ever had sex – by region and gender.. . . . . . . . . . 21 Figure 3.1.6c Percentage of ISY (15-19 years old) who had ever had sex – by region and gender.. . . . . . . . . . . 22 Figure 3.1.7 Cumulative percentage of youth who were sexually active at various ages – by gender. . . . . . . . 22 Figure 3.1.8 Sexually active youth who had more than one partner during the previous 12 months. . . . . . . . . 23 Figure 3.1.9 Condom use at last sex amongst sexually active youth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Figure 3.1.10 Consistent condom use with non-commercial partners in the last 12 months amongst sexually active youth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Figure 3.1.11a Exposure of ISY to HIV/AIDS messages through the mass media – by type of media and region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Figure 3.1.11b Exposure of OSY to HIV/AIDS messages through the media – by type of media and region.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Figure 3.1.12 ABC vs. sexual behavior amongst ISY and younger and older OSY.. . . . . . . . . . . . . . . . . . . . . . . 27 Figure 3.1.13a Percentage of sexually active OSY who had risky sex in the last year – by region. . . . . . . . . . . . . 27 Figure 3.1.13b Percentage of sexually active ISY who had risky sex in the last year – by region. . . . . . . . . . . . . . 28 Figure 3.1.14 Perceived effects of exposure to mass media HIV/AIDS messages on incidence of risky sex in the last year amongst ISY, and younger and older OSY.. . . . . . . . . . . . . . . . . . . . . . . 28 Figure 3.1.15 Perception of risk for HIV infection amongst OSY who had risky sex in the previous 12 months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Figure 3.2.1 Knowledge and misconceptions of FSWs by city. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Figure 3.2.2 Percentage of FSWs with at least one stigmatizing attitude towards PLWHA – by city . . . . . . . . . 33 Figure 3.2.3 Regular alcohol and khat use amongst ‘ever users’ – FSWs by city. . . . . . . . . . . . . . . . . . . . . . . . 34 Figure 3.2.4 Numbers of clients reported by FSWs during the previous seven days – by city. . . . . . . . . . . . . . 35 Figure 3.2.5 Percentage of FSWs who had been exposed to mass media messages about HIV/AIDS in the previous 12 months – by type of media. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Figure 3.2.6 Personal perception of risk for HIV infection amongst FSWs – by city.. . . . . . . . . . . . . . . . . . . . . 40 Figure 3.3.1 Adults with more than one partner in the last year (as a percentage of sexually active). N.B. Data for farmers and pastoralists include those for respondents who had polygamous marriages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Figure 3.3.2 Extramarital sex in the previous 12 months – by adult group. . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Figure 3.3.3 Condom use in sex with commercial partners – by adult group. . . . . . . . . . . . . . . . . . . . . . . . . . 56 Figure 3.3.4 Condom use in sex with non-regular partners – by adult group. . . . . . . . . . . . . . . . . . . . . . . . . . 57 Figure 3.3.5 ‘BC’ vs. sexual behavior – by adult group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Figure 3.3.6 Perception of risk for HIV infection amongst adult group respondents who had unprotected sex in the previous 12 months. (N.B. Data for farmers are not included as only four farmers had any unprotected sex during the previous 12 months). . . . . . . . . . . . . . . . . 59 x Forward Almost 18 years have past since the emergence of the HIV/AIDS epidemic in Ethiopia. In 1985, the national response to the epidemic was initiated promptly with the establishment of a taskforce on HIV/AIDS. Subsequently, in 1987, the Department of AIDS Control was established in the Ministry of Health and a national program to prevent and control HIV/AIDS was launched. These activities were followed by a number of sero-surveys across the country, to map out the extent of the epidemic. Given the startling figures of morbidity and mortality and socio-economic suffering of our people, the need to scale - up an extraordinary response and bring about a tangible impact on the epidemic is overwhelming. So, the current National AIDS activities must be expanded dramatically to curtail spread of this scourge and our government is enhancing its unprecedented leadership in fighting HIV/AIDS by coordinating all sectors, by building up partnership and acting in synergy with all stakeholders to ensure large scale, sustained and more effective and efficient multi-sectoral campaign with a shared vision and common goal to hold back spread of HIV/AIDS, and substantially reduce new HIV infections, provide a continuum of care for those infected and affected by HIV/AIDS, significantly reduce its impact on human suffering and arrest the further reversal of our peoples’ socio-economic development. This consorted, integrated and un-abating effort needs to be supported and guided by a clearly targeted, well-designed and analyzed surveillance studies, surveys and researches in order to have a shared analysis and shared perspective on gaps, and have shared priorities and proper allocation and utilization of resources towards identified problems and risk behaviors, as successful HIV prevention depends on changing risk behaviors. By using reliable methods, behavioral surveillance surveys can be used to track HIV risk behaviors overtime as part of an integrated surveillance system by monitoring various aspects of the epidemics. Therefore, in 2001, Ethiopia, in collaboration with national and international partners, started to implement Second Generation HIV Surveillance. The Second Generation HIV Surveillance system stresses the need to design a surveillance system that is appropriate to the stage of the country’s HIV epidemic. In particular, it emphasizes the importance of using behavioral data to inform and explain trends recorded in HIV infection amongst a population, and advocates for the increased use of behavioral data in planning, implementing and evaluation of appropriate responses to the epidemic. Round One of the Behavioral Surveillance Survey (BSS) in Ethiopia, in ten target populations, was conducted in 2002 with sample size around 27,000. This Baseline survey provides, in many instances for the first time, representative population-based data on the socio-demographic characteristics and behavioral risk of target groups. For tracking behavior helps us to evaluate the achievements of our programs and change in behavior will help to explain changes in HIV prevalence, the survey will assist the Federal Ministry of Health of Ethiopia to develop relevant and targeted communications and interventions that can materialize in the desired behavioral change. Furthermore, when BSS data and biological surveillance system data are combined; a clear focus for HIV/AIDS interventions will become apparent. The Ministry of Health is fully committed to working with national and international partners to utilize the findings of this survey. We believe this first baseline survey result will be useful to inform the design and implementation of subsequent rounds of BSS. I am delighted to launch this Round One BSS (Behavioral Surveillance Survey) report for Ethiopia. We thank those all who supported and participated in the production of this timely report. The Ministry of Health recommends the document to be utilized by all relevant bodies working on HIV/AIDS in Ethiopia. Thank You, June 2003 xi Acknowledgements The Department of Community Health (DCH), AAU/EPHA, implemented the study. We would like to acknowledge the support given by the MoH, HAPCO, MoND, Regional HIV/AIDS Prevention and Control Secretariats and regional health bureaus. This study was realized with major financial support from USAID. And technical support from FHI and additional financial support from UNICEF and SC-USA. The printing cost of this research was covered by HAPCO. Our deepest gratitude goes to all the Staff of National HAPCO for all rounded support from the inception to the completion of the 2002 BSS. In particular our thanks goes to Ato. Negatu Mereke, Head of HAPCO and Dr. Tekelu Belay, Advocacy, Mobilization and Coordination Department Head. The BSS team would like to thank all the study participants who gave their time and shared their experiences and knowledge, namely: the youth from the respective regions; truckers, minibus and intercity bus drivers and their associations; the farmers of Butajira and pastoralists of Borena; female sex workers; management and employees of the Akaki Textile Factory; and members of the uniformed services. We would also like to thank the Ministry of Education and all the schools that participated in the survey, the Administration of the Southern Technology Faculty Campus, the Mental Health Project, the Department of Psychiatry, ESTC, the Road Transport Authority and Taxi Owners’ Association in Addis Ababa, DKT–Ethiopia, EHNRI and the management of the Akaki Textile Factory. Furthermore, we would like to thank the data collectors, supervisors and wereda/kebele administrators in the respective regions, who worked hard and responsibly, in order to accomplish the data collection and maintain the quality of data. We thank the following experts for their invaluable comments and suggestions during implementation and review of this research: Dr Damen H/Mariam (DCH), Dr Dangnachew H/ Mariam (former Head of NAC), Dr Endalamaw Abera (WHO), Dr Yetnayet Asfaw (private consultant), Ato Mirgissa Kaba (UNICEF), Mr Mohammed Ali Bhuiyan (SC-USA), Dr Asegid Woldu (MoH), Dr Gail Davey (DCH) and Dr Ahmed Ali (DCH). Finally, our special thanks go to Ms Francesca Stuer, Country Director FHI Ethiopia and FHI-Ethiopia -Staff for their unreserved administrative support throughout the implementation of the study and Ms Jeanette Bloem (Secheba Consultants, Lesotho) for her extensive technical input. Last but not least, our heart felt thanks go to Ato Ali Beyene (EPHA) for facilitating the financial administration. xii Abbreviations AAU AC AIDS BCC BSS CSA DCH DHS EC FGD EHNRI ENARP EPHA ESTC ETB FGAE FHI FSW HAPCO HIV IDI IDU IEC ISY MoH MoND NGO OSY PA PLWHA PPS SC–USA SNNPR STI UDA UNAIDS UNICEF USAID WHO VCT Addis Ababa University Administrative council Acquired immunodeficiency syndrome Behavioral change communication Behavioral surveillance survey Central Statistical Authority Department of Community Health Demographic and health survey Ethiopian calendar Focus group discussion Ethiopian Health and Nutrition Research Institute Ethio-Netherlands AIDS Research Project Ethiopian Public Health Association Ethiopian Science and Technology Commission Ethiopian birr Family Guidance Association of Ethiopia Family Health International Female sex worker HIV/AIDS Prevention and Control Office Human immunodeficiency virus Individual in-depth interview Injecting drug user Information, education and communication In-school-youth Ministry of Health Ministry of National Defense Non-governmental organization Out-of-school youth Peasant association People living with HIV/AIDS Probability proportional to size Save the Children–USA Southern Nations and Nationalities Peoples Region Sexually transmitted infection Urban dwellers association United Nations Program on HIV/AIDS United Nations International Children’s Fund United States Agency for International Development World Health Organization Voluntary counseling and testing xiii Definitions Definitions of terminology Aba Geda– A Borena leader who is elected by a panel of elders; elections take place every eight years. An Aba Geda carries out social, economic, ritual and political activities that help to keep peace amongst the Borena pastoralists. (The term Geda may also be spelt Gada). Ethiopian Calendar (EC)– Ethiopia follows the Julian calendar, which consists of 13 months; 12 months with thirty days each and a thirteenth month of five days, six in a leap year. The calendar is seven or eight years behind the Western (Gregorian) calendar. The Ethiopian New Year begins on the first day of the month of Meskerem, which falls on September 11th on the Gregorian calendar. Female sex worker (FSW)– Female who sells sex for money. Kebele– The lowest administrative unit in Ethiopia. In urban areas it is also called an urban dwellers association (UDA) whilst in rural areas it is also called a peasant association (PA). Mass media– Radio, television and printed media. Region– Regions are national states that together form the Federal Democratic Republic of Ethiopia. There are ten regions and one administrative council (AC). In this study, region refers to regional capital or major urban cities of the region. Wereda– An administrative unit (equivalent to a district). Zone– Consists of a number of weredas. Operational definitions Buying and selling– Used to convey the retail trade e.g. the buying and selling low-cost goods (chiricharo). Commercial sex– A sexual relationship where money was paid in exchange for sex (paid sex). Commercial sex partner– A partner who was paid money in exchange for sex. Comprehensive knowledge about HIV/AIDS– Respondents were considered to have comprehensive knowledge about HIV/AIDS if they knew about the three HIV/AIDS prevention methods and had no misconceptions about HIV transmission. xiv Consistent condom use– Used a condom every time sexual relations took place. Drugs– Drugs considered in this study were stimulants other than alcohol e.g. khat (Catha edulis), shisha, hashish (marijuana), Mandrax, cocaine, crack and benzene. Ever drug use– Ever in ‘lifetime’ use of any of the drugs listed in the definition above. Informal employment– Employment was considered informal when: 1) the establishment/activity was not a corporate type of enterprise; 2) the establishment/activity was not registered by any legal authority (i.e. was unlicensed); 3) individuals were self-employed; or 4) an employer/establishment/activity did not keep a complete book of accounts. Informal employment was typically short-term and low-income e.g. daily laboring or domestic work. Involvement with community HIV/AIDS interventions– Included: participation in anti-AIDS clubs; contact with an outreach worker; discussion with a peer educator; participation in social events with an HIV/AIDS theme; discussion about HIV/AIDS with friends, sexual partners, families or other community members; and contact with HIV/AIDS support groups. Knowledge about HIV prevention– Respondents were considered to be knowledgeable about HIV prevention if they correctly identified the three major ways to prevent HIV transmission i.e. abstinence, being faithful to one uninfected partner and condom use. MisconceptionsRespondents were considered to have misconceptions about HIV/AIDS transmission and prevention if they agreed to any the following six incorrect statements about HIV/AIDS: a mosquito bite can transmit HIV; sharing a meal with someone who is HIV positive can transmit HIV; a healthy-looking person cannot be infected with HIV; eating raw meat (raw kitfo) prepared by an HIV-infected person can transmit HIV; eating an uncooked egg laid by a chicken that swallowed a used condom can transmit HIV; and drinking local hard liquor and eating hot pepper can protect from HIV. Multiple sexual partners– More than one sexual partner. Non-commercial partner– Used for youth – any partner other than a commercial partner. No incorrect beliefs about HIV/AIDS transmission– Respondents were considered to have no incorrect beliefs about HIV/AIDS transmission if they correctly rejected statements expressing the three most common misconceptions about HIV: a mosquito bite can transmit HIV; sharing a meal with someone who is HIV positive can transmit HIV; and a healthy-looking person cannot be infected with HIV. Non-paying partner– Sex partners of a FSW who did not pay money in exchange for sex. Non-regular partner– Non-regular partners included two groups: (a) sexual partners who had been together for less than 12 months, were not married, had never lived together and did not make any payment for sex; and (b) sexual xv partners who had been together in a relationship for more than 12 months but had never married or lived together. Paying client– Sex partner of a female sex worker (FSW) who paid money in exchange for sex. Regular alcohol use– Use of alcohol at least once a week amongst those who ever drank alcohol. Regular khat use– Use of khat at least once a week amongst those who reported ever having chewed khat. Regular partner– Spouse or cohabiting (live-in) sex partner. Risky sex– Any unprotected sex (i.e. sex without a condom) with any partner other than a regular partner. Shisha– A mixture that may include tobacco, honey, hashish and spices; it is smoked from an oriental tobacco pipe, which has a long, flexible tube that draws the smoke through a water-filled container. Uniformed services– Included only the ground force and air force. xvi Executive summary Introduction and methods Behavioral surveillance surveys (BSS) are an integral part of surveillance systems that enable monitoring of the HIV epidemic. Surveillance systems for assessing and monitoring of trends in HIV and sexually transmitted infection (STI) prevalence, and their interactions, are key to informing an effective and efficient response to the epidemic. United Nations Program on HIV/AIDS (UNAIDS), World Health Organization (WHO), Family Health International (FHI) and others have worked together to develop a new framework for HIV surveillance. This framework, known as Second Generation HIV Surveillance, stresses the need to design a surveillance system that is appropriate to the stage of the epidemic in a country, focusing surveillance resources on population groups in which HIV infection is most likely to be concentrated. In particular, it emphasizes the importance of using behavioral data to inform and explain trends recorded in HIV infection amongst a population, and advocates for the increased use of behavioral data in planning and evaluation of appropriate responses to HIV. The BSS methodology is a monitoring and evaluation tool designed to track trends in HIV/AIDS-related knowledge, attitudes and behaviors in sub-populations at particular risk of HIV infection, such as female sex workers, injecting drug users, migrant men and youth. However, groups included in a BSS depend on the stage of the epidemic in the country and on the distribution of risk in population groups. The BSS was introduced to Ethiopia in 2001 to compliment the sero-prevalence and other HIV surveillance systems instituted nationally. Ethiopia is currently experiencing a ‘generalized’ HIV epidemic, defined as an epidemic where the HIV sero-prevalence level amongst sexually active adults in the general population is greater than one percent. Furthermore, it is recognized that HIV sero-prevalence is considerably above this level amongst specific high-risk population groups such as sex workers and mobile populations. In Ethiopia, the fieldwork for the BSS Round One was conducted between December 2001 and May 2002. The basic objectives of the BSS were to: (i) identify risk behaviors which need to be addressed through interventions amongst specific sub-populations; (ii) identify priorities for the planning of prevention programs and for appropriate distribution of limited resources; (iii) establish a baseline to allow monitoring of trends and patterns in risk behaviors; (iv) provide information to explain changes in HIV prevalence; (v) provide key information for advocacy and policy making; and (vi) provide information to evaluate program impact. Ten different population groups were studied in this first round of BSS. These groups included in-school youth (ISY; 15-19 year olds, currently enrolled in school), out-of-school youth (OSY; 15-24 year olds, currently not enrolled in school), uniformed services (ground forces and the air force), transport workers (truckers, intercity bus drivers, minibus drivers and their assistants), farmers, pastoralists, factory workers and female sex workers (FSWs). These population groups were chosen as targets for the study because of their potentially high risk for HIV infection (FSWs, uniformed services, youth and drivers) or low risk for HIV infection (farmers, pastoralists and factory workers). Target group size was determined using probability- sampling techniques. Data were collected using quantitative and qualitative methodologies. Generic BSS questions were adapted to the Ethiopian context. However, considerable standardization was retained to allow for the tracking of behavioral indicators over time and comparison with BSS data from other countries. Questions addressed socio-demographic characteristics, sexual behavior, condom use (knowledge and practice), alcohol and drug use, STIs, availability of and access to HIV testing, HIV-related knowledge and beliefs (including misconceptions), and exposure to HIV interventions. Trained interview teams administered the questionnaires. Data were analyzed for each target group and region, as appropriate. The quantitative findings of the survey were enriched by a qualitative study, which was carried out between August and September 2002, after the dissemination of the preliminary findings of the BSS. The purpose of the qualitative research was to elaborate on the gaps identified and to further explore some of the major results. A total of 24 focus group discussions and 23 in-depth interviews were conducted amongst the target groups. xvii Summary of findings Almost all of the target groups had heard of HIV/AIDS and of ‘diseases that can be transmitted through sexual intercourse’. However, people knew little about details of the diseases. Level of knowledge relating to HIV prevention was highest amongst the ground forces and lowest in the female farmers of Butajira (79 and 1.8%, respectively). Comprehensive knowledge was also lowest amongst the female farmers of Butajira; less than 1% of this group had comprehensive knowledge. Almost all of the target populations had heard of male condoms and reported that they were readily accessible and inexpensive. Consistent condom use was low amongst most population groups. Nevertheless, the majority of FSWs consistently used condoms with their paying clients. In both adult and youth populations, use of alcohol and drugs (mostly khat or shisha) in the previous 12 months was associated with increased levels of unprotected sex (i.e. lower levels of condom use). Notable findings specific to each target group include the following: Youth Amongst the 20,434 youth (6210 ISY and 14,224 OSY), average age was 18 years. Alcohol and khat use were higher amongst OSY than ISY, and higher amongst males than females. Knowledge of HIV/AIDS preventive methods was higher amongst ISY than OSY. General awareness about HIV, STIs and condoms was widespread amongst the ISY. More than two-thirds of the youth said that they knew someone with HIV or someone who had died of AIDS. Almost all of the youth expressed one or more negative attitude about people living with HIV/AIDS (PLWHA). Amongst the 15- to 19-year-olds, more of the OSY than ISY had ever had sex. The OSY tended to start having sex at an earlier age than the ISY. Amongst the younger male OSY, those in the Gambella region and the Southern Nations and Nationalities Peoples Region (SNNPR), respectively, had the highest (54%) and lowest (24%) reported levels of premarital sex. Males reported that their first sexual partners were approximately the same age as themselves; in contrast, females reported that their first partners were older than themselves by around 5-10 years. Considerable proportions of sexually active OSY in Tigray (61.1%), Beneshangul-Gumuz (55.2%) and Gambella (48.9%) reported that they had had more than one sexual partner in the previous 12 months. Although condoms were readily accessible, only about 50% of sexually active ISY and OSY had ever used them with non-commercial partners. Consistent condom use in the past 12 months with non-commercial partners was low, 39 and 73.6% for the OSY and ISY, respectively. Amongst the youth, about 17% had had unprotected sex with one or more sexual partners in the previous 12 months. Levels of unprotected sex were highest amongst OSY in the Gambella, Beneshangul-Gumuz and Afar regions. The most common reason given for not using condoms was that individuals trusted their sexual partners. Less than 7% of the youth had ever had an HIV test. Adults Amongst the 5765 adults (uniformed services, factory workers, transport workers, pastoralists and farmers) interviewed, the average age was 30.4 years. Almost 66% of these individuals had attended school; however, years of schooling varied between the groups. With the exception of the uniformed services, male adult respondents commonly used alcohol and khat. Awareness of HIV/AIDS, STIs and condoms was relatively high in all groups (>90%). Knowledge of the three major preventive methods was highest amongst the uniformed services (all male) and lowest amongst female farmers (1.8%). Levels of misconceptions about HIV/AIDS were lowest amongst long distance truck drivers and their assistants (>60% had no misconceptions) and highest amongst the male and female farmers of Butajira (only 17.2 and 15.6%, respectively, had no misconceptions). Almost a third of the adult groups who were sexually active in the past 12 months, reported more than one sexual partner in the last 12 months. About 41% of the ground forces reported more than one sexual partner in the past year as compared with only 7% of the factory workers. xviii Extra marital sex was reported by 33% of the adult respondents in the past 12 months. The ground forces reported the highest level of extramarital sex (60%) while factory workers reported the lowest level (8%). Amongst adult respondents who had commercial sex, 95% had used condoms during their last (most recent) commercial sex. Around 66% had used condoms with non-regular partners in the previous 12 months. The practice of unprotected sex (with any type of partner) in the previous 12 months was most common among the ground forces and minibus drivers (18%) and least common amongst factory workers. The main reason given for not using a condom was trust of a partner. Very small proportions of the adult groups had taken HIV tests; overall, only 10% had ever been tested. The highest levels of HIV testing were amongst the uniformed services (air force 27% and ground forces 15.6%). Female sex workers (FSWs) Interviews were conducted with a total of 2487 FSWs, from six regions. On average FSWs were 22.2 years old. About 74% of the respondents had attended school; however, levels of literacy varied between the regions. The proportion of illiterate FSWs was high in Bahir Dar compared with the other urban centers. The majority (about 63.5%) of FSWs were born in a town/city. Amongst these FSWs, 73% were working in an area other than their place of birth. Around 20% of the FSWs reported that they were engaged in income-generating activities, additional to their sex work. About 28% of the FSWs were supporting at least one other person (adult or child). About 33% of the respondents reported drinking alcohol everyday; about 50% used khat regularly. Amongst the urban centers, the highest levels of alcohol and drug use by FSWs were found in Awassa and Nazareth. Amongst the FSWs, general awareness about HIV, STIs and condoms was universal. A high proportion of FSWs (86%) knew that consistent condom use could prevent HIV infection. Literate FSWs were about 3-times less likely to have misconceptions about HIV/AIDS than their illiterate counterparts. There were some regional differences in levels of knowledge about the preventive methods; knowledge was lowest amongst FSWs in the Gambella town and highest amongst those in Dire Dawa. Around 8% of the FSWs were <15 years old when they first became involved in commercial sex. Median numbers of sex partners reported by FSWs were three paying and one non-paying partner in the 7-day period preceding the interview. Overall, 92% used condoms during their last commercial sex (i.e. with paying partners), 91% used condoms consistently with paying clients in the 30 days preceding the interview and 70.5% used condoms consistently with their non-paying partners in the previous 12 months. Only 7.7% of the FSWs reported that they had ever had an HIV test. Between group comparisons Across the entire adult population studied, 13% reported that they had had unprotected sex at some time in the previous 12 months; in the youth, the corresponding figure was 17.4%. Interestingly, considerable proportions (around 73 and 80% of the adult and youth respondents, respectively) who had unprotected sex in the previous 12 months perceived themselves to be at no or low risk for HIV infection. Notably, less than 10% of the adult and youth respondents had had an HIV test in the previous 12 months. xix Conclusions In Ethiopia, the first round of BSS was successful in documenting HIV/AIDS-related knowledge, attitudes and behaviors in sub-populations including youth, adult groups and FSWs. A key benefit of the methodology was the standardized approach to questionnaire development, sampling frame construction and survey implementation and analysis. This BSS represents an important achievement that can be built upon by future surveillance efforts in Ethiopia. It is important that the results of BSS are recognized as a valuable national resource. Based on the findings the following conclusions were made: • About half of the respondents did not have knowledge of the three preventive methods. The knowledge gap amongst the rural population was high. • Misconceptions about HIV/AIDS existed amongst all population groups; however, level of misconceptions was highest amongst the farmers and pastoralists. • There was a high level of stigma and discrimination amongst all target groups. Level of stigma was highest amongst the rural population. • Risk perception relating to HIV infection was low amongst all target groups. • Premarital sex was more common amongst the OSY than ISY. • The level of HIV testing was very low despite a high level of willingness to undergo voluntary counseling and testing. • Apart from the exposure to mass media, involvement in community interventions was low. xx Recommendations • At all levels, involvement of leaders and sustained political commitment are needed to support • • • • • behavioral change, and decrease stigmatization and discrimination relating to HIV/AIDS. Parents, religious organizations, governmental and non-governmental organizations need to be mobilized and coordinated to influence public opinion relating to HIV/AIDS, and associated high-risk behaviors. Current information, education and communication (IEC) activities need to be evaluated with a view to adapting the country strategy for behavioral change communication (BCC) in order to enhance behavioral change and address widespread misconceptions. In the design and execution of BCC programs, the heterogeneous characteristics of the population and age/gender differences should be taken into account. The youth require special attention in relation to HIV/AIDS interventions. In particular, anti-AIDS clubs should be strengthened amongst the ISY and need to be expanded to OSY. Emphasis should be given to discouraging drug and alcohol use amongst the youth. Moreover, there is a need to promote the expansion of recreational facilities and libraries, and focus on the provision of employment opportunities for the youth. HIV/AIDS intervention programs need to extend to the rural communities (i.e. to pastoralists and farmers) and special strategies should be designed to increase access of these communities to the mass media; moreover, alternative methods that are appropriate to rural areas, such as outreach services, should be used. Increased awareness and expansion of VCT services are required to promote and sustain behavioral change. In particular, VCT services should be more accessible to the community, the uniformed services and mobile population groups. xxi 1 Introduction 1.1 Background Ethiopia is situated in the Horn of Africa where it is bordered by Djibouti, Eritrea, Sudan, Kenya and Somalia. The population of Ethiopia is estimated to be over 65 million. Less than 14% of the population lives in urban areas (CSA 1998). The majority of the population lives in the highlands of Ethiopia where subsistence farming predominates. Most inhabitants of the lowland areas are pastoralists. Agriculture accounts for 54% of the gross domestic product. In 1998, per capita gross national product was only US$ 100 (PRB 2000). Christianity and Islam are the major religions; 51% of the population is Orthodox Christian, 33% Muslim and 10% Protestant. The remaining 6% follows a diversity of other faiths. Ethiopia is home for over 80 ethnic groups (CSA 1998). Between 1974 and 1991, Ethiopia operated a central command economy, under the socialist banner of the Derg Regime. However, since the overthrow of this regime, the country has moved towards a market-oriented economy. A federal system of government exists with ten regional states plus the Dire Dawa Administrative Council (AC). Figure 1.1 presents a map of Ethiopia, which shows the various administrative regions. Each regional state is subdivided into zones and districts. The smallest administrative units of government are called kebeles; these are also known as urban dwellers associations (UDA) in urban areas and peasant associations (PAs) in rural areas. The majority of the population resides in the rural areas and has little access to any type of modern health institution. According to Ministry of Health (MoH) figures, potential health service coverage is only 51.2% (MoH 2001). Approximately, 75% of the population suffers from some type of communicable disease and malnutrition, both of which are potentially preventable (TGE 1995). Life expectancy is 55.4 years for women and 53.4 years for men. Between 1984 and 1994, life expectancy did not improve for either gender (CSA 2001). At present, the government’s health policy takes into account population dynamics, food availability, vulnerability, acceptable living conditions, availability and accessibility of health services and other requisites essential for improvement of health status (TGE 1993). In 2000, a demographic and health survey (CSA 2001) was conducted in Ethiopia with the objective of providing up-to-date and reliable data on fertility and family planning behavior, child mortality, children’s nutritional status, the utilization of maternal and child health services and knowledge about HIV/AIDS. This survey revealed a very low educational level amongst the majority of Ethiopians; about 62% of males and 77% of females had no formal education and <3% of males and 1.2% of females completed primary education. Only 18% of households had access to piped drinking water and the majority of Ethiopian households (82%) did not have a toilet. The practice of female circumcision was widespread in the country; about 80% of women were circumcised. About 25% of the Ethiopian women who died in the seven years preceding the survey had died from pregnancy-related causes. The maternal mortality rate was 871 deaths per 100,000 live births for the period 1994-2000. Neonatal mortality rate was 49 per 1000, infant mortality rate was 97 per 1000 and under-five mortality rate was 166 per 1000 live births (CSA 2001). 1.2 Overview of HIV/AIDS in Ethiopia Over 6.6% of Ethiopia’s adult population is thought to be HIV positive; accordingly, it is estimated that there are 2.2 million people infected with the virus (MoH 2002). As is the case elsewhere in Africa, transmission is almost exclusively through heterosexual contact. A large proportion of new HIV infection is occurring in young people (<25 years old). In Ethiopia, it is widely believed that the HIV epidemic began around 18 years ago. The first evidence of HIV infection in Ethiopia was discovered in serological samples collected in 1984 (Tsega et al. 1988) and was followed by the first reported cases of AIDS in 1986 (Lester et al. 1988). 1 All boundaries are approximate and unofficial Graphic produced by UN Emergencies unit for Ethiopia; march 2000 Figure 1.1 Map of Ethiopia showing administrative regions. The national response to the epidemic was initiated promptly with the establishment of a task force on HIV/AIDS in 1985. Subsequently, in 1987, the Department of AIDS Control was established in the Ministry of Health and a national program to prevent and contr ol HIV/AIDS was launched. These activities were followed by a number of sero-surveys across the country, to map the extent of the epidemic (Eshete and Sahlu 1996). Soon after the initial activities, major social and political changes occurred, including: the devolution of political power to the regional states; the creation of a federal system of government; economic liberalization; and the growth of the private and non-governmental sectors. These changes offered the regional states, non-governmental organizations (NGOs) and civil society a potentially conducive environment to tackle the spreading HIV epidemic. In Ethiopia, where poverty, lack of formal education, and natural and man-made disasters are widespread, it is almost inevitable that the HIV/AIDS epidemic continues to grow relentlessly and expand despite efforts to curb its spread. Indicators suggest that a large segment of society is affected by the epidemic. In response to this widespread problem, in August 1998, the government formulated a national policy on HIV/AIDS (GFRE 1998) and, in April 2000, it established the National AIDS Prevention and Control Council (GFRE 2000). Moreover, the Ministry of Health and regional health bureaus, collaborating with all stakeholders, have drafted multi-sectoral strategic five-year plans (MoH 1999a, 1999b and 1999c). Kebede et al. (2000) reviewed the most up-to-date sero-surveys conducted amongst various population groups in Ethiopia; in 1999, the prevalence of HIV was 6.4% amongst blood donors in Addis Ababa. In the same year, the prevalence of HIV was 15% amongst women receiving antenatal care in Addis Ababa (MoH 2000). Furthermore, in 1999, HIV prevalence data from visa applicants (another ‘self-selected’ group of individuals) showed that 9.1% were HIV positive (Tegbaru et al. 1999). Data on area of residence for this group are not available but most are expected to have been from Addis Ababa. In combination, these data indicate that the HIV/AIDS epidemic has affected a large segment of Addis Ababa’s population. 2 Less data are available for areas outside of Addis Ababa. However, amongst demobilized soldiers who consented to VCT, the HIV prevalence was 6.6% (Yigeremu Abebe, personal communication 2001). Although data from rural areas are scarce, recent evidence indicates that about 3.7% of the adult population of rural areas is HIV positive (MoH 2002). Similarly, amongst 62,000 rural and 10,000 urban army recruits (studied between 1999 and 2000), the prevalence of HIV was 3.8 and 7.2% respectively (Yigeremu Abebe, personal communication 2001). Table 1.1 illustrates trends in the prevalence of HIV-1 infections amongst antenatal clinic attendees at various sero-surveillance sites in Ethiopia (MoH 2002). An increase in HIV-related deaths is seriously limiting improvements in life expectancy in Ethiopia. Predictions of life expectancy made with or without the presence of AIDS in the population were markedly different e.g. 46 instead of 53 years in 2001, and 50 instead of the expected 59 years in 2014 (MoH 2002). Table 1.1 Percentage of pregnant women testing HIV positive by sentinel site (urban and rural) 1989-2001. Site Addis Ababa Metu Gambella Dire Dawa Awassa Attat Dilla Gambo Hossana Aira Soddo Shashemene Estie Bahir Dar (HC) Dire Dawa (HC) Nazareth Jijiga Mekele Maichew Adigrat Borena Dadim Borena Gosa Ambo Toke Jimma Nekemet Ginir Asaita Dire Dawa (Hsp) Bahir Dar (Hsp) Gondar (HC) Pawi 1989 1992–93 1995 Year 1996 1997 4.6 11.2 10.7 21.2 17.8 1998 1999–2000 17.5 12.7 12.3 14.4 0.8 14.5 3.6 9.2 13.0 12.3 15.1 4.0 19.0 13.6 11.5 4.0 11.7 0.7 4.8 2.0 10.7 14.3 7.3 20.8 13.6 2001 15.6 10.5 14.6 15.2 10.0 1.5 9.8 1.1 5.9 2.6 11.6 13.1 10.7 23.4 15.2 18.7 19.0 17.2 16.8 16.2 1.7 1.7 4.6 8.6 9.1 3.1 12.4 8.5 19.9 15.1 8.5 Note: Hsp = hospital; HC = Health center. Source: Ministry of Health 2002. Compulsory reporting of AIDS cases started in 1986 with a report of two cases (Negassa 1990a and 1990b). By 2001, a total of 107,575 cases had been reported to the Ministry of Health (MoH 2002). At present, data on the number of reported AIDS cases disaggregated by age and gender, area of residence and from presumed high-risk groups are available only for the years up to and including 1994 (see MoH 1995). More recent data are not available because of under diagnosis, under reporting and delayed reporting. 3 Nevertheless, AIDS case surveillance, with all its limitations, continues to be practiced in Ethiopia as it is used to estimate the number of HIV infections, related deaths and other impacts of the epidemic. For instance, AIDS case surveillance data have been used as the bases of several estimates and projections for Addis Ababa (Khodakevich et al. 1990; Addis Ababa Regional Health Bureau 1999; Mekonnen et al. 1999) and the entire country (MoH 1998; UNAIDS 1998; CSA 2001). Several surveys have indicated high levels of awareness about HIV/AIDS in Ethiopia (Gebresellassie 1988) but only a few studies have attempted to examine actual changes in behavior. Serial data on the proportion of students who use condoms are available only for Addis Ababa and Gondar. A recent review of the literature (Kebede et al. 2000) indicated that youth and other high-risk groups in Addis Ababa and Gondar are changing their behavior and adopting safer sexual practices. In Addis Ababa, the proportion of high school students reporting condom use increased from 6.6% in 1990 to 27.7% in 1993. About 34% of college students in Addis Ababa reported condom use in 1993. In Gondar, the proportion of college students reporting condom use increased from 24 to 45.9% between 1990 and 1996. Moreover, in Gondar, the proportion of students reporting sex with a non-regular partner decreased from 47% in 1990 to 9.3% in 1996; in Addis Ababa, it decreased from 36.2% in 1990 to 10.3% in 1993. Two large-scale nationwide studies on sexual behavior were conducted in 1987-88 and 1993 (Mehret et al. 1996; NAPCC 2000). Although the two studies used different methods to investigate condom use, differences between the results (condom use by 3.4 and 47% of participants, respectively) were too great to be dismissed on methodological grounds. There are several limitations to the reported behavioral data. These limitations include a lack of standardization of methods used in the various studies; for example, the studies did not use similar or standardized questions. Furthermore, data often represented a small group of individuals and covered limited geographic areas. Consequently, it is difficult to compare results and reach substantiated conclusions; this in turn affects monitoring and evaluation of trends in HIV/AIDS/STI related behaviors. Nevertheless, in other countries where behavioral surveillance surveys (BSS) have been used to overcome similar limitations, experience has shown that tracking of behaviors is essential to the strengthening of national HIV/AIDS prevention and control efforts. 1.3 Introduction to behavioral surveillance survey (BSS) BSS is a monitoring and evaluation tool designed to track trends in HIV/AIDS-related knowledge, attitudes and behaviors in subpopulations at particular risk of infection, such as female sex workers (FSW), injecting drug users (IDU), mobile men and youth. BSS consists of repeated cross-sectional surveys conducted systematically to monitor changes in HIV/STI risk behaviors based on HIV and sexually transmitted infection (STI) surveillance methods. The key benefit of this methodology is its standardized approaches to questionnaire development, sampling frame construction, and survey implementation and analysis. BSS findings serve many purposes: they yield evidence for impact of projects; provide indicators of project successes and highlight persistent problem areas; identify priority populations for interventions; identify specific behaviors in need of change; function as a policy and advocacy tool; and supply comparative data concerning risk behaviors. National BSS have been conducted by Family Health International (FHI) in more than 25 countries and their use is growing. Since 1999, they have been used in Asia and Africa, where they have proved beneficial in understanding the pandemic from regional and country-specific perspectives. In several countries, multiple rounds of BSS have already been conducted and the trend data are being used to formulate new programs and to adapt existing ones. The first round of BSS in Ethiopia was initiated following a series of consultations, negotiations and meetings. 1.4 Objectives of BSS in Ethiopia • To provide baseline information that will assist in the development of a system for tracking behavioral trend data for high risk and vulnerable target groups, i.e. those groups which influence the epidemic in Ethiopia; 4 • To provide information on behavioral trends amongst key target groups in some of the catchment areas where intervention projects are operating; • To strengthen the second generation surveillance system in the country; • To provide information that can guide program planning; • To open and develop a dialogue on HIV/AIDS amongst the population from the policy to the community level; • To provide evidence for the relative success of HIV prevention efforts taking place in selected sites; and • To obtain data in a standardized format, which will enable comparison with other BSS carried out in other countries. 5 2 Methodology 2.1 Quantitative survey Data for Round One BSS–Ethiopia were collected from all ten regions and Dire Dawa AC between December 2001 and May 2002; on average, data collection lasted three months for each region. 2.1.1 Target groups The BSS considered six target groups (including 10 subgroups), namely, the youth (both in-school and out-of-school), female sex workers (FSWs), transport workers (long-distance truck drivers, intercity bus drivers and minibus taxi drivers and their assistants), rural residents (farmers and pastoralists), factory workers and the uniformed services (ground force and air force). The justifications for focusing on these target groups were as follows: • Young people are particularly vulnerable and are the key to the future course of the HIV epidemic. They are the essential focus for prevention messages in every sexual health program. Since most new infections are in young people, even modest changes in behavior will have significant impacts on the epidemic. • Sex workers are considered to be one of the core groups driving the epidemic because of their high risk for HIV infection and exposure to multiple partners. • Because transport workers are highly mobile and have contact with many people they are considered a vulnerable group for sexually transmitted infections (STIs) including HIV/AIDS. • Over 80% of Ethiopia’s population is rural, consisting mainly of farm households and pastoralists. Although the importance of this sector to national development is recognized, the state of the HIV/AIDS epidemic in this group is not well documented. • Factory workers are an important target group for behavioral surveillance survey (BSS), primarily because of their importance to the national economy. • Because of the importance of the uniformed services to national security, the size of the group and its potentially high-risk behavior, the uniformed services have been given high priority in national HIV/AIDS prevention and control programs. 2.1.2 Sample design The BSS–Ethiopia used sampling strategies that are crucial to the measurement of trends over time. Some target groups were not easily accessible through conventional household or institutional sampling techniques. For most target groups, two-stage sample designs were used i.e. primary units (clusters) chosen at the first stage and individual respondents chosen at the second stage. When members of the target group were associated with sites in a fixed manner, conventional clusters were used; however, when the target groups were ‘floating’, time-location clusters and targeted snowball sampling were used. The probability-sampling method was used for the selection of respondents. The sampling frames for the household surveys and institution-based surveys were simple and readily available. However, sampling frame development required preliminary qualitative research and some level of mapping (social and geographic mapping). The objectives of the BSS mapping were to define target groups and identify their locations, to estimate sizes of the potential target groups and systematically list ‘clusters’ of groups to serve as a sampling frame for the main survey. The mapping also aimed to provide information on potential target groups for immediate commencement of intervention activities by governmental and non-governmental agencies, which were planning to operate in the area. The BSS team used various methods for mapping, including interview of key informants, observation by walking through the community, review of records and reports, and discussion with experts and program managers involved in STI/HIV/AIDS control. 6 The following formula was used to determine sample size for all target groups. 2 2 p(1 p) n D 1 p1 (1 p1 ) p 2 (1 p 2 ) 1 2 Where D = design effect; P1 = the estimated proportion at the time of the first survey; P2 = the proportion at some future date such that the quantity (P2 – P1) is the size of the magnitude of change it is desired to be able to detect; P = (P1 + P2)/2; 2 2 = (P2 – P1) = the z-score corresponding to the probability with which it is desired to be able to conclude that an 1 observed change of size (P2 – P1) would not have occurred by chance; and = the z-score corresponding to the degree of confidence with which it is desired to be certain of 1 detecting a change of size (P2 – P1) if one actually occurred. = 0.05 ( 1 = 1.65) and = 0.20 ( 1 = 0.84) To determine the sample size necessary to detect a change of 15 percentage points, for several different indicators, the initial value of (P1) was estimated at 50% (this was a conservative estimate, which yielded the biggest sample size). The design effect, D, was estimated at 2 because of the cluster design used to sample the target groups. The level of precision was set at 0.05. 2.1.3 Sample size and sampling procedure for target groups A summary of sample size for each target group is shown by region in Annex 1. A. Youth The following definitions were given to in- and out-of-school youth. • In-school-youth (ISY) were unmarried, daytime high school students attending grades 9-12 or vocational training schools. ISY were 15 to 19 years old; students out of this age range were excluded from the survey. • Out-of-school youth (OSY) were 15 to 24 years old. They did not attend day or night school, were not married, and were unemployed or employed informally. Some high school graduates were considered as OSY if they completed high school in or before the year 2000 (1992 EC) and fulfilled the other OSY specifications above. Since the age range (15-24 years) was too broad for a behavioral survey, this target group was subdivided into two narrower age groups, 15-19 and 20-24 years. OSY (equal numbers of males and females) was surveyed in all ten regions and Dire Dawa Administrative Council (AC). Due to limited resources, ISY (equal numbers of males and females) was surveyed only in the Amhara, Oromia, Somali, Harari and Addis Ababa regions and the Dire Dawa AC. Application of the ‘sample size’ formula yielded a sample size of 267 for each gender, and for each region and AC. Based on the information available from previous surveys, 45-55% of youth were sexually active. The higher percentage (55%) was used for the calculation of sample size for all youth. Based on this information and adjusting for estimated non-response rates of 25% (for OSY) and 10% (for ISY) the necessary sample sizes were 1220 (610 males and 610 females) for OSY and 1100 (550 males and 550 females) for ISY. (a) Sampling procedure: in-school youth (ISY) For ISY, a total of 6600 students were selected (1100 from each target region and AC). The sampling frames for selection of ISY were prepared in consultation with the Federal Ministry of Education, regional education bureaus and respective schools (to obtain details of classes and respective numbers of students in each grade). Probability proportional to size (PPS) was used to select classes at the first stage and then systematic sampling was applied to select students at the second stage. 7 (b) Sampling procedure: out-of-school youth (OSY) For OSY, the number of individuals selected was 14,224; these were sampled from urban centers of each of the ten regions and Dire Dawa AC, and from an additional area in Borena (accessible because of existing non-governmental organization (NGO) program structures). The sampling frames for selection of OSY were prepared using the 1994 Census Report (CSA 1998). Segmentation methods were used for larger regions and the preferred sampling frame for household surveys was the kind used by the Central Statistics Authority (CSA) census bureau, obtained from the most recent population census. This approach had several advantages, notably, the households had already been mapped and numbered within enumeration areas; moreover, the areas had population sizes associated with them that could be used as measures of size during sample selection, making control of the fieldwork easier. In most towns, enumeration areas corresponding with sub-districts (i.e. kebeles) were used as the sampling frame. In cities such as Addis Ababa, Dire Dawa, Harar, Nazareth and Mekelle that had 20 or more kebeles, the segmentation method was applied. In order to provide the required number of kebeles (>20) in the Amhara region and the Southern Nations and Nationalities Peoples Region (SNNPR), the towns of Bahir Dar and Gondar, and Awassa and Dilla, respectively, were coupled so that the segmentation method could be applied. In the smaller regions, i.e. Afar, Somali, Gambella and Beneshangul-Gumuz, the random walking method was applied after selecting a starting point. B. Female sex workers (FSWs) FSWs (15 to 49 years old) in seven urban centers (Addis Ababa, Bahir Dar, Nazareth, Awassa, Gambella, Dire Dawa and Liben-Borena) were targeted in this survey. These FSWs could be broadly divided into three categories: • Bar/hotel-based sex workers– women who were paid by bar/hotel owners as ‘barmaids’ but who also used the bar/hotel to pick up sex clients, and those who were not paid by the bar/hotel owners but visited to the bar/hotel to pick up sex clients. • Home-based sex workers– women who worked from their homes where they were involved in commercial sex work with/without selling local alcoholic beverages. • Street-based sex workers– women who went onto the streets in the evenings to pick up sex clients. Using the ‘sample size’ formula, the required sample size for FSWs was 267 in each site. Since, by definition, all the FSWs had non-regular partners, it was not necessary to increase the sample size. A 25% non-response rate was assumed and thus, sample size for FSWs was 334 (i.e. 267 x 1.25) at each site; this was rounded up to 350. Accordingly, the total sample size required for sex workers was 2100 (i.e. 350 at each site). However, in Addis Ababa a larger number of FSWs was sampled as a baseline for planned interventions. Sampling procedure The choice of sites where the 350 FSWs were selected was not uniform because the cities included in the study contained different numbers of sites where FSWs were found. Working with relevant governmental organizations, NGOs and members of the target group in the different cities, a list of locations where FSWs congregated was established, including the approximate number of FSWs found in each site per day/night. This information helped the estimation of sample size by PPS. Once the ordered lists had been constructed, ‘time-location’ clusters were used to take into account the possibility that sex workers exhibiting different behaviors might work on different nights of the week. The expanded list of locations included ‘high activity’ and ‘low activity’ periods (days and times of each day), along with the number of sex workers that were typically found at each site on those nights. A ‘quota’ approach was used to select sample respondents. This approach specified that a fixed (equal) number of interviews were conducted in each bar/hotel or site. The quota was determined based on the total number of FSWs selected, as well as the minimum number of FSWs estimated to be found in a particular bar/hotel or site. However, in bars where it was anticipated that only a few sex workers were present, all the sex workers were contacted. In contrast, when large numbers of sex workers were expected, a fixed number 8 of sex workers were selected randomly. Take all and targeted snowballing methods were used to select home-based and street-based FSW respondents. C. Farmers and pastoralists For logistic purposes, the study examined farmers (males and females, 15-49 years old) amongst the farming populations of areas where HIV sentinel and demographic surveillance systems were in place (Butajira in SNNPR). Pastoralist (males and females, 15-49 years old) were selected from the Borena pastoral community in Oromia; this community was chosen because of its geographic location and the existing experience of Save the Children–USA in conducting surveys and services amongst the population. Using the ’sample size’ formula, the required sample size for farmers and pastoralists was 267. However, based on the estimate that only 40% of them had non-regular partners, and recognizing that several of the survey indicators concerned only the subsample that had non-regular partners in the past 12 months, the sample size was increased to 665. Moreover, to compensate for an assumed non-response rate of approximately 25%, the sample size was increased to 850. Accordingly, the total sample size required for farmers and pastoralists was 1700 (i.e. 850 from each group). Sampling procedure A two-stage random sampling procedure was applied. The two stages were conducted separately for males and females. At the first stage, PPS was applied to select villages. At the second stage, the random walking method was used to select households. D. Transport workers As a sampling frame, the study examined three types of male transport workers (15 to 49 years old) namely, truckers, intercity bus drivers and minibus taxi drivers; each type included drivers and their assistants. Investigators contacted the Road Transport Authority in Addis Ababa to obtain a list of truck, bus and taxi owners’ associations in Ethiopia. Subsequently, the associations were contacted to obtain lists of drivers and their assistants. Using the ‘sample size’ formula, the required sample size for each type of transport worker (truckers, intercity bus and minibus) was 267. However, on the basis of estimates indicating that 60% of them had non-regular partners, and recognizing that several of the indicators concerned only the subsample that had non-regular partners in the past 12 months, the sample size for each group was increased to 334. Moreover, to compensate for an expected non-response rate of approximately 25%, the sample size was increased further to 600. Accordingly, the total sample size required for transport workers was 1800 (i.e. 600 from each group). Nevertheless, Ethio-Djibouti corridor truckers and their assistants in Logia, Afar were over sampled, because of the logistical importance of this transport route to Ethiopia, so that data for this group would stand alone as a baseline for planned interventions. Sampling procedure For truckers and their assistants, a list consisting of five routes leading in and out of Addis Ababa was assembled. During the mapping process, attempts were made to estimate how many of the trucks would be stopped at checkpoints (namely, Kara (east), Burayou (west), Sululta (north), Alemgena (southwest) and Mojo (south) for trucks traveling in all direction across the country, and at the town of Logia, Afar Region, for truckers and assistants traveling to and from Djibouti). For intercity bus drivers and their assistants, a similar list consisting of five routes was assembled. During the mapping process, investigators obtained daily schedules that indicated the date/time of departure and the size of the intercity buses traveling to and from Addis Ababa at the central bus station in Addis Ababa. Information was also obtained on the number and routes of minibus taxis in Addis Ababa; data were collected from key informants (including drivers, assistants, and minibus owners’ and taxi drivers’ associations) and to a large extent from observations made by the BSS team during the mapping procedure. Two-stage sampling was carried out for each category of transport workers. At the first stage, PPS was used to select taxi routes and time-interval selection was used at the second stage. 9 E. Factory workers National or regional samples of factories and their workers were not surveyed because of resource limitations. Instead, one factory, the Akaki Textile Factory, was identified for the BSS and male/female workers (15 to 49 years old) were selected. Using the ‘sample size’ formula and making the same assumptions as for transport workers, the sample size required for factory workers was 600 (proportional representation was used when deciding the number of males and females to be interviewed). Sampling procedure A list of eligible male and female factory workers (15 to 49 years old) was obtained from the pay roll. This list was used as a sampling frame to randomly (simple random sampling) select 600 factory workers. F. Uniformed services Men (15 to 49 years old) from two branches of the uniformed services were targeted: these were ground forces stationed in the eastern part of Ethiopia (Dire Dawa and Awash) and air force personnel stationed in Debre Zeit. Using the same formula and making the same assumptions as for transport and factory workers, the sample size required for the uniformed services would have been 1200 (i.e. 600 from each group). However, subsequent to the planning stage, at the request of the Ministry of National Defense (MoND), the number of individuals surveyed was increased and consequently, was greater than the sample size necessary for the study. For selection of men from the uniformed services, a two-stage random sampling procedure was applied. Lists of eligible personnel (15-49 years old) were obtained from the commanding officers in Debre Zeit and Harar. These lists were used as sampling frames to randomly select (simple random sampling) the respondents. The study was designed and conducted by the MoND. 2.1.4 Data collection and analysis Data were collected using a standardized pre-coded, pre-tested questionnaire. For each target group, the FHI core questionnaire for BSS was used. Definitions of BSS indicators are summarized in Annex 6. The questionnaire covered the following topics: • Socio-demographic characteristics of the respondents; • Sexual behavior; • Knowledge and use of condoms; • Knowledge about STIs and STI treatment-seeking behavior; • Knowledge, attitudes and opinions about HIV and AIDS, including misconceptions; • Stigma and discrimination; • Perception of risk; and • Exposure to HIV prevention interventions. The questionnaire was adapted (to make it suitable for use in Ethiopia and acceptable to the target populations) and translated into the appropriate local languages. Interviewers were selected from the 10 regions and one administrative council, the uniformed services, and Butajira and Borena for the farmers and pastoralists, respectively. The BSS team of supervisors selected the interviewers, with input from the regional HIV/AIDS secretariats. All interviewers had completed high school and had some previous experience of collecting survey data. Within each area, equal numbers of men and women were included in the team of interviewers. Interviewers were given a one-week training course by the BSS investigators and supervisors, with technical assistance from FHI. The training included: objectives and design of the study; administrative issues (e.g. length of interview, number of interviews/day, reporting systems and salaries); details of the questionnaire; role play; and field practice. At the end of the training period, the questionnaire was pilot tested in Addis Ababa. 10 All problems recognized during the pilot testing of the questionnaire were addressed, including those relating to selection of respondents, feasibility of conducting and completing interviews with the selected respondents, and timing. During the pilot study, it was observed that the interviewers needed to work together with the respective local (kebele) representatives in order to identify respondents in the selected target groups. The kebele representatives acted as guides for each team and introduced the interviewers to the respondents during the survey. The supervisors were graduates of public health and demography, and post-graduate students. They were trained for a week on the objectives, methods and instruments of the survey, including the use of mapping for developing sampling frames for each target group. Roles of the supervisors included: assistance with the mapping process; selection and training of interviewers; coordination and planning of day-to-day activities; contact with concerned officials and individuals; making spot checks during interviews; monitoring the performance of interviewers; editing of errors on completed questionnaires to maintain data quality; and management of survey finances. The BSS investigators also visited the interviewers and their supervisors, and discussed problems that arose in each site during the data collection. Data were entered and cleaned using the Epi-Info (Version 6; EPI6) statistical package. Various statistical packages (EPI6, SPSS and STATA) were used for data analysis. 2.2 Qualitative study 2.2.1 Purpose and objectives The qualitative study was not a separate study but a part of the BSS that aimed to substantiate and complement the quantitative survey. The major purpose was to explain target groups’ perceptions, misconceptions, attitudes, behaviors and knowledge about HIV/AIDS. The objectives were: • to explore knowledge gaps identified and discover reasons for some of the results obtained in the quantitative survey; • to triangulate the major findings of the quantitative survey; • to provide an additional angle for viewing the findings of the BSS and hence create an opportunity for initiating further research in some areas; and iv) to provide additional information for consideration in subsequent rounds of BSS. Qualitative data were collected between August and September 2002, after quantitative data had been collected and most quantitative data analysis was complete. 2.2.2 Methods and target groups Focus group discussions (FGD) and individual in-depth interviews (IDIs) were the major qualitative methods used. The target groups were the youth (ISY and OSY), factory workers, FSWs, farmers, pastoralists and transport workers (truckers, intercity bus drivers and minibus drivers) (see Annexes 5A to D for numbers and characteristics of the FGD and IDI participants). 2.2.3 Questions The questions were formulated to address the following topics: Knowledge • Knowledge about modes of transmission of HIV infection, preventive methods, relationships of STIs with HIV/AIDS and voluntary counseling and testing (VCT); • Misconceptions about HIV/AIDS, modes of transmission and condoms, and impacts of these misconceptions; and • Influence of knowledge, education and religion on behavior related to HIV/AIDS. 11 Attitudes and behavior • Stigma and attitudes towards people living with HIV/AIDS (PLWHA); • Perceptions and practice/behavior related to the prevention of HIV infection; • Risk groups for HIV infection and circumstances and factors facilitating engagement in unprotected sex; and • Perceived risk of behaviors and behavioral change in communities. Interventions • Sources of information about HIV/AIDS, and usefulness and preferences by target group; • Participation in anti-AIDS activities and clubs; and • Suggestions of ways to avert the spread of HIV/AIDS. 2.2.4 Tools and procedures for data collection Detailed guidelines on how to organize and conduct FGDs and IDIs were prepared and discussed with the supervisors. Discussions and the interviews were guided with semi-structured questionnaires, developed after a series of discussions with investigators and stakeholders following the national dissemination workshop on 24-25 June 2002. Supervisors of the BSS quantitative data collection and other similar surveys were involved in the qualitative study team. Participants were selected randomly from the target groups described in the quantitative methodology, with consideration of age, gender, religion and educational level. The regional HIV/AIDS secretariats’ offices assisted in the selection and organization of the qualitative study, as it formed part of the BSS. Participants in the FGDs were not involved in the IDIs. Moderators of the FGDs and IDIs were trained to facilitate discussions and group dynamics. Male and female moderators interviewed and discussed issues with male and female participants, respectively; this arrangement created favorable conditions for the discussions and interviews. Between 8 and 12 participants were included in each FGD. The discussions and interviews were tape-recorded after obtaining consent from the participants. FGDs and IDIs were conducted in places where there were no frequent interruptions. All the FGDs and IDIs were transcribed into the local language, Amharic, before the data were analyzed. 2.2.5 Analysis and write up Consultants amongst the BSS team of investigators produced the final write-up of the data. Tapes, full transcriptions, observation notes and summary sheets were sources for the write-up. 2.2.6 Presentation of results Although, the two parts of the BSS are complimentary, the results of the qualitative study are presented separately from those of the quantitative study. This layout was chosen: to maintain integrity of the quantitative and qualitative methodologies; to retain the narrative qualities of the qualitative data; and to ensure that the results in each section corresponded clearly with the objectives of the quantitative and qualitative parts of the BSS. Some of the major qualitative findings are discussed with corresponding quantitative survey results in Section 5. 2.3 Ethical considerations The BSS protocol was prepared in cooperation with the HIV/AIDS Prevention and Control Office (HAPCO). Investigators ensured that methodologies and procedures included were in accordance with Addis Ababa University (AAU) and the Ethiopian Science and Technology Commission (ESTC) rules governing health research. Ethical clearance was obtained from ESTC. The Family Health International (FHI) Protection of Human Subjects Committee also approved the study protocols for the target groups. 12 Participation of respondents in the survey was strictly on a voluntary basis. Measures were taken to ensure the respect, dignity and freedom of each individual participating in the study. During training of the interviewers, emphasis was placed on the importance of obtaining informed consent (orally) and the avoidance of any kind of coercion. Complete confidentiality for study participants was also emphasized. For example, names of respondents were not recorded anywhere on the questionnaires. 13 3 Quantitative Results 3.1 Youth 3.1.1 Socio-demographic characteristics Interviews were conducted with a total of 14,224 out-of-school youth (OSY) from the ten regions and Dire Dawa Administrative Council (AC). Of the 15- to 19-year-old OSY (constituting 51.1% of all OSY interviewed), 3607 (25.4% of all OSY) were male and 3660 (25.7% of all OSY) were female. Of those between 20 and 24 years old (48.9% of all OSY interviewed), 3503 (24.6%) were male and 3454 (24.3%) were female. For the remainder of this document, the 15- to 19-year-old OSY is referred to as younger OSY and the 20– to 24-year-old group as older OSY. Interviews were conducted with a total of 6210 in-school youth (ISY) from six regions (Amhara, Oromia, Somali, Harari, Addis Ababa and Dire Dawa). Amongst ISY, 3089 (49.7%) were males and 3121 (50.3%) females were interviewed. Age For the younger OSY, mean age was 17.3 years for the males and 17.2 years for the females. For the older OSY, mean age was 21.9 and 21.8 years for males and females, respectively. For ISY, mean ages for males and females were 17.5 and 17.1 years, respectively. Education The median number of years of schooling for ISY, 10 years, was the same for both genders. In most cases (51.4%), parents paid the children’s school fees. The majority (89.4%) of male and female in-school respondents reported that they were never absent during school days. The majority (87.2%) of OSY had at some time in the past attended school. Amongst those who had previously been to school, the median number of years of schooling was 9 years. More males than females reported ever having attended school; this seemed to be the case for both age groups (younger and older). Levels of literacy amongst male and female OSY reflected this trend (see Figure 3.1.1). 100 Percentage (%) 80 60 40 20 0 Illiterate Literate Illiterate 15-19 Literate 20-24 Age group (years) Male Female Figure 3.1.1 Levels of literacy by age and gender – OSY. OSY who did not complete 12th Grade were asked their reason for dropping out of school. The most common reasons given, by both genders, were shortage of money to continue school (19.7%), health 14 problems (12.6%), failed/academic dismissal (11.8%) and refusal to continue school (11.0%). Amongst females, 5.8% discontinued schooling because of pregnancy. Residence Amongst the OSY, the majority of respondents (48.4%) reported that they lived with their parents. Amongst female younger OSY, 18.4% reported that they lived with their employer; in contrast, this was reported by only 5% of their male counterparts. A similar pattern was observed amongst the older OSY, with slightly more females (11%) than males (3%) reporting living with their employer. The majority (70.0%) of ISY (males and females) reported that they lived with their parents; considerable numbers (22.6%) also lived with other relatives. Employment OSY were often engaged in informal employment. They were commonly involved in buying and selling (23.3%) or domestic work (18.8%), or were employed as shop/tea/pastry workers (15.3%). The majority (64.7%) of respondents with informal employment kept most of their earnings for their own use. Support Around 40% of OSY reported that they were supporting other people. Amongst this group, 71.4% were supporting 1-2 adults, 15% supported 3-5 adults, and 1.9% supported more than 5 adults. Moreover, 45% supported 1-2 children, 21.6% supported 3-5 children and 3.2% supported more than 5 children. Mobility Most OSY and ISY had lived in the same area for many years; indicating some degree of stability amongst both groups. Only 1523 (10.9%) of OSY had lived in the area for one year or less and 24.7% for less than five years, whilst 438 (7%) of the ISY had lived in the area for one year or less and 21.8% for less than five years. Greater levels of mobility were observed amongst the female OSY than their male counterparts; the females were more likely to have lived in the area for less than one year (P<0.001); this was the case in both age categories. Religion The majority (72.6%) of OSY was Christian and 26.1% was Muslim. Similarly, 71.4 and 27.2% of the ISY were Christian and Muslim, respectively. Circumcision Amongst the OSY, 82% of males and 68% of females were circumcised; amongst ISY, 97% of males and 51% of females were circumcised. Of the circumcised OSY females, 63.2% had undergone the non-infibulating type of circumcision while 11.2% had been infibulated. Of the ISY, 43 and 11% had undergone non-infibulating and infibulating type of circumcision, respectively. There was regional variation in the prevalence of circumcision for both genders. Male circumcision was common in all regions except in Beneshangul-Gumuz (44.2%) and Gambella (45.9%). Female circumcision was common in all regions except Beneshangul-Gumuz (14.5%) and Amhara (30.8%). The infibulating type of female circumcision was common in the Somali (55.3% of circumcised OSY and 38.5% of ISY) and Afar (14.4% of OSY) regions. 3.1.2 STI/HIV/AIDS related knowledge Knowledge of STIs A large majority of OSY (81.5%) and ISY (95.5%) said they had heard of STIs. Knowledge of the existence of sexually transmitted infections (STIs) was slightly higher amongst males than females. A higher proportion of the older OSY respondents (92% of males and 84% of females) than the younger OSY respondents (80% of males and 71% of females) said they had heard of STIs. Amongst the ISY, 97% of males and 94% of females had heard of STI. 15 All respondents who had heard of STIs were asked which female and male STI symptoms they knew. The most frequently mentioned female STI symptoms were a burning pain on urination and genital discharge, followed by genital ulcers. The most commonly mentioned male STI symptoms were genital ulcers/sores and a burning pain on urination. Knowledge and misconception about HIV/AIDS Knowledge of HIV prevention methods and absence of incorrect beliefs about HIV transmission are the two major indicators presented in this subsection. Amongst the OSY, over 95% of respondents in both age and gender groups reported that they had heard of HIV/AIDS. The proportion of ISY who had heard of HIV/AIDS was 99.9%. Respondents were asked whether they knew of anyone who was infected with HIV or had died of AIDS. Amongst respondents who said they had heard of HIV/AIDS, over half of the younger OSY respondents knew of someone who was HIV infected or had died of AIDS. More than two thirds of the older OSY said they knew someone who was infected with HIV or had died of AIDS. A similar pattern was observed amongst the ISY where 76% of males and 81% of females knew someone who was infected with HIV or had died of AIDS. Those who said they knew someone who was HIV infected or had died of AIDS were asked whether it was a close friend or a relative. Only a very few respondents said it was either of these. About 10 and 12% of OSY and ISY, respectively, responded that they had a relative who was infected with HIV or had died of AIDS whilst about 7% of each group had a close friend in the same situation. Overall, 57.7% of all youth (OSY and ISY combined) knew the three major preventive methods for HIV/AIDS. When disaggregated, around half of the younger OSY (55% of males and 45% of females) knew the three preventive methods; amongst older OSY, 65% of males and 53.7% of females were aware of the three methods. More than two-thirds (70%) of male and 62% of female ISY knew the three major preventive methods. The proportion of younger OSY who knew that people could protect themselves from HIV by always using a condom when having sex tended to be slightly higher amongst male compared with female respondents (67% for males and 61% for females). A slightly higher proportion of male (83%) than female (71%) younger OSY replied correctly that people could protect themselves from HIV by being in a ‘one-to-one’ relationship (faithfulness). Likewise, more male (81%) than female (70%) younger OSY agreed with the statement that ‘people could protect themselves from HIV by abstaining from sex’. Similar knowledge patterns with slightly higher proportions were seen amongst the older OSY (see Annex 2F). About 74% of male and 68.1% of female ISY agreed that consistent and correct use of condoms when having sex could protect people from HIV infection. Having one uninfected faithful sex partner was recognized as one of the prevention methods of HIV/AIDS transmission by 93.5 and 87.0% of male and female ISY, respectively. The proportion of ISY who responded that abstaining from sexual intercourse could protect people from HIV was similar between male and female respondents (94.4% for males and 93.5% for females). Knowledge level, by region, is shown in the summary indicator table (Annexes 2B, 2D and 2F). Knowledge of the three preventive methods amongst ISY was lowest in the Somali region. Amongst OSY, knowledge level was high in Amhara, Tigray and Harari but relatively low in the Gambella, Somali and Afar regions. People’s beliefs or myths about HIV/AIDS play an important role in determining their attitudes towards people living with HIV/AIDS (PLWHA) and practice of preventive methods. Various statements were read out to respondents and they were asked to agree or disagree with each statement (see Annexes 2A-F). Those respondents with at least one incorrect response were identified as having misconceptions. More than three quarters (76.5%) of all youth had at least one misconception about HIV/AIDS transmission (72.1% of males and 81% of females). More OSY (82.2%) than ISY (63.7%) were found to have at least one misconception. Figure 3.1.2 shows the frequency of each misconception amongst the OSY and ISY. Regional differences were observed in the distribution of misconceptions relating to HIV/AIDS. The proportion of OSY with at least one misconception was highest in Afar (90.4%), Tigray (89.9%) and Addis Ababa (89.6%). Amongst ISY, in Addis Ababa (78.8%), Amhara (74.6%) and Somali (73.8%) were found to have the highest levels of misconceptions. (see Figure 3.1.3). 16 Percentage (%) 50 40 30 20 10 0 OSY ISY Target group HIV can be transmitted by eating raw meat prepared by HIV-infected person Consuming local hard liquor and hot pepper can protect from HIV infection HIV can be contracted by eating uncooked egg laid by a chicken that has swallowed a used condom Mosquito bites can transmit HIV HIV can be contracted by sharing a meal with an HIV-infected person A healthy looking person cannot be infected by HIV Figure 3.1.2 Percentage of ISY (15-19 years old) and OSY (15-24 years old) with commonly observed misconceptions. 100 Percentage (%) 80 60 40 20 0 Tigray Afar Amhara Oromia Somali Beneshangul- SNNPR Gumuz Gambella Harari Addis Ababa Dire Dawa National Region OSY (15–24 years old) ISY (15–19 years old) Figure 3.1.3 Percentage of OSY and ISY who, when prompted, voiced at least one misconception about HIV/AIDS transmission. (Note: ISY was surveyed only in the Amhara, Oromia, Somali, Harari and Addis Ababa regions and the Dire Dawa AC). In terms of the ‘no incorrect beliefs’ indicator used by United Nations Program on HIV/AIDS (UNAIDS), which is based on the three most common misconceptions, about half of the OSY and just over half of the ISY respondents correctly rejected all three statements (See Annexes 2A, 2C and 2E). In this study, a combination of composite indicators, knowledge of the three preventive methods and no incorrect belief about HIV/AIDS transmission was used to examine comprehensive knowledge amongst the 17 youth (see Annexes 2A, 2C and 2E). Overall 35.8% of youth had comprehensive knowledge. Comprehensive knowledge was higher in ISY (45%) than in younger OSY (27.2%). Males (41.2%) were more knowledgeable than females (30.5%). Knowledge about condoms Condom use remains one of the key methods to prevent HIV transmission. Over the past years, both government and non-governmental organization (NGO) partners in the response to HIV/AIDS have been involved actively in the promotion of condom use for HIV and STI prevention, and contraception. Knowledge about condoms is an important indicator of HIV/AIDS-related behaviors. A significant proportion of OSY (94.4%) in both age groups reported having heard of male condoms. For the younger OSY a slightly higher proportion of males (96%) than females (87%) had heard of male condoms. An almost equal proportion of males (98%) and females (95%) in the older OSY reported ever having heard of male condoms. Similarly, equal proportions of males and females (>98%) amongst the ISY had heard of male condoms. In comparison, the proportion of youth who reported ever having heard of female condoms was low: 57% of males and 43% of females amongst ISY; 27% of males and 21% of females amongst the younger OSY; and 41% of males and 25% of females amongst the older OSY. Most ISY (94.5%) and OSY (84.2%) knew where to obtain condoms. More males than females knew places where they could obtain condoms. The most frequently mentioned sources of male condoms were shops, pharmacies and hospitals/health centers (see Figure 3.1.4). 100 ISY OSY Percentage (%) 80 60 40 20 0 r e at lth ic in cl y er nt ic in cl ce ng ni an pl ac m ea l/h ta pi os Ba iv Pr ily m Fa H ar Ph op Sh Location Figure 3.1.4 Locations where youth obtain male condoms. The majority (>90%) of respondents (ISY and OSY, and both genders) reported that it took less than 30 minutes to obtain a male condom. Stigma and discrimination Questions were asked to determine the acceptance of PLWHA and levels of stigma and discrimination. Stigma and discrimination against PLWHA was widespread amongst youth with 97.8% of all youth (98.7% of males and 96.9% of females) expressing at least one stigmatizing attitude. Amongst OSY the large majority of males (98%) and females (95%) demonstrated at least one stigmatizing attitude; likewise, the proportion of ISY who expressed at least one stigmatizing attitude was 95% for males and 99% for females. About 24.7% of OSY and 9.1% of ISY believed that a person who was infected with HIV should be quarantined in health care facilities. Furthermore, 79.6% of OSY and 90% of 18 ISY believed that infected students should not continue at school. In fact, the very high levels of stigmatizing attitudes amongst youth revealed by the overall composite indicator were a direct result of the stigmatized responses regarding continuation of schooling. Analysis of results by region showed that stigmatization was widespread in all regions; however, youth in the Beneshangul-Gumuz region had slightly lower levels of stigmatizing attitudes (88.5%). Mother-to-child transmission of HIV/AIDS Most OSY and ISY recognized that HIV could be transmitted from an infected mother to her unborn child (81 and 88%, respectively) and from an infected woman to a child she was breastfeeding (71 and 70%, respectively). Female youth was slightly more knowledgeable than male youth. Individuals, who were aware that HIV could be transmitted to an unborn child, were asked a further question relating to the actions a pregnant woman could take to reduce the risk of HIV transmission to the unborn child. Only 17% of ISY and OSY (20% of males and 13.9% of females; P<0.001) knew that the risk for mother-to-child HIV transmission could be decreased by antiretroviral therapy. When asked to select possible ways that mother-to-child HIV transmission could be reduced (from a list of options), 6% of ISY and 10% of OSY selected ‘abortion’. About 29 and 30% of ISY and OSY, respectively, thought that nothing could be done to prevent the transmission. 3.1.3 Alcohol and drug use In the four weeks preceding interview, 9% of ISY and 29.1% of OSY (22.9% of the younger and 35.6% of the older) had consumed drinks containing alcohol. Regular consumption of alcohol (consumption at least once a week) was reported by 19.5% of the younger OSY (24% of males and 15% of females) and 32.7% of the older OSY (42.8% of males and 22.5% of females). Amongst ISY, 8.9% (10% of males and 7.8% of females) were regular alcohol users. For the OSY, the highest percentages of regular alcohol users were found in the Amhara (48.1%) and Tigray (37.2%) regions and lowest percentages in the Somali (11.8%) and Afar (12.3%) regions. Amongst ISY, the highest and lowest percentages of regular alcohol users were found in the Amhara (19.5%) and Addis Ababa (2.4%) regions, respectively. Overall, 9.7% of ISY (16.4% of males and 3% of females) and 28.5% of OSY (42.2% of males and 14.9% of females) had ever used drugs. Amongst OSY, ‘ever drug use’ was highest in the Somali (48.4%) and Harari (45.1%) and lowest in the Tigray (12.3%) and Amhara (13.2%) regions. For ISY, ‘ever drug use’ was highest in the Harari region (21.2%) and lowest in the Addis Ababa region (3.1%). The proportion of ISY and OSY who had ever used specific types of drugs is shown in Table 3.1.1. Khat was the major drug used by the youth. Table 3.1.1 ‘Ever use’ of specific types of drugs by the youth. Number (%) Khat Females Total Shisha Benzene Hashish Mandrax Cocaine Crack IDU* 92 (2.9) 599 (9.69) 55 (0.9) 11 (0.2) 1 (0.0) 0 (0.0) 0 (0.0) 8 (0.1) 36 (0.6) Males Target group ISY 507 (16.4) Younger OSY 1131 (31.5) 393 (11.0) 1524 (21.2) 280 (3.9) 23 (0.3) 23 (0.3) Older OSY 1837 (52.6) 637 (18.7) 2474 (35.9) 483 (7.0) 10 (0.1) 28 0.4) 4 (0.1) 2 (0.0) 4 (0.1) 1 (0.0) 5 (0.1) 1 (0.0) 59 (0.8) 49 (0.7) *IDU = injecting drug user Amongst ‘ever khat users’, 82.9% of male and 81.3% of female younger OSY used khat regularly. For the older OSY, 88.6% of males and 84.2% of females reported regular use of khat. Amongst ISY, 78.9% of males and 60.9% of females used khat regularly. Comparing between regions, regular khat use by OSY was common in Somali (99.3%) and Harari (92.4%) while it was less common in Amhara (59.3%). For ISY, regular khat use was highest in Harari (87.4%) and Dire Dawa (85.2%) and least in Addis Ababa (41.9%). Figures 3.1.5a and b summarize the regional variations in regular alcohol and khat use amongst ISY and OSY, respectively. 19 Regular alcohol use Regular khat use 100 Percentage (%) 80 60 40 20 0 D i D ar ire ar aw a ba ba sA di Ad H i al m So a ia m ro O r ha Am Region Figure 3.1.5a Regular alcohol and khat use amongst ‘ever users’ by region – ISY. Regular alcohol use Regular khat use 100 Percentage (%) 80 60 40 20 0 ar ar i lla be am a aw D ire D ba ba sA di Ad H G PR uz N um SN l-G gu an sh ne Be i al m So a ia m ro O r ha Am ay ar Af gr Ti Region Figure 3.1.5b Regular alcohol and khat use amongst ‘ever users’ by region – OSY. 3.1.4 Sexual behavior Understanding the sexual behavior of young people is very important since most new HIV infections occur in this group. Premarital sex Abstinence from sex before marriage and delay of sexual debut are important strategies that help to reduce the spread of HIV amongst youth. The proportion of OSY and ISY who had ever had sex was 49 and 16%, respectively. Amongst the younger OSY, 35% of males and 29% of females had ever had sex; in the older OSY, 74% of males and 60% of females had ever had sex. In contrast, amongst the ISY only 19% of males and 13% of females had ever had sex. 20 By region, proportions of younger OSY reporting having had sex were highest in the Gambella region (53.8%) and lowest in the SNNPR (24%). Similarly amongst the older OSY, the proportion was highest in the Gambella (89.7%) and Beneshangul-Gumuz (87.7%) regions, and lowest in Harari (56.6%). Amongst ISY, proportions that reported having had sex were highest in the Oromia region (31.3%) and lowest in the Addis Ababa region (6.5%). Figures 3.1.6a, b and c show, by region and gender, the proportions of younger and older OSY, and ISY who had ever had sex. 100 Male Female Percentage (%) 80 60 40 20 0 l na io at N a aw D ire D ba ba sA di Ad i ar ar H lla be am G uz PR um N l-G SN gu an sh ne Be a i al m So ia m ro O r ha Am ay ar Af gr Ti Region Figure 3.1.6a Percentage of OSY (15-19 years old) who had ever had sex – by region and gender. 100 Male Female Percentage (%) 80 60 40 20 0 l na io at N a aw D ire D ba ba sA di Ad i ar ar H lla be am G uz PR um N l-G SN gu an sh ne Be i al m So ia m ro O a r ha Am ay ar Af gr Ti Region Figure 3.1.6b Percentage of OSY (20-24 years old) who had ever had sex – by region and gender. About 33% of the younger OSY and more than 25% of the ISY had had sex by the time they were 15 years old. The two most common reasons for starting sex were personal desire (68%) and peer pressure (22%). One of the UNAIDS indicators on adolescents is median age at sexual debut. The median age of first sex for older OSY was 18.9 years for males and 19.4 years for females. Data indicated that at 15.5 years old, only 6.6% of males and 10.3% of the females were sexually active; however, by 18.5 years old more males (38.8%) than females (34.7%) were sexually active (see Figure 3.1.7). 21 100 Male Female Percentage (%) 80 60 40 20 0 N D l aw na io at i D ar ire ar a ba ba sA di Ad H i al m So a ia m ro O r ha Am Region Figure 3.1.6c Percentage of ISY (15-19 years old) who had ever had sex – by region and gender. Percentage (%) 100 50 Male 24 .5 23 .5 22 .5 21 .5 20 .5 19 .5 18 .5 17 .5 16 .5 15 .5 14 .5 13 .5 12 .5 11 .5 10 .5 0 Exact age (years) Female Figure 3.1.7 Cumulative percentage of youth who were sexually active at various ages – by gender. Most male ISY (49.3%) and OSY (37.6%) said that their first sexual partner had been close to their own age, on average 16 years old. In contrast, female youth reported that first sexual partners were often considerably older than they were. Accordingly, 44.2% of OSY and 35.9% of ISY reported that their first sexual partner had been 5-10 years older; moreover, 15% of all female youth reported that their first sexual partner had been more than 10 years older. Number of sexual partners Amongst those who had ever had sex, respondents were asked about their non-commercial and commercial partners during the previous 12 months. Non-commercial partners were reported by 52.5% of the OSY (57.5% of males and 46.5% of females) and 52.9% of the ISY (44.9% of males and 64.8% of females). In comparison, far fewer respondents reported having had commercial partners in the past 12 months; commercial partners were reported by only 19.5% of OSY (16.8% of the younger and 20.8% of the older group) and 1.5% of ISY. Amongst those who were sexually active, a smaller proportion of ISY (16.9%) than OSY (35.1% of the younger and 40.9% of the older) reported having more than one sexual partner in the previous 12 months. A greater proportion of male than female OSY had more than one sexual partner in the previous 12 months 22 (49.7% of males and 22.4% of females; P<0.05). The percentage of ISY reporting more than one sexual partner in the previous 12 months (16.9%) was significantly lower (P<0.05) than the corresponding value for either age group of OSY (25.3% of younger OSY and 28.0% of older OSY). Figure 3.1.8 shows the proportion of youth (ISY, and younger and older OSY) in each region that reported having more than one sexual partner during the previous 12 months. By region, the percentages of OSY reporting more than one sexual partner during the previous 12 months were highest in Tigray, Beneshangul-Gumuz and Gambella (61.1, 55.2 and 48.9%, respectively). 100 90 Younger OSY Older OSY ISY Percentage (%) 80 70 60 50 40 30 20 10 0 ll ra ve O a aw D ire D ba ba sA di Ad i ar ar H lla be am G uz PR um N l-G SN gu an sh ne Be i al m So a ia m ro O r ha Am ay ar Af gr Ti Region Figure 3.1.8 Sexually active youth who had more than one partner during the previous 12 months. Condom use Amongst those OSY who had non-commercial partners in the previous 12 months, 55.7% (62.6% of males and 45.4% of females) said that they had used a condom at their last sexual encounter and 39% (44.6% of males and 30.7% of females) had used condoms consistently. During their last sexual encounter with non-commercial partners, 52.4% of ISY (64.2% of males and 40.2% of females) had used a condom and 73.6% (79.2% of males and 64.4% of females) had used condoms consistently during the previous 12 months. Although the proportion of youth who reported using a condom during their most recent sexual encounter tended to be higher amongst OSY than ISY, (56.6 vs. 52.4%, respectively) the difference was not significant. In contrast, consistent condom use was less common amongst OSY than ISY (39.1 vs. 73.6%, respectively; P<0.05). The commonest reasons for non-use of condoms amongst the youth were partner trust (54.4%) and partner objection (9.4%). Figure 3.1.9 shows condom use at last sex with non-commercial partners by ISY and OSY (younger and older groups combined) by region. The numbers, as a percentage of sexually active youth, were highest for OSY in the Harari (79.5%) and Tigray (67.9%) regions and lowest amongst OSY in the Afar (38%) region. Figure 3.1.10 shows the percentages of sexually active ISY and OSY, by region, that used condoms consistently with non-commercial partners during the previous 12 months. Amongst OSY, the percentage using condoms consistently during the previous 12 months was highest in the Harari region (51.4%) and lowest in Dire Dawa AC (22.5%). For the ISY, consistent use of condoms with non-commercial partners was highest in the Somali (94.1%) and lowest in the Oromia (45.6%) region. More male than female youth reported using a condom with their last sexual partner (63.6% of males vs. 45.5% of females; P<0.05). Considering condom use at last sex by type of partner, male youth used condoms more often with commercial partners than with non-commercial sex partners (87.8% with commercial vs. 63.6% with non-commercial partner; P<0.05). 23 100 OSY ISY Percentage (%) 80 60 40 20 0 ar ar i lla be am l na io at N a aw D ire D ba ba sA di Ad H G PR uz N um SN l-G gu an sh ne Be i al m So a ia m ro O r ha Am ay ar Af gr Ti Region Figure 3.1.9 Condom use at last sex amongst sexually active youth. Note: ISY were only surveyed in the Amhara, Oromia, Somali, Harari and Addis Ababa regions and the Dire Dawa AC. Percentage (%) 100 OSY ISY 80 60 40 20 0 l na io at N a aw D ire D ba ba sA di Ad i ar ar H lla be am G uz PR um N SN l-G gu an sh ne Be a i al m So ia m ro O r ha Am ay ar Af gr Ti Region Figure 3.1.10 Consistent condom use with non-commercial partners in the last 12 months amongst sexually active youth. 3.1.5 STI and treatment seeking behavior Amongst the sexually active respondents, few (4.7%) reported ever having had a STI. When the younger and older OSY were asked whether they had ever had genital discharge or genital ulcers/sores, around 4 and 5% reported the respective symptoms. Amongst ISY, less than 2% of sexually active respondents reported having had the symptoms in the previous 12 months (see Table 3.1.2). 24 Table 3.1.2 Percentage of sexually active respondents who reported having had STI symptoms in the previous 12 months – by target group. ISY Symptom Genital discharge Genital ulcers/sores Males (n = 274) 1.8 1.4 Females (n = 257) 0.8 0 Percentage Younger OSY Males Females (n = 783) (n = 574) 5.7 6.1 3.3 3.3 Older OSY Males Females (n = 1679) (n = 1026) 5.2 5.6 3.2 3.2 Respondents who said they had experienced symptoms of STIs in the past year were asked whether they sought medical treatment. Around half of the respondents sought medical treatment from health institutions, mainly at a health center or hospital. Notably, around 20% of the respondents reported that they stopped having sex when they had the STI symptoms. Only, 10% said that they told their sexual partners about the STI and less than 5% reported condom use when having sex during that period. Traditional medicine was sought by 15.5% of OSY but none of the ISY. 3.1.6 HIV testing Amongst OSY, 26.9% of males and 29.5% of females said that they knew where they could get a confidential HIV test in their community. Amongst ISY, 31.5% of males and 29.1% of females knew that the service was available in their communities. Key indicators used in this study included the proportion of respondents reporting that they had undergone voluntary HIV testing and the proportion that had obtained the result of their test. In general, very few youth (4.6%) reported ever having had an HIV test. Data indicated that only 3.3% of the younger OSY and 6.6% of the older OSY had ever had an HIV test. Comparable proportions of ISY (4%) said that they had been tested for HIV. Almost all of those tested said the testing was voluntary. All respondents who reported having undergone voluntary HIV testing obtained the results of their test. The majority (2.6%) of respondents who had taken an HIV test reported that their most recent VCT was undertaken within the past year; this was true for all age and gender groups. 3.1.7 Exposure to interventions Use (at least once a week in the previous four weeks) of the different types of media was examined. A considerable proportion of OSY and ISY (59 and 77.9%, respectively) listened to the radio; similarly, 63 and 80.6% of OSY and ISY, respectively, watched television. In comparison, smaller proportions of OSY (23.1%) and ISY (32.7%) read printed media. Respondents who had heard of HIV were asked whether they had heard or seen HIV/AIDS messages on radio or TV, or seen the messages in print during the previous 12 months. Amongst ISY, 93.1% reported that they had heard HIV/AIDS messages on the radio and of these the majority (87.5%) felt that the messages were clear. A large percentage (86.8%) of ISY had seen HIV/AIDS messages on television and of these 80.8% commented that the TV messages were clear. Some 63% of ISY read about HIV/AIDS in the printed media. The most commonly read types of printed media were brochures/leaflets (66.6%) and newspaper articles (47.7%). Exposure to HIV/AIDS messages in the media was lower amongst OSY than ISY. Amongst OSY, 76% had heard about HIV/AIDS on the radio and 71% had seen TV messages. The majority (90%) of OSY who had heard or seen HIV/AIDS messages on radio or television said the messages were clear. About 43% of OSY read about HIV/AIDS in the printed media. The most commonly read types of printed media were brochures/leaflets (62.5%) and newspaper articles (52%). Amongst ISY and OSY, there was regional variation in the coverage of radio, television and printed media messages relating to HIV/AIDS. Nevertheless, over two-thirds of the ISY and OSY reported that they had been exposed to messages on HIV/AIDS in the mass media (see Figures 3.1.11a and 3.1.11b). 25 Radio TV Print 100 Percentage (%) 80 60 40 20 0 N D aw l na io at i D ar ire ar ba ba sA di Ad H i al m So a ia m ro O r ha Am a Region Figure 3.1.11a Exposure of ISY to HIV/AIDS messages through the mass media – by type of media and region. Radio TV Print 100 Percentage (%) 80 60 40 20 0 ar ar i lla be am l na io at N a aw D ire D ba ba sA di Ad H G PR uz N um SN l-G gu an sh ne Be ia al m So a ia m ro O r ha Am ay ar Af gr Ti Region Figure 3.1.11b Exposure of OSY to HIV/AIDS messages through the media – by type of media and region. 3.1.8 Relationship between knowledge, behavior, VCT and perception of risk The relationship between knowledge and behavior was investigated. Figure 3.1.12 shows the gap between knowledge and behavior amongst the youth. More than 60% of the older OSY had had premarital sex despite knowing that abstinence could protect them from HIV/AIDS. Over 33% of the OSY who knew the message ‘Be faithful’ had had more than one partner in the previous 12 months. However, ISY who knew that consistent condom use could protect them from HIV/AIDS had almost always used condoms during non-commercial sexual encounters in the previous 12 months. Compared with OSY, the ISY who had correct knowledge about HIV/AIDS prevention methods seemed to exhibit safer sexual behaviors. This seemed to indicate that education played an important role in converting knowledge into practice (sexual behavior). The gap between knowledge and behavior was shown clearly by data for older OSY; this group knew that abstinence and monogamy were protective against HIV infection but were still likely to have premarital sex and more than one partner in the last year. The practice of risky sex was also examined amongst OSY and ISY. Amongst all youth, 17.4% reported having had risky sex, with a commercial or non-commercial partner, in the previous 12 months. More male 26 ISY (15-19 years old) OSY (15-19 years old) OSY (20-24 years old) 0 20 40 60 80 Percentage (%) Knows 'C - Condom use' but didn't use condoms in all non-commercial sex Knows 'B - Faithfulness' but had more than one sexual partner in the last 12 months Knows 'A - Abstinence' but had premarital sex Figure 3.1.12 ABC vs. sexual behavior amongst ISY and younger and older OSY. youth was engaged in risky sex than female youth (19.4% of males vs. 16.1% of females; P<0.05). Figures 3.1.13a and 3.1.13b show regional variation in the percentages of OSY and ISY who reported having risky sex during the previous 12 months. Percentage (%) 100 OSY- sex in last year OSY - risky sex 80 60 40 20 0 l na io at N a aw D ire D ba ba sA di Ad i ar ar H lla be am G uz PR um N l-G SN gu an sh ne Be i al m So a ia m ro O r ha Am ay ar Af gr Ti Region Figure 3.1.13a Percentage of sexually active OSY who had risky sex in the last year – by region. The highest levels of risky sex were reported by OSY in the Gambella (35.6%), Beneshangul-Gumuz (26.3%) and Afar (25.6%) regions. Amongst ISY, around 6% had been engaged in risky sex in the previous 12 months. The most common reason all youth gave for engaging in risky sex was that they trusted their partner. More than half of the ISY and OSY respondents didn’t use a condom the last time they had sex with a non-regular partner because they trusted their partner. Amongst those with more than one partner, 72% had engaged in risky sex during 27 100 ISY - sex in the last year ISY - risky sex Percentage (%) 80 60 40 20 0 N D na io at i D ar ire ar l aw a ba ba sA di Ad H i al m So a ia m ro O r ha Am Region Figure 3.1.13b Percentage of sexually active ISY who had risky sex in the last year – by region. the previous 12 months. These findings were examined in relation to use of VCT services. Data showed that VCT services had been used by <4% of the youth reporting risky sex in the last year. The effect of regular alcohol and khat use on sexual behavior amongst the youth was also examined. Amongst those who reported having had risky sex in the previous 12 months, 44% used alcohol and khat regularly. In general, levels of risky sex were lower amongst youth who had seen HIV/AIDS messages in the mass media during the last year. HIV/AIDS information seemed to have had more impact on the ISY and younger OSY than on older OSY (see Figure 3.1.14). OSY (20-24 years old) OSY (15-19 years old) ISY 0% 10% 20% 30% Information helped change behaviour 40% 50% 60% 70% 80% 90% 100% Interesting, but didn’t change behaviour Figure 3.1.14 Perceived effects of exposure to mass media HIV/AIDS messages on incidence of risky sex in the last year amongst ISY, and younger and older OSY. Most youth respondents (93.5%) felt that they were not at risk or were at low risk for HIV infection. This was even true for OSY who reported having had risky sex (22.3%) in the last year (see Figure 3.1.15). Amongst OSY who reported having had risky sex in the previous 12 months, a higher proportion of OSY in Somali (94.5%), Dire Dawa (93.4%) and Harari (91.8%) said that they felt at no or low risk for HIV/AIDS 28 National Dire Dawa Addis Ababa Harari Gambella SNNPR Beneshangul-Gumuz Somali Oromia Amhara Afar Tigray 0% 10% 20% 30% 40% Feel at no risk or low risk for HIV 50% 60% 70% 80% 90% 100% Feel at medium or high risk for HIV Figure 3.1.15 Perception of risk for HIV infection amongst OSY who had risky sex in the previous 12 months. compared with those in other regions. Of the ISY who had risky sex in the last year (6% of total), only 21% felt at moderate or high risk for HIV/AIDS. 3.2 Female sex workers 3.2.1 Socio-demographic characteristics Interviews were conducted with a total of 2487 female sex workers (FSW) from seven urban centers in Ethiopia (namely, Bahir Dar, Nazareth, Liben-Borena, Awassa, Gambella, Addis Ababa and Dire Dawa). Amongst the FSW, 1266 (51.1%) were hotel/bar-based, 972 (39.2%) were home-based and the remaining 240 (9.7%) were street-based. Table 3.2.1 summarizes the socio-demographic characteristics of the FSWs. Age Respondents were between 15 and 49 years old (mean and median = 22.2 and 21.0 years old, respectively). The majority of respondents (44.6%) were between 20 and 24 years old. Notably, however, about 30% of the respondents were young women between 15 and 19 years old. Education About 74% of the respondents had attended school. Mean number of years of education was 7.1 years (median = 7 years), indicating that considerable numbers of the FSWs were literate. The proportion of illiterate FSWs (52.9%) was higher in Bahir Dar than in the other urban centers (see Table 3.2.1). Marital status Amongst the FSWs, 41.7% had ever been married. FSWs were between 7 and 29 years old at first marriage (median = 16 years old). Most respondents (88.6%) had married when they were <19 years old; notably, 43.7% of respondents had married at <15 years old. Only 3.8% of the FSWs were married at the time of the interview. Most of the FSWs (77.4%) were not married and did not live with a sexual partner; nevertheless, some unmarried FSWs (18.1%) were living with a sexual partner. Very few FSWs reported that they were currently married and living with their spouse (0.4%). A further 0.6% were married but lived with a sexual partner other than their husband. 29 Table 3.2.1 Socio-demographic characteristics of FSW by city. Percentage of FSWs Variables Age group (years) 15–19 20–24 25–30 >30 Education Illiterate Read & write 1–4 years 5–8 years 9–10 years 11–12 years 12+ years Currently married Living with spouse Living with other sexual partner Not living with spouse or other sexual partner Currently unmarried Living with sexual partner Not living with sexual partner Lived in current place (years) Less than 5 5–10 More than10 Circumcision (Yes) Type of circumcision Non-infibulation Infibulation Do not know type Bahir-Dar (n=344) Nazareth (n=338) LibenBorena (n=350) 32.5 34.6 18.3 14.5 37.6 41.1 14.5 6.8 24.4 41.1 17.5 17 24.9 51.6 18.7 4.7 33.6 47.2 15.3 4 31.5 43.3 17.7 7.4 29.5 53.8 14.5 2.3 30.5 44.6 16.7 8.2 52.9 1.5 10.5 26.5 6.9 1.5 0.3 21.9 1.2 12.7 44.3 17.3 2.3 0.3 29.8 0.6 14.9 38.9 11.7 3.4 0.6 10.3 2.3 19.3 44.3 15.5 8.3 0 21.6 1.7 16.6 43.2 13.3 3.3 0 27.9 1.5 10.6 33.5 19.8 5.6 0.6 14.7 0.8 16.2 44.2 18.2 5.8 0 25.8 1.4 14.2 38.9 14.9 4.4 0.3 1.5 0.3 0.6 0 0 0 0.3 0.4 1.5 0 0.6 0.6 1.7 0.2 0 0.6 1.5 0.9 3.4 0.9 8.3 4.1 0.3 2.7 37.8 26 15.7 15.5 15.6 11.5 6.9 18.1 56.7 72.8 79.4 82.5 74 81.7 92 77.4 60.8 18.1 21.1 63.3 80.8 10.9 8.3 74.9 67.6 10.3 22.1 82.6 89.6 9 1.4 85.6 82.8 12.5 4.7 89.4 64.6 18.9 16.5 72.8 81.9 8.8 9.4 74.3 75 12.8 12.2 77.2 25.8 0.5 69.1 53.8 0.4 45.1 75.1 0.7 23.9 99.3 0 0.3 55.8 0.4 43.5 35.3 1.2 46.8 90.3 1.2 8.6 62.9 0.6 32.8 Awassa Gambella Addis Ababa Dire Dawa National (n=460) (n=346) (n=2487) (n=348) (n=301) Residence, mobility and employment The majority (63.5%) of FSWs had been born in urban areas while the rest (36.4%) had been born in the countryside. However, most urban born FSWs (72.9%) were not working in the towns/cities of their birth. Results showed considerable mobility amongst the FSWs. Duration of residence in their current town/city ranged from less than a year to 49 years (median = 2 years of residence). Most FSWs (75.0%) had resided in their current location for <5 years. About 62% of the FSWs had moved to their current locations from other towns/cities where almost 32% of them had previously been sex workers. Only 20.3% of the FSWs reported that they were involved in income-generating activities other than sex work. Commonly, this income-generation involved the sale of local alcoholic drinks (43.6%) or employment at a bar/hotel (38.9%). Support Around 28% of the FSWs reported that they were supporting other people. The number of adults supported ranged from 1 to 19. Around 29% of FSWs who had people to support were supporting 2 adults; a small 30 proportion (2.3%) supported >5 adults. The number of children supported ranged from 1 to 8, with about 37% of FSWs supporting 2 children. Religion Amongst the FSWs, 91% were Christians while 7.1% were Muslims. Circumcision Many of the FSWs (77.2%) were circumcised; a few FSWs (6.0%) did not know whether they were circumcised or not. Around 33% of FSWs did not know which type of circumcision had been performed on them. Amongst those who knew the type of circumcision, non-infibulation was the most common type (reported by 62.9%). 3.2.2 STI/HIV/AIDS and related knowledge Summaries of BSS indicators, and BSS knowledge indicators and components are presented in Annexes 3A and 3B. Knowledge of STI symptoms To assess general knowledge about STIs, all FSWs were asked whether they had heard of diseases that could be transmitted through sexual intercourse. Most FSWs (95.3%) had heard of STIs. Those who were aware of STIs were asked to describe the symptoms of STIs, for men and women separately (N.B. the symptoms were not read out). Table 3.2.2 summarizes the FSWs’ responses. For STI in women, the most commonly mentioned symptoms were genital discharge, followed by burning pain on urination and foul smelling discharge. For STI in men, genital discharge was also the most commonly mentioned symptom, followed by burning pain on urination and genital ulcers/sores. Table 3.2.2 Knowledge of STI symptoms amongst FSW who were aware of the existence of STIs. Variables Know female STI symptoms Genital discharge Burning pain on urination Foul smelling discharge Genital ulcers/sores Abdominal pain Swelling in groin area Itching Others No response Know male STI symptoms Genital discharge Burning pain on urination Genital ulcers/sores Swelling in groin area Others No response Percentage of total (n = 2371) 51.6 48.5 41 29 25 15.1 12.5 7.1 9.9 45.7 39.6 34.8 20.4 11.3 15.1 Knowledge and misconceptions about HIV/AIDS The vast majority (98.2%) of FSWs had heard of HIV or AIDS. About 70% of FSWs said that they knew someone who was infected with HIV or had died of AIDS. Amongst this group of respondents, 7.0% said it 31 was a close relative and 21.9% said it was a close friend; 65.4% said it was neither a close friend nor a relative. Misconceptions about HIV transmission and knowledge of HIV prevention methods were used to indicate the FSWs’ knowledge about HIV/AIDS. Amongst FSWs, 66.7% identified all three major methods for preventing HIV/AIDS. The majority (85.5%) of FSWs knew that correct and every time use of a condom when having sex was one of the three ways to prevent HIV/AIDS. Faithfulness with one uninfected partner and abstinence were mentioned as prevention methods against HIV/AIDS by 80.1 and 79.3% of FSWs, respectively. However, for FSWs, consistent condom use to reduce the risk of contracting HIV is the only appropriate primary prevention method. Overall 89.7% of the FSWs had at least one misconception. Over half (53.4%) of the respondents believed that mosquito bites could spread HIV. Moreover, 23.2% of FSWs believed that sharing a meal with a person who is infected with HIV could transmit the virus. Another 23.1% of the FSWs did not think that a healthy looking person could be infected with HIV. With regard to local (country-specific) misconceptions, about 77 and 53% of respondents, respectively, thought that HIV could be acquired by eating raw eggs laid by a chicken that had swallowed a used condom or by eating raw meat prepared by a person infected with HIV. Another 20% of the FSWs believed that people could protect themselves from HIV by drinking local hard liquor or by eating hot pepper (berbere/mitmita). Most respondents (94.3%) mentioned the shared use of needles as a mode of HIV transmission. In terms of the UNAIDS indicator of ‘no incorrect belief’, which consists of only three of the misconceptions (see Annex 3B), about one third of the respondents correctly identified the misconceptions. Comprehensive knowledge about HIV/AIDS was defined as knowledge of the three prevention methods and absence of misconceptions about HIV/AIDS transmission. By these criteria, only 23.7% of the FSWs had comprehensive knowledge. Between the towns/cities, there were some variations in the knowledge and misconceptions of FSWs about HIV/AIDS (see Figure 3.2.1). For example, knowledge of the three preventive methods was least amongst FSWs in Gambella (45.2%) and highest among those in Dire Dawa (76.9%). Misconceptions about HIV/AIDS transmission (level of incorrect beliefs in terms of the three UNAIDS indicators) were widespread amongst FSWs in Bahir Dar (80.5%), Liben-Borena (78%) and Addis Ababa (75.9%). Notably, despite relatively high levels of HIV intervention activities, FSWs in Addis Ababa were amongst the least knowledgeable; this was true in terms of knowledge of preventive methods, levels of misconceptions and the total score for comprehensive knowledge about HIV/AIDS. FSWs in Dire Dawa had fewer misconceptions than FSWs in other towns/cities. 100 Percentage (%) 80 60 40 20 0 ire ve O D ra aw a na Had no incorrect beliefs Figure 3.2.1 Knowledge and misconceptions of FSWs by city. 32 Had comprehensive knowledge ll D lla be am e or h et sa as ar ar ba ba sA di Ad G Aw az rD hi B nbe Li N Ba City Knew three preventive methods Knowledge about condoms FSWs were asked about their awareness of and accessibility to condoms. Nearly all FSWs knew about male condoms. Even amongst those respondents who had never used condoms (n = 182), 83% said that they had heard of them. The majority of FSWs (99.3%) said that they knew where they could obtain male condoms; the most commonly mentioned sources were shops (87.8%), bars/hotels (57.2%), pharmacies (45.2%), health centers/hospitals (31.7%) and family planning centers (20.4%). According to 95.9% of FSWs, male condoms were available at locations close to (i.e. <30 min away from) their living or work places. At the time of the interview, the number of condoms in the possession of each FSW ranged from nil (23.8%) to 402 condoms (one person), with a median of three condoms. Less than half of the FSWs (43.6%) had heard of female condoms. Overall, slightly higher proportions of street-based FSWs (59%), and FSWs in Dire Dawa (56.3%) and Addis Ababa (51.5%) had heard of female condoms. Stigma and discrimination Various questions relating to stigma and discrimination (see Annex 3B) were used to assess FSWs’ attitudes towards PLWHA. Most respondents (87%) were willing to care for relatives who become ill with AIDS. Moreover, most FSWs (77.7%) felt that if a member of their family had AIDS it should not be kept a secret. Nevertheless, a considerable amount of discrimination towards PLWHA was observed. Overall, 88.1% of the respondents had at least one stigmatizing attitude towards PLWHA. Amongst FSWs, 44.3% were unwilling to share a meal with a person they knew who had HIV/AIDS. Furthermore, 62.7% said that they would not be willing to buy food from a shopkeeper or food seller who was known to have HIV. In addition, 68.5% thought that PLWHA should be quarantined in health care facilities. Figure 3.2.2 indicates the proportion of FSWs in each city who had at least one stigmatizing attitude towards PLWHA. Data show variation amongst the attitudes of FSWs in the different cities; stigma and discrimination seemed to be least amongst FSWs in Awassa. 100 Percentage (%) 80 60 40 20 0 ire ve O D ra aw ll D lla be am na a e or h et sa as ar ar ba ba sA di Ad G Aw az rD hi B nbe Li N Ba City Figure 3.2.2 Percentage of FSWs with at least one stigmatizing attitude towards PLWHA – by city Mother-to-child transmission of HIV/AIDS FSWs were asked various questions relating to mother-to-child transmission of HIV. The majority of respondents (83.6%) knew that a woman who was HIV positive could transmit the virus to her unborn child. 33 Amongst this subgroup, the majority (85.1%) knew that a woman with HIV could transmit the virus to her newborn child through breast-feeding (see Annex 3B). Respondents who were aware that HIV could be transmitted to an unborn child were asked what actions a pregnant woman could take to reduce mother-to-child transmission of HIV. Only 9.5% of FSWs who were asked this additional question said that the woman could take antiretroviral (ARV) medication. Other responses given by the FSWs were abortion (13.9%), nothing could be done (36.6%) and don’t know (21.0%). Results indicate that most respondents had no idea that it was possible to reduce mother-to-child transmission during pregnancy. 3.2.3 Alcohol and drug use Overall, 79% of the FSWs had consumed drinks containing alcohol in the previous four weeks. This subgroup of respondents was asked about the frequency of their drinking; 72% of them reported regular alcohol use and about 33% reported that they drank alcohol everyday. More than half (56.1%) of the regular alcohol users were based in hotels or bars, 36% of them were home-based and the rest (7.9%) were street-based. Amongst the FSWs who drank any alcohol during the previous four weeks, the highest levels of regular alcohol use were found amongst FSWs in Awassa (89.7%) and Nazareth (88.5%); the smallest proportion of regular alcohol users (44.3%) was found amongst FSWs in Addis Ababa (see Figure 3.2.3). Regular alcohol use Regular khat use 100 Percentage (%) 80 60 40 20 0 Ba hi rD N az ar ar et h Li be nB Aw or e na as sa G am be lla City Ad di sA ba ba D ire D aw O ve a ra ll Figure 3.2.3 Regular alcohol and khat use amongst ‘ever users’ – FSWs by city. Overall, 52.2% of the respondents had ever used a drug. The most commonly mentioned drug was khat (51.7%), followed by shisha (8.8%) and hashish (1.2%). Table 3.2.3 shows the proportion of FSWs who had ever used each specific type of drug. Table 3.2.3 ‘Ever use’ of specific types of drugs by FSW. Category of FSW Hotel/bar-based Home-based Street-based Khat 703 (55.5) 438 (45.1) 141 (58.8) Shisha 114 (9.0) 64 (6.6) 40 (16.7) Benzene 7 (0.6) 7 (0.7) 5 (2.1) Number (%) Hashish Mandrax 12 (0.9) 0 (0.0) 13 (1.3) 0 (0.0) 5 (2.1) 0 (0.0) Cocaine 0 (0.0) 3 (0.3) 0 (0.0) Crack 0 (0.0) 0 (0.0) 0 (0.0) IDU* 8 (0.6) 5 (0.5) 2 (0.8) *IDU = injecting drug user About 80% of those who had ever used khat had used khat regularly during the previous four weeks. A very high proportion of FSWs in Dire Dawa (96.9%), Awassa (93.2%) and Nazareth (91.4%) had used khat 34 regularly during the previous four weeks. The smallest percentage of regular khat users was observed amongst FSWs in Gambella (40%). More than 66% of the FSWs were regular khat and alcohol users. 3.2.4 Sexual behavior Amongst those FSWs who knew/remembered the age at which they first had sex, 90.8% reported that they were <19 years old. Worryingly, 49.9% reported that they were £ 15 years old. Age when respondents first received money for sex ranged from 10 to 40 years old (mean and median = 19.2 and 19 years old, respectively). A small group of FSWs (8.2%) started to sell sex when they were £ 15 years old. On average, street-based FSWs started selling sex at younger ages than their hotel/bar- or home-based counterparts (18.2 vs. 19.2 and 19.5 years old, respectively, for street-based vs. hotel/bar- and home-based FSWs; P<0.001). The most commonly mentioned reasons for becoming a sex worker were financial problems (36%), divorce/separation (18.4%) and disagreement with people they lived with (18.4%). A further 14% of the respondents said that they personally chose to become FSWs. The amount of money received by FSWs in exchange for sex varied greatly, ranging from no charge to ETB 800 (US$ 1 = ETB 8.5 in May 2002). The FSWs received an average payment of ETB 41.7 the last time they had sex with a client. Accordingly, 52.1% of the FSWs reported that the last time they had sex with a client they had received between ETB 21 and 50. A lesser proportion (18.4%) of FSWs received between ETB 11 and 20. About 6% of the respondents reported receiving ETB 5 or less. On average, home-based FSWs had received smaller payments than their street- or hotel/bar-based counterparts the last time they had sex with a client. (ETB 20.2 for home-based vs. ETB 54.5 for street-based and ETB 55.1 for hotel/bar-based FSWs; P<0.001). Number and type of sexual partners FSWs were asked about their sexual partners in the previous seven days. They were asked how many of their partners were ‘paying clients’ and how many were ‘non-paying partners’. FSWs reported having between nil and 84 paying clients in the previous seven days (median = 3 clients). A small proportion of FSWs (3.9%) reported that they had no clients in the previous seven days and 5.2% of FSWs did not know/remember how many clients they had had. A further 24.7% of FSWs reported having five or more clients over the previous seven days. Figure 3.2.4 shows the proportion of FSWs in the different cities who had 0, 1-4 and >5 clients during the previous seven days. FSWs in Addis Ababa and Nazareth had the highest numbers of clients; 45.1 and 44.8% of them, respectively, had had >5 clients. None 100 1 to 4 5 and above Percentage (%) 80 60 40 20 0 ire ve O D ra aw ll D lla be am na a e or h et sa as ar ar ba ba sA di Ad G Aw az rD hi B nbe Li N Ba City Figure 3.2.4 Numbers of clients reported by FSWs during the previous seven days – by city. 35 About a third (34.5%) of FSWs reported having non-paying partners over the previous seven days, numbers ranged from 0 to 9 (median = one partner). Only 3.5% of FSWs had two or more non-paying partners. A further 8.3% of FSWs didn’t know/remember how many non-paying partners they had had over the previous seven days. The median number of different sexual partners (paying and non-paying) during the previous seven days was three. Five or more different partners were reported by 30% of the FSWs. A few (5.4%) of the FSWs didn’t know/remember how many different sexual partners they had had over the previous seven days. On average, home-based FSWs had had a greater number of sexual partners during the previous seven days than their street- or hotel/bar-based counterparts (8.1 partners for home-based vs. 4.0 for street-based and 3.3 for hotel/bar-based FSWs; P<0.001). Over 90% of the FSWs reported having at least one client on their most recent day of work. Condom use Results relating to condom use were encouraging; 91.6% of FSWs had used a condom the last time they had sex with a paying client. Findings were also positive with respect to the level of influence the FSWs had on condom use; 95.3% of those who used a condom were involved in the decision to use the condom (suggested by FSW in 52% of cases and as a joint decision by FSWs and clients in 43.3% of cases). Disaggregating condom use by FSW category showed that 93.9% of the home-based FSWs as compared with 98.6% of hotel/bar- and street-based FSWs had used a condom the last time they had sex with a paying client. Level of condom use by FSWs at the last sexual encounter with a paying client also showed some differences between the various cities; 100% of FSWs in Dire Dawa but only 80.2% of FSWs in Bahir Dar reported last-sex condom use. Nevertheless, 27.1% of FSWs reported that they did not use a condom the last time they had sex with a non-paying partner; a further 17.5% of FSWs did not remember/respond to the question. The three most common reasons given for not using a condom at the last sexual encounter with a non-paying partner were: trusting the partner (42.2%), partner objection (22.4%) and use of other contraceptives (12.9%). Although only 55.4% of FSWs used a condom with their non-paying partner at the last sexual encounter, 92.3% of them were involved in the decision to use the condom. Table 3.2.4 summarizes the four most common reasons given by the FSWs for non-use of condoms at their last-time sex; data are displayed by partner type (i.e. separately for paying clients and non-paying partners). It is particularly worrying to note that 28.9% of the FSWs who didn’t use a condom said that they had not used condoms with paying clients because they trusted them. Table 3.2.4 Reasons commonly given by FSWs for non-use of condoms at last sexual encounters with paying clients and non-paying partners. Reason given for non-use of condom I trust my partner Partner objected Didn’t think it was necessary I was drunk Used other contraceptives Percentage (%) Paying clients Non-paying partners (n = 161) (n = 76) 28.9 42.2 22.4 22.4 11.8 7.5 9.2 – – 12.9 Consistent use of condoms was also high amongst FSWs. Most FSWs (90.8%) had used condoms with all paying clients during the previous 30 days; moreover, 70.5% of FSWs had consistently used condoms with their non-paying partners during the previous 12 months. Home-based FSWs had used condoms with paying clients less consistently than their hotel/bar- or street-based counterparts (87.8 vs. 94.8%, respectively). There was regional variation in the consistent use of condoms with paying clients; consistent use was highest among FSWs in Dire Dawa (98.6%) and least among those in Liben-Borena (78.0%). Respondents who had not used condoms with their most recent partners (n = 137) were asked whether they had ever used male condoms; 36.5% said they had used condoms previously. 36 During the previous 12 months, 9.7% of FSWs reported that one or more of their sexual partners had forced them to have sex without their consent. Moreover, 13.5% of the respondents reported that they had been forced to have sex with an unknown person at sometime in their lives. 3.2.5 STIs and treatment seeking behavior Respondents were asked whether they had experienced any genital discharge and/or genital ulcers during the previous 12 months. Overall, 4.9% of the FSWs reported having had STIs (genital discharge or ulcer/sore). The proportion of FSWs who had had symptoms of STIs during the previous 12 months is shown in Table 3.2.5. Table 3.2.5 Percentage of FSWs who reported having had an STI in the past 12 months by category. Symptoms Genital discharge Genital ulcers/sores Hotel/bar-based (n =1266) 2.1 1.7 Percentage Home-based (n = 972) 7.4 6 Street-based (n = 240) 2.5 1.7 FSWs who had experienced an STI during the previous 12 months were asked what treatment they had received. A list of treatment behaviors was read out to the respondents and they could answer in one of four ways: yes, no, don’t know or no response. Multiple responses were possible. In general, 83.5% of the FSWs had sought medical care from health service institutions. The two most commonly mentioned health service institutions were government clinics/hospitals (50.0%) and private clinics/hospitals (29.2%). Other actions mentioned included: stopping sexual activities at the time when symptoms were present (20.8%); seeking advice from peers/friends about the symptoms (19.2%); and seeking advice/medicine from a private pharmacy (14.9%). About one in ten (9.2%) of the FSWs with a history of STI sought advice/medicine from a traditional healer or took traditional medicine they had at home. When asked what they did first, 35.6% of FSWs mentioned that they sought advice/medicine from a government clinic/hospital. FSWs were also asked how long they waited after experiencing symptoms before they sought advice/medicine from a health worker in a clinic/hospital; 45.1% said they sought treatment within a week of experiencing symptoms of STIs. Most (79.6%) of the respondents said they had received a prescription for the medicine and the majority (>90%) had obtained and taken all the prescribed medicine. FSWs reported that the cost of STI medication ranged from free treatment to ETB 200 (mean and median = ETB 35.5 and 28.0, respectively); 15.3% of FSWs received free treatment. 3.2.6 HIV testing FSWs were asked various questions relating to HIV testing. These included questions assessing their knowledge of the existence of confidential testing facilities in the community, issues of disclosure of results, voluntary testing and the procedure for obtaining test results. Overall, only 31.1% of respondents said that it was possible to get a confidential HIV test in their community; between towns/cities the percentages varied from 58% in Awassa to 5.8% in Dire Dawa. As few as 7.7% of the sex workers said that they had ever had an HIV test; of these, 73.8% said that testing was voluntary. Most (91.4%) of those who had taken an HIV test reported that they had obtained the results of their test. Not all HIV testing was carried out in conjunction with counseling; for example, only 81.8 and 77.5% of the tested respondents had received pre- and post-test counseling, respectively. Around 60% of the FSWs who had been tested, had taken their most recent test within the previous year. Many FSWs (81.9%) said that they would be willing to undergo VCT if the services were made available to them. 37 3.2.7 Exposure to interventions Respondents were asked about their general exposure to the mass media during the previous four weeks and specific exposure to HIV/AIDS messages in the previous 12 months. Results showed that radio, television and the printed media had been used, at least once a week over the previous four weeks, by 74.4, 38 and 14.9% of the respondents, respectively. Notably, 28.7, 46.6 and 67.9% of the respondents did not use radio, TV and printed media, respectively. Amongst the respondents, 78.1, 61.6 and 26.6%, respectively, had listened to, watched and read messages about HIV/AIDS during the previous 12 months. Most (83%) of the FSWs had been exposed to messages about HIV/AIDS through radio, TV or printed materials. The vast majority of respondents thought that radio and TV messages about HIV/AIDS were clearly stated (93.2 and 94.5%, respectively). Amongst the printed media, the most commonly seen or read articles about HIV/AIDS were those printed on brochures/leaflets (64.6%) followed by those in newspapers (44.7%). Figure 3.2.5 shows the geographic variation in exposure of FSWs to mass media messages on HIV/AIDS issues. Radio messages had reached a considerable proportion of FSWs in all cities, except Gambella. Television messages had reached a considerable proportion of FSWs in Dire Dawa, Nazareth and Liben-Borena cities. In all cities, printed materials were the least penetrative media, although they reached a substantial proportion (42.4%) of FSWs in Awassa. Amongst printed materials, those read most often by FSWs in Awassa were brochures/leaflets (68.7%) and magazine/newspaper articles (51%). Radio Television Printed media At least one media 100 Percentage (%) 80 60 40 20 0 ire ve O D ra aw ll D lla be am na a e or h et sa as ar ar ba ba sA di Ad G Aw az rD hi B nbe Li N Ba City Figure 3.2.5 Percentage of FSWs who had been exposed to mass media messages about HIV/AIDS in the previous 12 months – by type of media. Only 4.1% of the respondents knew of a FSW support group in their community; amongst this group, 52.4% had attended a FSW support group during the previous 12 months. Almost half of the FSWs (48%) had discussed HIV/AIDS with partners, family members or someone from the community. Nevertheless, interaction of the FSWs with targeted community interventions was very poor. Only 15.2% participated in anti-AIDS activities and only 14.5% had been in contact with outreach workers, mostly government health service providers who gave them counseling on HIV/AIDS, in the previous six months. Furthermore, in the previous 12 months, peer educators at social venues (such as youth clubs and religious places) had approached only 15.6% of the respondents. In addition, only 12.4% of FSWs had attended any community events in which issues on HIV/AIDS were discussed or presented. Overall, 60.5% of the FSWs had participated in or had been exposed to at least one of the above community interventions during the previous 12 months. 38 3.2.8 Relationships of knowledge, behavior and perception of risk Analysis of knowledge and misconceptions with respect to socio-demographic factors showed that literate FSWs were about 3-times less likely to have misconceptions than their illiterate counterparts (P<0.001). Level of education had no effect on the FSWs’ knowledge about preventive methods for HIV/AIDS. Exposure to mass media messages about HIV/AIDS was significantly and positively associated with knowledge of the three preventive methods and lack of misconceptions (P<0.001). The relationship between FSWs’ knowledge and sexual behavior was examined. Knowledge that correct and consistent condom use could protect from HIV infection was positively associated with condom use at last sexual encounter with a paying client. Accordingly, 93.8% of FSWs who knew about correct and consistent condom use compared with only 78.3% of FSWs without this knowledge had used a condom at their last sexual encounter with a paying client (P<0.001). Moreover, 92.1% of FSWs who knew about correct and consistent condom use compared with only 81.6% of FSWs (P<0.001) without this knowledge used condoms consistently with paying clients during the previous 30 days. Other factors significantly associated with the use of condoms included education, alcohol and drug use, exposure to media and personal risk perceptions. For example, considerably more literate than illiterate FSWs (97.3 vs. 86.6%; P<0.001) had used condoms consistently during sexual encounters over the previous 30 days. The role of the media in shaping the HIV/AIDS knowledge and practice of FSWs was examined. Most (89%) of the FSWs who had been exposed to HIV/AIDS messages in the previous 12 months, through at least one of the media channels (i.e. radio, TV or printed media), knew that correct and consistent use of condoms during sex could prevent HIV infection; in contrast, only 78% of FSWs who had not been exposed to media messages had similar knowledge (P<0.001). Furthermore, exposure to media messages had a positive effect on the level of misconceptions relating to HIV/AIDS amongst FSWs; there were no misconceptions about HIV/AIDS amongst 34.7% of FSWs exposed to media messages but only 24.4% of those who were not exposed to media messages were without misconceptions (P<0.001). FSWs who were exposed to HIV/AIDS messages, through at least one of the mass media channels, were twice as likely to have used condoms during their most recent commercial sex encounter than FSWs who were not exposed to mass media HIV/AIDS messages (odds ratio (OR) = 2.23; 95% confidence interval (CI) 1.57, 3.18). FSWs were asked to rank their chances of becoming infected with HIV (as no chance, low, moderate or high chance) based on their past sexual and other risk behaviors. Many FSWs (38.3%) could not rank their chance of contracting the HIV infection. However, 16.7 and 15.6% of the FSWs perceived their chances of contracting HIV to be high and moderate, respectively; a further 16.4% said there was a low chance and the remaining 9.7% thought there was no chance that they would become infected. Respondents were asked to give reasons for their personal perceived risk of HIV infection. The majority (86.5%) of FSWs who perceived their risk as nil or low, said that they always used condoms and 35% said sterile needles had been used whenever they had received injections. Amongst the FSWs who perceived their risk of HIV infection as moderate or high, the most common reason given was that they had multiple sexual partners. Other reasons given for personal perceived risk of HIV infection included condom breakage (46.9% of respondents) and sex without a condom (23.1% of respondents). Data indicated that 65.1% of FSWs who practiced unprotected sex at their last commercial sex encounter and 73.7% of FSWs who didn’t use condoms consistently with paying clients during the previous 30 days perceived themselves at medium or high risk of HIV infection. Personal risk perception amongst FSWs was found to be associated significantly with attitudes towards PLWHA. Respondents who perceived their chance of acquiring HIV as moderate or high were three-times more likely to have accepting attitudes to PLWHA than were respondents who perceived their risks as nil or low. Figure 3.2.6 summarizes, by town/city, the FSWs’ personal perceptions of risk for HIV infection. More than 60% of FSWs in the towns/cities of Gambella, Liben-Borena, Nazareth and Bahir Dar perceived their risk of HIV infection as moderate or high. 39 Li Ad be D G di ire nam sA O Aw Bo D ve ar b ba r a aw e e ra ss et l b n l a a ll a h a a az ar N hi rD Ba 0% 20% No or low chance 40% 60% 80% 100% Moderate or high chance Figure 3.2.6 Personal perception of risk for HIV infection amongst FSWs – by city. 3.3 Uniformed services, transport workers, the rural population and factory workers 3.3.1 Uniformed services (ground forces and the air force) 3.3.1.1 Socio-demographic characteristics Interviews were conducted with a total of 1872 men belonging to the uniformed services. Participants were from the two major Ethiopian Defense Forces; ground forces stationed in the eastern parts of Ethiopia (n = 1250) and air force personnel (n = 622) stationed in Debre Zeit. Age Respondents were between 18 and 45 years old (mean and median = 26.2 and 25.0 years old, respectively). The majority (77.4%) of uniformed services participants were less than 30 years old. More than 49% were between 18 and 24 years old. This target group included a small proportion (7.7%) of young people between 18 and 19 years old. Education A significant proportion of the respondents had attended school (72.5 and 93.9% of the ground forces and air force, respectively) indicating that many of the uniformed services respondents were literate. The mean number of years of schooling was 7.0 years for the ground forces and 11.1 years for the air force. Marital status About 43.8% of the uniformed services group had ever been married. Mean age at first marriage was 26.0 years for the ground forces and 27.4 years for the air force. Data indicated that a considerable proportion of the target group had married at £ 20 years old (48.5 and 19.5% of the ground forces and air force, respectively). Amongst the ground forces and air force, 62.9 and 43.4%, respectively, reported that they were not married or living with any sexual partner. Only a few (7.2%) of the ground forces were married and living with their spouses; considerably more of the air force respondents (41.6%) were married and living with their spouses. A greater proportion of ground force than air force personnel was married but currently living alone (26 vs. 6.8%, respectively). Very small numbers reported that they were currently married but living 40 with other sexual partners (0.6 and 0.2% of the ground forces and air force respondents, respectively). In addition, a small proportions of the participants were unmarried but living with sexual partners (3.3 and 7.9% of the ground forces and air force respondents, respectively). Residence, mobility and employment Data showed that the uniformed services, particularly the ground forces, were highly mobile. More than 90% of the ground forces respondents reported that they had been stationed at their current bases for less than a year. In contrast, the air force personnel were less mobile; only 21.7% reported that they had been stationed at their base for less than a year. About one third of respondents (30 and 26.5% of the ground forces and air force, respectively) had been based away from their units for over a month in the previous 12 months Amongst uniformed services participants, the mean number of years of service was 3.4 and 9.1 years for the ground forces and the air force, respectively. The majority of the uniformed services participants (97.6 and 81.4% of ground forces and air force, respectively) were privates and their air force equivalents. Religion Most participants were Christians (83 and 95.3% of ground forces and air force, respectively) whilst 15.6 and 4.0% of the ground forces and air force participants, respectively, were Muslims. Circumcision More than 90% of the uniformed services group was circumcised. 3.3.1.2 STIs, HIV/AIDS and related knowledge Knowledge of STIs Amongst uniformed services respondents, more than 90% were aware of the existence of STIs. Of the group that knew STIs existed, respondents were asked whether they knew any symptoms of STIs. The most commonly mentioned symptom of STI in women was genital discharge, followed by burning pain on urination and foul smelling discharge. For STIs in men, genital discharge was also the most commonly mentioned symptom, followed by burning pain on urination and genital ulcers/sores. Respondents were more aware of male than female STI symptoms. Knowledge and misconceptions about HIV/AIDS Over 99.5% of both ground forces and air force respondents had heard of HIV/AIDS. Amongst these, 60.1% of the ground forces and 84.0% of the air force respondents knew someone who was infected with HIV or had died of AIDS. Of these groups which reported first-hand knowledge of HIV/AIDS, 25.8% of the ground forces and 42.3% of the air force reported that the affected person/people were close relatives or close friends. Knowledge of the three major preventive methods and level of misconceptions and incorrect beliefs about HIV transmission were the major indicators used to assess the knowledge about HIV/AIDS amongst the uniformed services. Knowledge of the three preventive methods was similar in the two defense forces, with 78.5% of ground forces and 73.8% of air force respondents mentioning the three major methods of HIV prevention correctly (see Annex 4A). Various statements (common misconceptions about HIV/AIDS) were read out to respondents and they were asked to agree or disagree with each (see Annex 4B). Those respondents with at least one incorrect response were identified as having misconceptions. Selected UNAIDS indicators of misconception are presented in the summary indicator table (see Annex 4B). Almost all (99.6 and 99.4% of ground forces and air force, respectively) of all the uniformed services had at least one misconception about HIV/AIDS transmission. Amongst the uniformed services, the three major misconceptions relating to HIV transmission were that the virus could be contracted by eating uncooked egg from a chicken that had swallowed a condom (97.2%), eating raw meat prepared by a person infected by HIV (55.5%) and from mosquito bites (41.9%). 41 To assess comprehensive knowledge of the uniformed services, both composite indicators (i.e. knowledge of the three preventive methods and no incorrect belief about HIV/AIDS transmission) were combined. Overall, 33.5% of the ground forces and 48% of the air force had comprehensive knowledge. Knowledge about condoms Amongst uniformed services respondents, more than 95% had heard of male condoms. Of those aware that male condoms existed, 86.9% of ground forces and 69.5% of air force respondents knew where they could obtain condoms. The most commonly mentioned sources were shops and uniformed services health institutions (85.0 and 78.0%, respectively), followed by health centers/hospitals (30.8%) and pharmacies (25.3%). A proportion of respondents (20.0%) reported that they could obtain male condoms from FSWs. Respondents said that they had to travel less than 30 minutes from their respective deployment areas/work places to obtain male condoms. Only 31.6% of ground forces and 43.6% of air force respondents had ever heard of female condoms. Stigma and discrimination Amongst all the uniformed services respondents: 68.9% were not willing to eat food prepared by a person whom they knew to be HIV positive; 62.8% believed that an army officer who has HIV but appears healthy should not be allowed to continue to work in the army; and 61.6% would not buy food from a shop keeper if they knew that he had HIV. Moreover, 51% of the respondents believed that PLWHA should be quarantined in health care facilities. Mother-to-child transmission of HIV/AIDS More than 90% of respondents knew that an HIV infected woman could transmit the virus to her unborn child; this group of respondents was asked to agree or disagree with suggestions of various strategies a pregnant woman could take to reduce the risk of HIV transmission to her unborn child. Only 9.1% replied that taking antiretroviral therapy could reduce the risk of transmission of HIV to an unborn child. However, 30.9% responded that nothing could be done. In general, it was clear that the majority of respondents did not know how to reduce the risk of mother-to-child transmission during pregnancy. Considerable proportions of ground forces (85%) and air force respondents (69%) knew that an HIV infected mother could transmit the virus to her baby through breastfeeding. 3.3.1.3 Alcohol and drug use Regular alcohol drinking coupled with drug use was a risk factor for unprotected sex amongst the uniformed services respondents. Data showed that amongst the ground forces and air force respondents, 47.4% had consumed drinks containing alcohol in the previous four weeks. Amongst all groups of uniformed services respondents, alcohol was consumed regularly (at least once a week) by 22.5%. Fewer respondents had ever used drugs, 13.4% of the ground forces and 10.5% of the air force. Table 3.3.1 shows the percentages of respondents who had ever used various types of drug. Khat was the major drug used by the uniformed services respondents; amongst those who had ever used khat, 16.4% were regular users. Table 3.3.1 ‘Ever use’ of specific types of drugs by uniformed services respondents. Target group Ground forces Air force Khat 167 (13.4) 65 (10.5) Shisha 3 (0.2) 0 (0.0) Benzene 1 (0.1) 0 (0.0) Number (%) Hashish Mandrax 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Cocaine 0 (0.0) 0 (0.0) Crack 0 (0.0) 0 (0.0) IDU* 7 (0.6) 4 (0.6) *IDU = injecting drug user 3.3.1.4 Sexual behavior Across both groups of uniformed services respondents, average age at first sex was 18.8 years. In general, the ground forces were younger than the air force respondents when they first had sex (18.5 and 19.5 years old, respectively; P<0.001). 42 Most (85.2%) of the uniformed services respondents had been sexually active during the previous 12 months. Amongst sexually active respondents in the ground forces, 25.5% had regular partners, 76% reported commercial partners, 11.2% reported non-regular partners with whom they had had sexual relations for less than 12 months and 2.1% reported non-regular partners with whom they had had sexual relations for 12 months or more. The pattern of regular and commercial partners differed markedly between the ground forces and air force respondents. Amongst sexually active air force respondents, 63.4% had regular partners, 21.0% reported commercial partners, 22.0% reported non-regular partners with whom they had had sexual relations for less than 12 months and 3.5% reported non-regular partners with whom they had had sexual relations for 12 months or more. Multiple partners Amongst those who had been sexually active, 63.5% of ground forces and 20.8% of air force respondents reported having more than one sexual partner during the previous 12 months. Amongst the married uniformed services respondents, 52.7% of the ground forces and 10.7% of the air force respondents had had extramarital sex during the previous 12 months. Condom use Amongst the ground forces respondents with regular sex partners, 15% used condoms during their most recent sexual encounter; the same proportion used condoms consistently. Amongst those with commercial sex partners, 91% used condoms during their most recent sexual encounter and 80% used condoms consistently. Amongst ground forces respondents with non-regular partners, 78% used condoms during their most recent sexual encounter and 66% used condoms consistently. Amongst air force respondents with regular sex partners, almost 20% used condoms during their most recent sexual encounter and almost 15% used condoms consistently. Amongst those with commercial sex partners, 88% used condoms during their most recent sexual encounter and 79% used condoms consistently. Amongst those with non-regular partners, 77% used condoms during their most recent sexual encounter and 60% used condoms consistently. There was no indication that condoms were too expensive for use by the uniformed services respondents, a further indicator that male condoms were accessible to this group. 3.3.1.5 STIs and treatment seeking behavior Respondents who reported that they had had symptoms of STIs in the previous 12 months were asked whether they had sought medical treatment (see Table 3.3.2). Amongst this subgroup, 46.3% reported that they sought advice/medicine from a work-place clinic or hospital, while 12.2% sought advice/medicine from a government clinic/hospital. Table 3.3.2 Proportion of uniformed services respondents who reported that they had experienced STI symptoms during the previous 12 months. Symptoms Genital discharge Genital ulcers/sores Percentage Air force Ground forces (n = 220) (n = 706) 4.4 0.9 2.7 1.4 3.3.1.6 HIV testing and exposure to interventions HIV testing Similar proportions (about 47% each) of the ground forces and air force respondents knew places where confidential HIV testing was available. About 16% of the ground forces and 27% of the air force had been tested for HIV; amongst these respondents, 43.5% reported that the test was voluntary, 72% returned to collect their test result and about 33% had been tested during the previous 12 months. Although less than 28% of all uniformed services respondents had been tested for HIV, 97% said that they would be willing to use VCT services in the future. 43 Exposure to interventions Amongst the uniformed services, 75, 82 and 49% of respondents, respectively, listened to radio, watched television and read printed media at least once a week. Of those exposed to the mass media, 93, 89 and 68% of respondents had heard or seen messages about HIV/AIDS on the radio, on TV and in the printed media, respectively, during the previous 12 months; most respondents commented that the messages were clear. Amongst all uniformed services respondents, 65% participated in anti-AIDS activities, 36% had discussed HIV/AIDS with an outreach worker (health service provider) and 46% had discussed HIV/AIDS with a peer group educator. 3.3.1.7 Perception of risk Amongst the uniformed services respondents, 66.0% perceived themselves to be at no or low risk of HIV infection while 16.5% considered themselves to be at moderate or high risk. The most common reasons given for these perceptions by those who perceived themselves to be at low or no risk were as follows: 54.8% said that they always used condoms; 34.0% said that they trusted their sexual partner; and 16.0% said that they practiced abstinence. The most common reasons given by respondents who perceived themselves to be at moderate or high risk were as follows: 51% said they participated in unprotected sex; 28% said they had sex with commercial partners; and 22% said that they had more than one sexual partner. 3.3.2 Transport workers 3.3.2.1 Socio-demographic characteristics A total of 1793 male drivers and their assistants took part in the study; these included truckers and their assistants (n = 746) from the Ethio-Djibouti transport corridor, intercity bus drivers and their assistants (n = 537) from the central bus station and minibus drivers and their assistants in Addis Ababa (n = 510). Hereinafter, the terms truckers, intercity bus drivers and minibus drivers are used to refer to both the drivers and their assistants. Age Many of the drivers and their assistants were over 30 years old (>80% of truckers, >50% of intercity bus, >30% of minibus). The mean age of the respondents was 36.6, 31.0 and 26.7 years for truckers, and intercity and minibus drivers, respectively. Education Nearly all the respondents had attended school (99.1% of truckers, 97.6% of minibus drivers and 97.2% of intercity bus drivers) indicating that many of them were literate. Mean number of years of schooling was 8.8 years for the truckers, 9.0 years for the minibus drivers and 9.1 years for the intercity bus drivers. Marriage and relationships About 46, 21.6 and 56.4% of the intercity bus, minibus and trucker respondents, respectively, had ever been married. The mean age at first marriage was 26.6 years for intercity bus and minibus drivers, and 26.9 years for truckers. For the whole group of transport workers, the median age at first marriage was 27 years. Of the currently married respondents, 58.6% of truckers, 18.6% of minibus drivers and 36.7% of intercity bus drivers reported that they lived with their spouses. Amongst the trucker, minibus and intercity bus respondents, 30.4, 71.0 and 50.5%, respectively, reported that they were not married or living with any sexual partner. Small proportions of the transport workers (7%) were unmarried but living with sexual partners. Moreover, a few of the transport workers reported that they had more than one wife: 8.7, 1.6 and 3.6% of trucker, intercity bus and minibus respondents, respectively. Residence and mobility More than 93% of all the transport workers lived in cities. As was expected, considerable proportions of the long distance transport workers (56% of truckers and 34.8% of intercity bus respondents) had been away 44 from home for more than a month during the previous 12 months; in contrast, only 11.8% of minibus drivers had traveled away from home for similar periods of time. Employment and support Amongst the trucker, minibus and intercity bus respondents, 57.5, 33.7 and 47.5%, respectively, had worked as transport workers for more than 5 years. More than 66% of intercity bus drivers, 59% of minibus drivers and 84.3% of truckers were supporting their families. About 25% of minibus drivers, 17.8% of truckers and 12.5% of intercity bus drivers used less than half of their monthly income to support their relatives. Nearly all of the transport workers were supporting other adults (96.0, 93.8 and 91.0% of truckers, intercity bus and minibus respondents, respectively) whilst more than 70% of the transport workers were supporting one or more child. Religion Most transport workers (79.6, 83.3 and 87.3% of the truckers, minibus, and intercity bus drivers, respectively) were Christians. A smaller proportion (19.3 and 15.5 and 12.1% of the truckers, minibus drivers and intercity bus drivers, respectively) was Muslim. Circumcision More than 96% of the transport workers were circumcised. 3.3.2.2 STI/HIV/AIDS related knowledge Knowledge of STIs Over 95% of all transport workers were aware of the existence of STIs. Of this subgroup, 49.1 and 46.1% could spontaneously name one correct symptom of STIs in women and men, respectively. The most commonly mentioned symptoms of STIs were genital discharge, followed by burning pain on urination and foul smelling discharge. Knowledge and misconceptions about HIV/AIDS More than 97% of all transport workers had heard of HIV/AIDS. Amongst those who were aware that HIV/AIDS existed, over 86% knew someone who was infected with HIV and/or someone who had died of AIDS; 44.5% reported that the infected person/people were close relatives and/or close friends. Amongst trucker, intercity bus and minibus respondents, 61.7, 71.3 and 72%, respectively, were able to name all of the three major HIV preventive methods. Transport workers scored less for their ability to correctly identify misconceptions than for their knowledge of preventive methods. In general, misconceptions reduced the comprehensive knowledge levels of the transport workers. Overall, 61.6% of the respondents had at least one misconception about HIV transmission. The commonest misconceptions about HIV transmission were that the virus could be contracted by eating raw meat prepared by an infected individual (46.3%), by eating uncooked egg laid by a chicken that had previously swallowed a used condom (42.3%) and from mosquito bites (56.6%). Only 42.8, 31.1 and 32.9% of the trucker, intercity bus and minibus respondents, respectively, had comprehensive knowledge about HIV/AIDS. Knowledge about condoms Over 95% of transport workers had heard of male condoms. Amongst these respondents, about 75% knew of places or people from whom they could obtain condoms. The most commonly mentioned sources of condoms were shops (97%), pharmacies (75%), and bars or hotels (>50%). Most of the respondents reported that male condoms were available within a 30-minute journey of their residential area or workplace. About one third of the transport workers (38.1, 34.5 and 32.0% of truckers, intercity bus drivers and minibus drivers, respectively) had heard of female condoms. 45 Stigma and discrimination About two thirds of all transport workers expressed at least one stigmatizing attitude. Many respondents were not willing to share meals with an HIV positive person or to buy food from a shopkeeper or food seller whom they knew was HIV positive (reported by about 25 and 33% of respondents, respectively). Amongst intercity bus, minibus and trucker respondents, 26.4, 19.4 and 21.8%, respectively, thought that HIV infected but seemingly well transport workers should not continue to work. Nevertheless, 95% of respondents said that they were willing to care for male/female relatives who were HIV positive. Mother-to-child transmission of HIV/AIDS Over 84% of transport workers were aware that an HIV infected pregnant woman could transmit the virus to her unborn child. This subgroup of respondents was asked to agree or disagree with suggestions of various strategies a pregnant woman could take to reduce the risk of HIV transmission to her unborn child. Anti retroviral medication (19%) and abortion (12%) were the most frequently selected strategies. A further 28% of respondents thought that nothing could be done. In general, most transport workers had no idea that it was possible to reduce the risk of mother-to-child transmission of HIV during pregnancy. About 70% of the transport workers knew that an HIV infected woman could transmit the virus to her child by breastfeeding. 3.3.2.3 Alcohol and drug use For drivers and their assistants, regular alcohol drinking coupled with drug use was a risk factor for the practice of unprotected sex. In the previous four weeks, 52.5% of transport workers had consumed drinks containing alcohol while 44, 43.2 and 40% of truckers, intercity bus and minibus drivers, respectively, had drunk alcohol regularly. The proportion of transport workers who had ever used specific types of drugs is shown in Table 3.3.3. Across all groups, the most commonly used drug was khat. Moreover, amongst those transport workers who used khat, many chewed khat regularly (82.3, 73.3 and 81.8% of truckers, intercity bus and minibus drivers, respectively). Table 3.3.3 ‘Ever use’ of specific types of drugs by transport workers. Target group Truckers Intercity bus drivers Minibus drivers Khat 293 (39.3) 210 (39.1) 275 (53.9) Shisha 30 (4.0) 33 (6.2) 58 (11.4) Benzene 4 (0.5) 0 10 (2.0) Number (%) Hashish Mandrax 4 (0.5) 4 (0.5) 0 0 0 0 Cocaine 6 (0.8) 0 0 Crack 4 (0.5) 0 0 IDU* 4 (0.5) 2 (0.4) 2 (0.4) *IDU = injecting drug user 3.3.2.4 Sexual behavior Mean age at first sex was 18.5, 19.3 and 20.1 years for minibus respondents, intercity bus respondents and truckers, respectively. The majority of transport workers reported that they had been sexually active during the previous 12 months (82.9, 68 and 81.4% of intercity bus, minibus and truckers, respectively). During the previous 12 months, >48% of the transport workers reportedly had regular sex partners, >13% had commercial sex partners and about 10% had non-regular sex partners. Multiple sexual partners Amongst those who were sexually active, 31.8% minibus of the, 23.2% of intercity bus and 20.8% of truckers respondents reportedly had more than one sexual partner during the previous 12 months. Amongst those who were married, 7.8% of truck, 2.9% of minibus and 7.1% of intercity bus respondents reported having had extramarital sex in the previous 12 months. 46 Condom use Amongst truckers with commercial sex partners, 91% used condoms during their most recent sexual encounter and 84% used condoms consistently during the previous 12 months. Amongst those with non-regular sex partners, 80% used condoms during their most recent sexual encounter and 73% used condoms consistently during the previous 12 months. Amongst intercity bus respondents with commercial sex partners, 97% used condoms during their most recent sexual encounter and 91% used condoms consistently during the previous 12 months. Amongst those with non-regular sex partners, 82% used condoms during their most recent sexual encounter but only 12% used condoms consistently during the previous 12 months. Amongst minibus respondents with commercial sex partners, 98% used condoms during their most recent sexual encounter and 92% used condoms consistently during the previous 12 months. Amongst those with non-regular sex partners, 74% used condoms during their most recent sexual encounter and 51% used condoms consistently during the previous 12 months. There were no indications that condoms were too expensive for the transport workers. 3.3.2.5 STIs and treatment seeking behavior All respondents were asked whether they had experienced any genital discharge and/or genital ulcers during the previous 12 months. Overall, 2% of the transport workers reported having had STIs (genital discharge or ulcer/sore). The proportion of transport workers who had experienced symptoms of STI during the previous 12 months is shown in Table 3.3.4. Table 3.3.4 Proportion of transport workers who reported that they had experienced STI symptoms during the previous 12 months. Symptoms Genital discharge Genital ulcers/sores Truckers (n = 746) 2 (1.0) 1 (0.5) Number (%) Intercity bus drivers (n = 537) 2 (0.9) 0 (0.0) inibus drivers (n = 510) 6 (2.1) 2 (0.7) Transport workers who had experienced an STI during the previous 12 months were asked what treatment they had received. A list of treatment behaviors was read out to the respondents and they could answer in one of four ways: yes, no, don’t know or no response. Multiple responses were possible. Overall, 62.5% of the transport workers had sought medical care from health service institutions. 3.3.2.6 HIV testing and exposure to interventions HIV testing Amongst truckers, 10% had been tested for HIV. Of those tested, 80% said the test was taken voluntarily and 95% returned for their test results; 47% had been tested within the previous 12 months. Amongst all truckers, 80% said that they would volunteer to undergo VCT in the future. Amongst minibus drivers, 35% said that it was possible to get confidential HIV tests. Only 7% had been tested for HIV. Of those tested, 70% said the test was taken voluntarily and all of them returned for their test results; 44% had been tested within the previous 12 months. Amongst all the minibus respondents, 91% said that they would volunteer to undergo VCT in the future. Amongst intercity bus drivers, 36% said that it was possible to get confidential HIV tests. Only 11% had been tested for HIV. Of those tested, 74% said the test was taken voluntarily and all of them returned for their test results; 62% had been tested within the previous 12 months. Amongst all the intercity bus respondents, 93% said that they would volunteer to undergo VCT in the future. Exposure to interventions During the previous four weeks, 77, 55 and 28% of truckers, respectively, had listened to radio, watched TV and read printed media at least once a week. Amongst those who had ever heard of HIV/AIDS, 96, 92 and 73% of truckers had been exposed to HIV messages by radio, TV and printed media, respectively; the majority of these respondents commented that the messages were clear. Amongst truckers, only 12% 47 participated in anti-AIDS activities in their communities, 9% had been in contact with an outreach worker and 26% had discussed HIV/AIDS issues with a peer group educator during the past year. During the previous four weeks, 87, 63 and 37% of minibus drivers, respectively, had listened to radio, watched TV and read printed media at least once a week. Amongst those who ever heard about HIV/AIDS, 96, 86 and 70% of minibus respondents had been exposed to HIV messages by radio, TV and printed media, respectively. The majority of these respondents commented that the messages were clear. Amongst minibus drivers, 25% participated in anti-AIDS activities in their communities, 12% had been in contact with an outreach worker and 29% had discussed HIV/AIDS issues with a peer group educator during the past year. Around 78, 61 and 37% of intercity bus drivers, respectively, had listened to radio, watched TV and read printed media at least once a week. Amongst those who ever heard about HIV/AIDS, 95, 86 and 70% of intercity bus respondents had been exposed to HIV messages by radio, TV and the printed media, respectively. Amongst intercity bus drivers, 23% participated in anti-AIDS activities in their communities, 13% had been in contact with an outreach worker and 39% had discussed HIV/AIDS issues with a peer group educator during the past year. 3.3.2.7 Perception of risk When asked about their perception of risk, 60% of truckers felt that they were at no or low risk for HIV infection because they trusted their partner (60%), had no contact with infected people (20%) or because they practiced abstinence (17%). The small percentage of truckers (3%) who felt at moderate or high risk for HIV infection, said that they perceived their risk level as moderate or high because they had more than one sexual partner or had experienced condom breakage. About 69% of minibus drivers said they felt at no or low risk for HIV infection because they trusted their partner and/or always used condoms. The 11% of minibus respondents who perceived themselves to be at moderate or high risk for HIV infection did so because they had more than one sexual partner and/or practiced unprotected sex. Amongst intercity bus drivers, 70% felt themselves to be at no or low risk for HIV infection because they trusted their sexual partner, regularly used condoms and/or never had any injections. Those who perceived themselves to be at moderate or high risk (7.3%) felt so because they practiced unprotected sex, had more than one sexual partner and/or had sex with FSWs. 3.3.3 Rural population groups (farmers and pastoralists) 3.3.3.1 Socio-demographic characteristics A total of 1489 individuals from two rural population groups were studied: farmers from the locality of Butajira (n = 798) and pastoralists from Borena (n = 703). There were 743 females amongst the rural respondents (61% of total) including 390 farmers and 353 pastoralists. Age Amongst rural groups, considerable proportions of the respondents were over 30 years old (46.9% of pastoralist and 35.2% of farmers); mean ages for the groups were 31.7 years for the pastoralists and 28.5 years for the farmers. Education Many of the rural respondents had not attended school (70.0% of pastoralists and 65.5% of farmers). Amongst those who had attended school, the mean number of years of schooling was 6.9 and 4.6 years for pastoralists and farmers, respectively. Marital status About 70.6% of the farmers and 87.8% of the pastoralists had ever been married. Out of those who reported marriage, 66.9% of the farmers and 79.4% of the pastoralists were currently married and living with their spouse. About 32% of the farmers and 17.8% of the pastoralists were unmarried and were not living with a sexual partner. Age at first marriage was below 20 years for 48.5 and 60.1% of the farmers and pastoralists, respectively. 48 Amongst the married pastoralists and farmers, 26.7 and 17.4%, respectively, had polygamous marriages. Residence and mobility A relatively higher proportion of pastoralists (23.8%) than farmers (2.6%) had been away from home for more than a month in the previous 12 months. Religion About 72% of the farmers and 59% of the pastoralists were Muslims. A further 27.7% of farmers and 13.1% of pastoralists were Christians. About 27.3% of the pastoralists reported ‘no religion’ as compared with only 0.1% of farmers (one respondent). Circumcision About 99% of the farmers and 93% of the pastoralists were circumcised. In the case of females, 100% of the female farmers and 90.6% of the female pastoralists had been circumcised. 3.3.3.2 STIs/HIV/AIDS and related knowledge Knowledge of STIs Amongst the pastoralists, 90.9% had heard of STIs; in contrast, only 20.9% of the farmers were aware that STIs existed. The rural respondents, who knew that STIs existed, were asked whether they knew any symptoms of STIs for men and women, separately (symptoms were not read out to the respondents). Compared with farmers, the pastoralists were better able to name the most common symptoms of STIs. Amongst pastoralists, the most commonly mentioned three symptoms of STIs in women were genital discharge (56.8%), burning pain on urination (71.2%) and foul smelling discharge (40.4%); in comparison, the same symptoms were mentioned by only 11, 12.2 and 2.4% of farmers, respectively. The most commonly mentioned symptoms of STIs in men were genital discharge (57.7% of pastoralists vs. 22.6% of farmers), burning pain on urination (75.5% of pastoralists vs. 26.2% of farmers) and genital ulcers/sores (66.4% of pastoralists vs. 7.9% of farmers). In general, respondents were more aware of male than female STI symptoms. Knowledge and misconceptions about HIV/AIDS Over 95% of the rural respondents were aware that HIV/AIDS existed. Of the respondents who had heard of HIV/AIDS, 76.1% of pastoralists but only 34.7% of farmers knew someone who was infected with HIV and/or had died of AIDS. Amongst this subgroup, 10.3% of the farmers and 17.0% of the pastoralists reported that the affected person/people were close relatives and/or close friends. Amongst farmers and pastoralists, respectively, only 17.7 and 24.5% were able to name all three of the major HIV preventive methods. The three most common misconceptions amongst the pastoralists and farmers were that HIV could be contracted by eating uncooked egg from a chicken that had swallowed a condom (92.3 and 88.5%, respectively), by eating raw meat prepared by a person infected with HIV (66.4 and 65.4%, respectively) and by mosquito bites (54.2 and 64.3%, respectively). These misconceptions lowered the comprehensive knowledge level of the respondents. Only 8.8 and <1.0% of the male and female farmers, respectively, were considered to have comprehensive knowledge of HIV/AIDS; in contrast, 11.7% of male pastoralists and 9.1% of female pastoralists were considered to have comprehensive knowledge. Knowledge about condoms Most pastoralists (84.6%) and 52.2% of farmers had heard of male condoms. Of those who were aware that male condoms existed, considerable proportions (87.9% of pastoralists and 51.4% of farmers) knew where they could obtain male condoms. Only 13.5% of pastoralists and 2.6% of farmers were aware of the existence of female condoms. 49 Stigma and discrimination Indicators used to assess stigma and discrimination are shown in Annex 4B. More than 98% of the rural respondents had at least one stigmatizing attitude (pastoralists 99.3% and farmers 97.4%). Amongst all rural respondents, the three major stigmatizing attitudes were: an unwillingness to buy food from a shop-keeper who was known to have HIV (92.8 and 84.2% of pastoralists and farmers, respectively); a belief that PLWHA should be quarantined (77.1 and 71.5% of pastoralists and farmers, respectively); and an unwillingness to allow PLWHA to participate in community meetings or to allow infected youth to look after cattle (71.2 and 67.8% of the pastoralists and farmers, respectively). Mother-to-child transmission of HIV/AIDS About 79.3% of the pastoralists and 77.4% of the farmers were aware that an HIV infected pregnant woman could transmit the virus to her unborn child; however, only a small proportion of these (9.9 and 2.9% of pastoralists and farmers, respectively) knew that antiretroviral medication could be used to reduce the risk of transmission. Other respondents thought that nothing could be done (45.7 and 42.1% of pastoralists and farmers, respectively). Most rural respondents had no idea that it was possible to reduce the risk for mother-to-child transmission of HIV during pregnancy. More than 80% of the rural respondents were aware that an HIV infected mother could transmit the virus to her baby through breastfeeding. 3.3.3.3 Alcohol and drug use Very few pastoralists and farmers drank alcohol regularly (4.9 and 7.5% of pastoralists and farmers, respectively). Amongst pastoralists and farmers, 27.3 and 47%, respectively, reported ‘ever use’ of khat. Furthermore, amongst those who had ever used khat, 76.2% of the farmers and 62.5% of the pastoralists were regular users. A few pastoralists (2.4%) but no farmers reported ‘ever use’ of shisha. No pastoralists or farmers reported any use of hashish, Mandrax, cocaine, crack, benzene or injected drugs. 3.3.3.4 Sexual behavior On average, farmers and pastoralists had been 19.8 and 17.4 years old, respectively, at sexual debut. Female respondents were younger than male respondents at sexual debut: 17.8 vs. 22.1 years old, respectively, for farmers (P<0.001) and 16.2 vs. 18.7 years old, respectively, for pastoralists (P<0.001). Amongst those who had ever had sex, the majority of respondents (93.5 and 81.2% of farmers and pastoralists, respectively) reported that they had been sexually active during the previous 12 months. Virtually all of these farmers and pastoralists reported having regular sex partners (87.4 and 99.8%, respectively); in contrast, none of the farmers and only 0.28% of the pastoralists reported having had commercial sex partners. A small proportion of pastoralists (12.4%) and only 0.2% of farmers reported having non-regular sex partners during the previous 12 months. Amongst those who were sexually active, 3.8% of farmers and 22.6% of pastoralists reported having had more than one sexual partner during the previous 12 months. Amongst the respondents who were married, only 0.2% of farmers but 15.7% of pastoralists reported having extramarital sex during the previous 12 months. Condom use Only 2 of 703 pastoralists reported having had a commercial sex partner in the previous 12 months; one of these men used condoms with their commercial sex partner. None of the farmers reported having a commercial sex partner and none reported condom use with their regular or non-regular partners. STI symptoms To assess the prevalence of STIs, the respondents were asked whether they had experienced genital discharge and/or genital ulcers/sores in the previous 12 months. Amongst the pastoralists, 11.0 and 2.6%, respectively, reported that they had experienced genital discharge and genital ulcers/sores. However, none of the farmers reported either genital discharge or genital ulcers/sores. 50 3.3.3.5 HIV testing and exposure to interventions HIV testing Amongst farmers, 11% said it was possible to get confidential HIV tests in their community; however, only 0.8% had ever had an HIV test. Of those farmers who had taken an HIV test, 50% said it was voluntary and 50% returned for their test results. Nevertheless, 83% said that they were willing to undergo VCT in the future. Amongst pastoralists, only 1.4% said it was possible to get confidential HIV tests in their community; a similar proportion (1.9%) had taken an HIV test. Of those pastoralists who had taken an HIV test, 85% said it was voluntary and 82% of them returned for their test results. Nevertheless, 77% said that they were willing to undergo VCT in the future. Exposure to interventions Amongst farmers, 40% listened to radio, 3% watched TV and 1.5% read printed media regularly during the previous four weeks. Of those who used the mass media regularly during the previous four weeks, 64% had listened to HIV/AIDS messages on the radio, 4.5% had seen HIV messages on TV and 4% had read about HIV in the printed media; most of these respondents commented that the meaning of the messages was clear. In the previous year, only 2% of farmers had participated in anti-AIDS activities in their communities, 2% had discussed HIV/AIDS with an outreach worker and 17% had discussed HIV/AIDS with a peer educator. Amongst pastoralists, 35, 5 and 0.4%, respectively, listened to radio, watched TV and read printed media regularly during the previous four weeks. Of those who used the mass media regularly during the previous four weeks, 61% had listened to HIV messages on the radio, 25% had seen HIV messages on TV and 4.5% had read articles about HIV; most of these respondents commented that the meaning of the messages was clear. In the previous year, only 10% of pastoralists had participated in anti-AIDS activities in their communities, 16% had discussed HIV/AIDS with an outreach worker and 26% had discussed HIV/AIDS with a peer educator. 3.3.3.6 Perception of risk When asked about their perception of risk, 96% of the farmers reported that they felt at no or low risk for HIV infection because they trusted their partners and had no contact with infected people. A very small proportion of farmers (0.6%) felt at moderate or high risk of HIV infection because they practiced unprotected sex. Amongst pastoralists, 89% felt that they were at no or low risk for HIV infection because they trusted their partners, took no injections and had no contact with infected people. A small proportion (6.3%) of pastoralists felt that they were at moderate to high risk because they had more than one sexual partner, had practiced unprotected sex or had taken ‘unsafe’ injections. 3.3.4 Factory workers 3.3.4.1 Socio-demographic characteristics A total of 599 factory workers, 434 male and 165 female, participated in the study. Age The respondents were between 15 and 49 years old. Most of the factory workers (72.6%) were over 30 years old (mean = 35.1 years old). Education A considerable proportion of the respondents (88.3%) had attended school (mean number of years of schooling = 8.8 years) indicating that most of the factory workers were literate. 51 Marital status More than 70% of the factory workers had ever been married (84.2 and 67.3% of females and males, respectively). For female factory workers, age at first marriage ranged from 9 to 34 years with a mean age of 17.9 years. For male factory workers, age at first marriage ranged from 9 to 38 years with a mean age of 23.8 years. Circumcision Of the factory workers, 95.6% of the males and 84.8% of the females were circumcised. Religion Most of the factory workers were Christians (93.5 and 92.1% of male and female workers, respectively). Only 6.2% of the male and 6.7% of the female factory workers were Muslims. Residence and mobility The majority of the factory workers lived in Akaki. Duration of residence in Akaki ranged from less than one year (2.2%) to 50 years (1.0%). Most of the factory workers (53.7%) had lived in Akaki for more than 24 years (mean and median 25.7 and 25.0 years, respectively). Only 6.7 and 5.5% of the female and male factory workers, respectively, reported that they had been away from their homes for more than a month within the previous 12 months. Employment and support Amongst the factory workers, 19.2% reported that their spouses or sexual partners were employees of the factory. Of those whose spouses or sexual partners were employed at the factory, 23.5% said that they worked the same shifts as their partners. The mean and median monthly incomes were ETB 296.50 and 255.00, respectively. Most of the factory workers (80.1%) reported that they supported someone (children, parents or others). The proportion of monthly income shared with family differed between the factory workers: 19.5% reported that they gave up to half of their monthly income; 38.7% said that they gave more than half; and 11.5% gave all of their monthly income to their family. 3.3.4.2 STIs, HIV/AIDS and related knowledge Knowledge of STIs Most factory workers (95%) had heard of sexually transmitted diseases. Those who had heard of STIs were asked to describe STI symptoms in women and men. The most commonly mentioned symptoms of STIs in women were genital discharge (21.8%), burning pain on urination (17.7%) and foul smelling discharge (12.1%). The most commonly mentioned symptoms of STIs in men were genital discharge (43.2%), genital ulcers/sores (40.9%) and burning pain on urination (37.2%). Knowledge and misconceptions about HIV/AIDS Most factory workers (97.3%) had heard of HIV/AIDS. Of those who had heard of HIV/AIDS, 75.1% knew someone who was infected with HIV and/or had died of AIDS; 39.3% reported that the individual was a close relative and/or a close friend (see Annex 4B). About 55 and 30% of the male and female factory workers, respectively, could correctly name the three major methods for preventing HIV infection. Misconceptions relating to HIV transmission were read out and the respondents were asked to agree or disagree with each statement (see Annex 4B). Respondents with one or more incorrect response were considered to have misconceptions. A summary of the responses to the individual indicator statements (selected from UNAIDS indicators of misconception) is presented in Annex 4B. Nearly all of the factory workers (99.1 and 100% of male and female respondents, respectively) were found to have at least one misconception about HIV/AIDS. The three major misconceptions relating to modes of HIV transmission were that: HIV could be contracted by eating an uncooked egg, laid by a chicken that had previously swallowed a condom (97.4%); HIV could be contracted by eating raw meat prepared by 52 a person infected by HIV (69.4%); and that HIV transmission could be prevented by drinking local alcoholic liquor and eating hot pepper (21%). The composite indicators, knowledge of the three preventive methods and absence of misconceptions about HIV/AIDS transmission, were combined to examine comprehensive knowledge about HIV/AIDS. On this basis, only 19% of the factory workers had comprehensive knowledge. Although many factory workers knew the three major preventive methods, their inability to identify misconceptions greatly reduced the levels of comprehensive knowledge. Knowledge about condoms The majority of factory workers (96.1%) had heard of male condoms. Most of those who had heard of male condoms knew where to get them (84.6%). Shops and pharmacies were the most commonly mentioned sources (90.8 and 61.1% respectively), followed by health centers/hospitals (41.1%), family planning centers (15.7%) and bars/guest houses/hotels (15.1%). A very small number of factory workers (0.6%) reported that they could obtain male condoms from FSWs. Regarding accessibility of condoms, most factory workers (90.0%) reported that they could obtain condoms at locations less than 30 minutes (by foot) from their home or work. There was no indication that condoms were expensive to obtain. Nearly 25% of all the factory workers mentioned that they had heard of female condoms. Stigma and discrimination Amongst the factory workers, 59.2% said that they would be unwilling to buy food from a shopkeeper or food seller if they knew that he/she was HIV positive. Moreover, 40% of the respondents were not willing to share a meal with an HIV positive person. In addition, 27.6% of the respondents believed that if a worker in their factory had HIV but was not sick, he/she should not be allowed to work in the factory. Mother-to-child HIV transmission Most factory workers were aware that HIV could be transmitted from an HIV infected mother to her unborn child (84.3 and 92% of male and female factory workers, respectively). Respondents who knew that HIV could be transmitted from an HIV positive mother to her unborn child were asked what a pregnant woman could do to reduce the risk for transmission of HIV to her unborn child. Possible actions were suggested to which respondents could answer ‘yes’ or ‘no’. The majority of participants said that nothing could be done (41.5%) whilst 14.3% recommended seeking medical advice and 8.3% suggested abortion. Of all the respondents, only 11.5% recommended antiretroviral therapy. Factory workers (male and female) were more aware that HIV could be transmitted from a pregnant woman to her unborn child than that HIV could be transmitted through breastfeeding. Results showed that slightly more women than men were aware of the risk of HIV transmission during breastfeeding (74.8 and 69.8% for women and men, respectively; see Annex 4B). 3.3.4.3 Alcohol and drug use Amongst the factory workers, 41.4% had ever drunk alcohol and only 29.4% drank alcohol regularly. Overall, 22.1% of male and 3.6% of female factory workers had ever used drugs (see Table 3.3.5). The most commonly used drug was khat; it was used by 102 (17.0%) of the male and female factory workers. Table 3.3.5 ‘Ever use’ of specific types of drugs by factory workers. Target group Male factory workers Female factory workers Khat 96 (22.1) 6 (3.6) Shisha 7 (1.6) 1 (0.6) Benzene 7 (1.6) 1 (0.6) Number (%) Hashish Mandrax 3 (0.6) 3 (0.6) 1 (0.6) 0 (0.0) Cocaine 3 (0.6) 0 (0.0) Crack 3 (0.6) 0 (0.0) IDU 0 (0.0) 0 (0.0) 3.3.4.4 Sexual behavior Amongst the factory workers, average age at first sex was 19.2 years for males and 17.1 years for females (P<0.001). In the previous 12 months, most factory workers had had regular sex partners (89%); a further 8% reported having non-regular sex partners and 1% (6 men) reported having commercial sex partners. 53 Amongst those who were sexually active, only 5.8% had had multiple sexual partners in the previous 12 months. Amongst married factory workers, 2.9% had had extramarital sex in the previous 12 months. Condom use Of those who ever used male condoms, 88.0% of the male and 76.1% of the female respondents knew where they could obtain condoms. Amongst those who had been sexually active in the last 12 months, 46.4% of males and 75% of females had used condoms the last time they had sex with a non-regular sexual partner of less than 12 months; in contrast, 53.3% of males and 33.3% of females had used condoms the last time they had sex with a non-regular partner of 12 months or more. Amongst those who had been sexually active in the last 12 months, 53.8% of males and 100% of females used condoms consistently with non-regular partners of less than 12 months; in comparison, 37.5% of males and 100.0% of female factory workers used condoms consistently with non-regular partners of 12 months or more. The six male factory workers who reported sex with commercial partners were asked whether they used condoms. All six men had used condoms the last time they had sex but only four (66.7%) of them used condoms consistently with commercial partners. STIs and treatment seeking behavior Factory workers who reported that they had experienced symptoms of STIs in the previous 12 months (see Table 3.3.6) were asked whether they had sought medical treatment (some respondents gave more than one answer). About 50% of those reporting symptoms had sought advice/treatment from a workplace clinic or hospital, 33.3% had sought advice/treatment from a government clinic/hospital, 16.7% sought advice/treatment from traditional healers and 33.3% said that they didn’t seek any advice/treatment. Table 3.3.6 Proportion of factory workers who reported that they had experienced STI symptoms during the previous 12 months. Symptoms Genital discharge Genital ulcers/sores Number (%) Male factory workers Female factory workers (n = 434) (n = 165) 2 (0.5) 3 (2.0) 2 (0.5) 1 (0.7) 3.3.4.5 HIV testing and exposure to interventions HIV testing Amongst the factory workers, 35.8% reported that it was possible to get a confidential HIV test in their community. It was noted that some workers at factories in the area were part of an Ethio-Netherlands AIDS Research Project (ENARP) cohort and had undergone VCT; unfortunately, further information about this testing was not available when this report was prepared. Exposure to mass media Of the factory workers, 71% listened to radio, 53% watched TV and 19.5% read printed media regularly during the previous four weeks. In the previous 12 months, a considerable number of the factory workers had heard or seen HIV messages on radio, on TV or in the printed media (88, 69 and 42%, respectively); the majority commented that the messages were clear. Exposure to interventions In the past year, 64% of the factory workers had participated in HIV/AIDS interventions, 11% had discussed HIV/AIDS with an outreach worker and 23% had discussed HIV/AIDS with a peer educator. 54 3.3.4.6 Perception of risk Amongst factory workers, 69% felt at little or no risk for HIV infection, primarily because they trusted their partner, had taken no injections or practiced abstinence. A small proportion of factory workers (4.6%) felt at moderate or high risk for HIV infection because they had multiple sexual partners, had practiced sex without a condom or had received unsafe injections. 3.3.5 Comparisons between the adult groups 3.3.5.1 Alcohol and drug use Transport workers reported the highest rates of regular alcohol intake in the previous four weeks. Drug use was highest amongst minibus drivers and farmers. The uniformed services (ground forces and air force) reported the lowest rates of regular alcohol consumption and drug use. 3.3.5.2 Sexual behavior Multiple sexual partners Across all adult groups, almost a third of those who were sexually active during the previous 12 months reported that they had had more than one sexual partner in the last 12 months (see Figure 3.3.1). Multiple sexual partners were most common amongst ground forces personnel (63.5%) and least common amongst farmers (3.8%) and factory workers (5.8%). Extramarital sex Overall, 33% of married respondents from the uniformed services, transport workers, rural population and factory worker groups had had extramarital sex in the previous 12 months (see Figure 3.3.2). Extramarital sex was most common amongst ground forces personnel (60%) and least common amongst factory workers (8%). 100 Percentage (%) 80 60 40 20 0 G ro un d Ai rF Fo rc es or c Tr uc k e M er s in ib us dr iv In te r er s ci ty Fa r bu sd riv m er er s Pa sto ra Fa c lis ts to ry w or k er s s Target group Figure 3.3.1 Adults with more than one partner in the last year (as a percentage of sexually active). N.B. Data for farmers and pastoralists include those for respondents who had polygamous marriages. 55 70 60 Percentage (%) 50 40 30 20 10 0 ra ll w k or ts lis s s er er es riv sd bu iv dr s s ry to ve O c Fa ra sto Pa er m er ty ci us ib in r Fa M r te In k uc Tr rc fo e d un ro c or rf Ai G er s Adult group Figure 3.3.2 Extramarital sex in the previous 12 months – by adult group. Condom use Condom use with commercial and non-regular sexual partners was examined and comparisons were made between the adult groups. Figures 3.3.3 and 3.3.4 show the data for commercial and non-regular sexual partners, respectively. condom use at last sex always condom use 100 Percentage (%) 80 60 40 20 0 ra us ib in ve O M ll iv dr er es s s er riv sd bu rc fo e d un ro ty ci k or er s Figure 3.3.3 Condom use in sex with commercial partners – by adult group. 56 c or rf Ai G r te In w s ts lis ry to er ra sto Pa c Fa k uc Tr Adult groups Condom use at last sex Consistent condom use 100 Percentage (%) 80 60 40 20 0 ra us ib in ve O M ll iv dr e er es s s er riv sd bu k or rc fo ty ci d un ro c or rf Ai G r te In w s ts lis ry to er ra sto Pa c Fa k uc Tr er s Adult group Figure 3.3.4 Condom use in sex with non-regular partners – by adult group. At last sex with a commercial partner, the majority of the adult groups had used condoms (overall, >95% of uniformed services, transport workers, rural population groups and factory workers). Only two pastoralists and none of the farmers surveyed had commercial sexual partners; one of the two pastoralists used condoms and used them consistently. At last sex with a non-regular partner, many of the adults had used a condom. Condom use at last sex with a non-regular sexual partner was highest (82%) amongst intercity bus drivers, about 62% amongst factory workers and lowest (1.6%) amongst pastoralists. Across all adult groups (uniformed services, transport workers, rural population groups and factory workers) around 60% had used condoms consistently with non-regular partners during the previous year; however, amongst intercity bus drivers only a small percentage (12.4%) had used condoms consistently. 3.3.5.3 HIV testing and exposure to interventions Access to confidential HIV testing was greatest amongst the uniformed services (46.6%) and least (1.4%) amongst pastoralists. A greater percentage of air force respondents than other groups had ever taken HIV tests (27.3%); other adult groups reported much lower percentages, ranging from 0.8% amongst farmers to 15.6% amongst the ground forces. In the majority of cases (approximately 70%) testing was voluntary, except amongst the uniformed services where 55.4% of those tested said that they were required to have the test. Of the uniformed services respondents who took HIV tests, only 75% collected their test results. Nevertheless, in other adult groups, most of those who took HIV tests also obtained their test results. Participants reported that much of the HIV testing was provided without counseling. The proportion of HIV tested respondents who had received pre- and post-test counseling ranged from 38.3% amongst uniformed services personnel to 92.3% amongst pastoralists. Interestingly, most of the adult group respondents who had taken an HIV test had taken the test during the previous 12 months. Exposure to mass media HIV messages The majority of respondents in the adult groups had listened to the radio or watched television during the previous four weeks (71, 87, 54 and 82% of the uniformed services, transport workers, rural residents and factory workers, respectively). Most respondents had heard HIV/AIDS messages on the radio in the past year; amongst the various adult groups, exposure to radio messages was highest amongst intercity bus drivers (95.7%) and minibus drivers 95.3%, and lowest amongst pastoralists (61.4%). Most respondents (85%) in each adult group thought that the radio messages were clear. Across all the adult groups, fewer respondents had seen HIV/AIDS messages on TV than had heard HIV/AIDS messages on the radio. As with 57 radio messages, most respondents considered the TV messages to be clear. Exposure to HIV/AIDS messages on TV was highest amongst truckers (92.2%) and lowest amongst farmers (4.5%). Overall, more than 62% of the adult group respondents had been exposed to HIV/AIDS messages through at least one of the three mass media channels. Many adult group respondents reported that they had participated in at least one community HIV/AIDS intervention in the previous 12 months (96, 80.8, 46.4 and 45.9% of uniformed services, truckers, pastoralists and farmers, respectively). Nevertheless, none of the farmers and pastoralists, and <25% of the uniformed services and truckers knew of organizations in their communities that provided assistance to PLWHA. To assess the role of the media in increasing knowledge about HIV/AIDS and influencing behavior change, the relationship between exposure to media HIV/AIDS messages and knowledge of the three HIV preventive methods was examined. Amongst the adult groups, exposure to HIV/AIDS messages in the last year was positively correlated with knowledge of the three major preventive methods for HIV/AIDS (P<0.001). However, exposure to HIV/AIDS messages in the media had no significant impact on the reported number of misconceptions. Higher levels of exposure to HIV/AIDS messages in the media were associated with higher levels of condom use with commercial sex partners. Most (94%) of those who reported media exposure to HIV/AIDS messages had used a condom the last time they had sex with a commercial partner; in contrast, condom use at last sex with a commercial partner was considerably less (82%) amongst those who had not seen or heard HIV/AIDS messages in the media. Nevertheless, exposure to media HIV/AIDS messages had no obvious effect on condom use during extramarital sex (i.e. when both commercial and non-regular sex partners were considered). 3.3.5.4 Relationships between knowledge, sexual behavior, HIV testing and perception of risk for HIV infection Adult group Relationships between knowledge of HIV/AIDS and sexual behavior were examined. Adult group respondents were found to engage in risky sex (any unprotected sex with a non-regular or commercial partner), irrespective of whether they knew that abstinence and faithfulness protected against HIV infection. Amongst adult group respondents who knew that faithfulness with one uninfected partner could prevent HIV infection, 24% reported having more than one sexual partner in the previous year. Moreover, amongst adult group respondents who knew that consistent condom use could protect against HIV/AIDS, 13.9% had risky sex in the previous year (see Figure 3.3.5). The most frequently given reason for not using a condom was trust in the partner. ts lis ra o t s Pa rs ke or w y or s ct er Fa rm Fa s er riv d us ib s in er M iv dr s bu s ity er rc ck e t u r n I T ce or rf i A es rc fo d 0 un ro G 5 10 15 20 25 30 35 40 Percentage (%) Knows 'C - Condom use' but still had unprotected sex at some time in the previous 12 months Knows 'B - Faithfulness' but still had more than one partner in previous 12 months Figure 3.3.5 ‘BC’ vs. sexual behavior – by adult group. 58 45 or k w er s to ry dr iv Fa c 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% G ro un d fo rc es Tr uc k er s in ib us M Adult group er s Across all adult groups, 13% of respondents reported that they had had risky sex in the previous year. Ground forces respondents and minibus drivers reported that around 18% of all sex in the previous year had been risky sex. The most frequently cited reason for not using a condom was trust in the partner. These findings were examined in relation to use of VCT services. Data showed that only 13% of adult respondents who had risky sex in the previous year had also undergone VCT. Most (91%) adult group respondents perceived themselves to be at low or no risk for HIV infection, primarily because they trusted their partners. Amongst uniformed services respondents who perceived themselves to be at low or no risk, the majority (54.8%) justified their perceptions by saying that they used condoms consistently. Amongst factory workers who perceived themselves to be at low or no risk for HIV infection, 17% justified their perceptions by saying that they practiced abstinence. Across all adult groups, those who perceived themselves to be at moderate or high risk for HIV infection did so primarily because they had practiced unprotected sex and/ or had multiple sexual partners. Amongst adult group respondents who reported that they had had unprotected sex in the previous 12 months, only 27% perceived themselves to be at moderate or high risk of HIV infection (see Figure 3.3.6). Feel at no risk or low risk for HIV Feel at medium or high risk for HIV Figure 3.3.6 Perception of risk for HIV infection amongst adult group respondents who had unprotected sex in the previous 12 months. (N.B. Data for farmers are not included as only four farmers had any unprotected sex during the previous 12 months). 59 4 Qualitative Results A total of 24 focus group discussions (FGD) and 23 individual in-depth interviews (IDI) were conducted with the in-school and out-of-school youth (ISY and OSY), factory workers, truckers, intercity bus and minibus drivers, pastoralists, farmers and female sex workers (FSWs) (see Annexes 5A-D for numbers and characteristics of the FGD and IDI participants). In this section, the results are presented separately for each target group. FGD and IDI participants are referred to as discussants and interviewees, respectively. When referring to a combination of discussants and interviewees, the term ‘participants’ is used. 4.1 In- and out–of-school youth in three regional cities (Dire Dawa, Bahir Dar and Jijiga) 4.1.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS Modes of transmission Almost all of the ISY and OSY participants knew that unprotected sexual intercourse or the sharing of sharp objects (blood contaminated) with an infected person could transmit HIV; this was mentioned during all FGDs and IDIs in the three cities. Moreover, a few participants mentioned mother-to-child transmission during pregnancy and breastfeeding, transmission by blood transfusion, transmission from contaminated medical equipment and transmission during traditional malpractices that involve cutting (e.g. uvulectomy). Misconceptions relating to HIV transmission included transmission by sharing clothes or kissing. Methods of prevention In all three cities, almost all the female and the majority of male participants were able to name the three major preventive methods (i.e. abstinence, faithfulness and condom use). However, in Jijiga a few male participants were unable to name the three major methods correctly. Females were more aware of preventive methods than males. 4.1.2 Relationship between HIV infection and other STIs All female participants, irrespective of the target region, mentioned syphilis and gonorrhea as examples of STIs. All participants (male and female) said that both STIs and HIV were transmitted by sexual contact. In Dire Dawa and Bahir Dar, male and female participants said that infection with STIs facilitated the transmission of HIV infection. The reason given was that wounds resulting from STIs facilitated transmission of HIV. In Jijiga, males were not able to point out the relationship between HIV infection and other STIs beyond describing both STIs and HIV as sexually transmitted diseases. Male participants, at all locations, mentioned that AIDS does not have a cure while other STIs do have cures. The males also commented that condom use could prevent STIs but that solely using condoms could not prevent HIV infection. 4.1.3 Misconceptions about HIV/AIDS, its transmission, and condoms and their effects Various misconceptions existed amongst the youth. Both female ISY and OSY focus groups in Jijiga and Dire Dawa mentioned similar misconceptions. The first misconception, described by females, related to the use of stimulants (drugs) such as khat and alcohol by male youth. According to the females in Dire Dawa, male youths were saying, ‘There is no HIV/AIDS after 2.00 pm [1400 hours].’ This was the time (1400 hours) when the male youths started to chew khat. Use of khat stimulated and encouraged the male youths to forget 60 their fear of HIV/AIDS. Similarly, according to female youths in Jijiga the male youths were saying, ‘There is no HIV/AIDS after 10.00 pm [2200 hours].’ The second misconception related to sexual pleasure when using a condom. The male youths in Jijiga were saying, ‘Having sex using condoms is like eating chocolate together with its cover.’ The third misconception seemed to be deeply rooted. According to the females in Dire Dawa the males were saying, ‘The lubricant in the condom itself has the virus’ and ‘It [HIV] is designed to destroy us, the Africans.’ In Jijiga, the female OSY discussants strengthened this idea by suggesting reasons for their belief. They asked one related question, ‘Why is a condom so cheap in Ethiopia when it is expensive in developed countries?’ This was a point of discussion and argument for some of the youth when trying to justify why the youth was not interested in using condoms. The above concern was also shared by female ISY and OSY discussants in Bahir Dar, where they associated low cost with ‘poor quality of condoms’. In Dire Dawa, the youths were saying, ‘There are people who believe that HIV/AIDS became widely spread in our country after people started to use condoms.’ Male groups of ISY and OSY in Dire Dawa both mentioned the belief that ‘condoms cause HIV infection’. In Bahir Dar, participants agreed that this type of thinking was common. In addition, males in Bahir Dar mentioned a further misconception that, ‘Raw eggs and raw meat also transmit the HIV infection.’ The male ISY interviewee in Dire Dawa said, ‘I do not trust condoms.’ He believed that condoms were a cause of the spread of the disease. He also discouraged care to HIV/AIDS patients because it sustained the spread of the disease. In contrast, in Dire Dawa, the male OSY interviewee felt that there were no misconceptions, especially in recent times. In Jijiga, according to the youth, there were additional misconceptions amongst Somali people >40 years old. The older Somalis believed that, ‘HIV/AIDS is a disease of the Christians and the Amhara [non-Somalis]’; this was assumed because they thought that Muslims were not involved in premarital sex and extramarital affairs. Implications of the misconceptions Both discussants and interviewees stated clearly that the youth was suspicious of condoms and refrained from using condoms for fear of getting the virus from the lubricant. Therefore, although condoms were readily available, the actual use of condoms was low unless partners were commercial sex workers. Most of the youth gave great emphasis to protecting themselves from sharp objects rather than protecting themselves during sexual contact. Misconceptions relating to condoms were masking the main mode of transmission i.e. heterosexual transmission. 4.1.4 Stigma and attitudes towards PLWHA During FGDs it was noted that some of the youth, especially those belonging to anti-AIDS clubs, had better attitudes than other members of the general population towards PLWHA. These youths prepared food and washed clothes for, and were friends to PLWHA. However, amongst the general population there were problems; for example, because of stigma and discrimination PLWHA were not able to rent houses or have somebody to care for them. Moreover, some people were scared that simply touching PLWHA could transmit the virus. One female discussant from Dire Dawa talked about a woman who was believed to be HIV positive. The discussant said, ‘When we, the anti-AIDS club members, went to talk to her, she told us not to come to her house again but to meet her at the kebele.’ She was afraid that the people around her would make her an outcast if they knew that she had the virus. A similar example was mentioned by the OSY discussants from Jijiga. The female OSY interviewee from Dire Dawa mentioned that she faced opposition from her family and other people because she was caring for an AIDS patient. Interviewees from all cities said, ‘The youths have positive attitudes towards PLWHA.’ They all said that they were willing to provide their support and care for PLWHA. One of them, from Dire Dawa, had already started to provide care to a neighbor who was suffering from AIDS. Male participants in Dire Dawa and Bahir Dar revealed that PLWHA were rejected and stigmatized by most community members. However, the male OSY interviewee felt that stigmatization was decreasing. In Jijiga, with the exception of the male OSY interviewee, all agreed that there was some kind of rejection and 61 stigmatization of PLWHA. They pointed out that HIV positive people did not want to expose themselves for fear of rejection by the community. However, they believed attitudes amongst the youth were changing and that the youth had started to be involved in HIV/AIDS care and support activities. 4.1.5 Voluntary counseling and testing (VCT) Female interviewees in Dire Dawa said that they were not aware whether VCT services were available in their area. The male ISY interviewee in Dire Dawa (15 years old) said he had never heard of VCT in his area but that he knew there was ‘a testing machine’ in Addis Ababa. Some ISY and OSY discussants in Dire Dawa mentioned that they had heard of VCT services but felt that they were too expensive (50 Ethiopian birr (ETB); US$ 1 = ETB 8.5 in August 2002). The female discussants in Dire Dawa stated that, ‘If the service puts emphasis on being voluntary, it has to be free of charge.’ Many youths, especially members of anti-AIDS clubs, wanted to have VCT; however, they had not undergone VCT because it was not free-of-charge. Nevertheless, they said, ‘Knowing our HIV status is very advantageous in that we will take care of ourselves much better than before.’ In Jijiga, male interviewees, and female discussants and interviewees said that the VCT service was not available in their area. Female discussants said, ‘Most of the youth may not be willing to be tested because of stigmatization.’ However, female ISY and OSY expressed their willingness to be tested. Unlike the participants in the other towns, in Bahir Dar, both the focus group discussants and the individual interviewees were aware that VCT services were provided at the zonal hospital in Bahir Dar. 4.1.6 Influence of knowledge, education and religion on behavior Knowledge Female participants said that although they expected informed individuals to behave better, in general, those with knowledge of HIV preventive methods did not adapt their behavior accordingly. No behavioral changes were observed in the youth although almost all had knowledge of the preventive methods. This lack of behavioral change was related to widespread misconceptions, drug abuse and unemployment. The male discussants from Dire Dawa and Jijiga commented on this problem from two angles. The OSY discussants mentioned that practice of safe behavior was influenced positively by knowledge of preventive methods. When considering practices of the youth, the discussants felt that the ISY at lower grades were at higher risk because they did not have knowledge of how to protect themselves. Conversely, when the th youths completed 12 Grade, most were unemployed; observation of these OSYs showed that they were exposed to high-risk behaviors despite their knowledge of preventive methods. Education Female discussants in Jijiga and ISY and OSY interviewees in Dire Dawa and Bahir Dar said, ‘The educated ones are the most exposed to the disease. They have risky behaviors.’ The female discussants in Dire Dawa commented that education did not seem to have any effect. They felt that rather than educational level, the most important thing determining the practice of preventive methods was an individual’s personal strength and nerve. In Dire Dawa, the female discussants used a nickname, ‘sugar daddy’, for relatively wealthy older men who had relationships with young girls. These men were usually educated but insisted on having sex with the girls without using condoms. Most girls who were commercial sex workers, refused to have sex without a condom; however, there were occasions when men had forced them to have sex without a condom where they shouted for help and were saved by the police. Girls who were not commercial sex workers, usually agreed to have sex without a condom in order to receive money from the ‘sugar daddies’. According to the female discussants, in spite of their level of education, behavior of the ‘sugar daddies’ was dangerous to the community. The female OSY interviewee from Dire Dawa said, ‘Educational level does not matter in the case of HIV/AIDS.’ She said that what matters is ‘the individual’s thinking’. 62 In Bahir Dar, with the exception of the ISY discussants, all participants commented that educational level did not alter behaviors related to HIV/AIDS. It was pointed out that educated individuals were observed to be involved in risky sexual behaviors. The male ISY and OSY discussants from Dire Dawa and Jijiga, believed that education contributed to self-protection and that as education level increased, risky sexual behavior decreased. However, those who th were educated (12 Grade complete) and yet unemployed were involved in risky behavior, attributing this behavior to unemployment and hopelessness. The male OSY interviewee said, ‘Educational status has no contribution because we are observing that those who are educated are equally practicing unsafe sex and dying of HIV/AIDS.’ He also said, ‘When one does not have a stable life and is getting no money, the individual will be involved in high-risk behaviors due to hopelessness.’ Religion In Dire Dawa, female participants said, ‘Religions advise people to be faithful’ and ‘In the churches, the preachers teach us about HIV/AIDS’ and ‘The Bible itself restricts us not to have sex before marriage.’ These points indicate that religions contribute significantly to safer and appropriate behaviors. Each religion had its own contribution, as long as the religion was followed strictly. One of the group members felt that the issue of teaching about condoms should be reconsidered amongst religious people, so that religious leaders could teach people; however, most other group members disagreed with her. These females objected to preaching about condoms in churches and mosques because they felt that it encouraged promiscuity. They felt that teaching from religious leaders should only emphasize faithfulness and abstinence. According to one of the female discussants, the Moslem faith allows men to have more than one wife. Nevertheless, as long as the Koran’s teachings are followed properly, the man will not go to women other than his wives and the wives will not go to other men. Therefore, their behavior will not spread HIV/AIDS. Males from Dire Dawa and Jijiga raised the same issues as the females. They believed that all religions had something to contribute to HIV/AIDS prevention. They said, ‘Religions teach us to avoid premarital sex and to avoid extramarital affairs.’ However, the male ISY discussants added that some of the religious leaders did not have adequate knowledge of HIV/AIDS and consequently, it was difficult for them to teach about HIV/AIDS. 4.1.7 Contribution of information sources to increased knowledge and behavioral change Sources of information about HIV/AIDS Amongst the mass media, radio, television and printed materials (magazines, newspapers, posters and brochures) were mentioned as sources of information about HIV/AIDS. Moreover, other sources such as health bureaus, NGOs, HIV/AIDS secretariat offices and associations of PLWHA, anti-AIDS clubs and parents were mentioned. In Bahir Dar, teachers and health professionals were also included as sources of information. Additional sources of information in Jijiga included friends, teachers, religious institutions and school mini-media. The male ISY interviewee felt that there was underutilization of family as a source of information on HIV/AIDS. However, the male OSY interviewee mentioned that families participated in teaching their daughters. The discussants in Jijiga pointed out the absence of TV programs in the Somali language; in consequence, because of language barriers, they felt that the Somali people did not benefit from watching TV programs on HIV/AIDS. Usefulness of the information Almost all discussants considered that TV programs were the most useful source of information. In particular, TV programs were considered useful because the information was sometimes accompanied by experiences of PLWHA. Nevertheless, in Jijiga some ISY discussants preferred newspapers because they could be read several times. 63 Participants agreed that all types of information from PLWHA were useful. According to the female OSY discussants from Jijiga, brochures were not useful as sources of information because most people did not like to read and the messages were often unclear. Weaknesses of the information sources In Dire Dawa, the female OSY said, ‘The information transmitted on TV screens is not adequate for those who are knowledgeable about the disease.’ Some participants considered frightening messages bad. Long messages were considered ineffective and boring. Moreover, it was considered inappropriate to teach children <15 years old about condoms; it was felt that the messages might encourage them to be sexually active. The female interviewees from Jijiga felt that educational maxims, such as ‘value your life’, did not convey clear messages on HIV/AIDS; instead, the interviewees recommended better explanations about the virus and the disease. The interviewees expanded this concept with the explanation that people value their lives when they see hope in their lives; they felt that young people who were struggling for existence would not take the messages seriously. In Dire Dawa, the ISY said that there was little contribution by family (parents) in the prevention of HIV/AIDS. Some participants mentioned that people became suspicious when an infected person who was still physically fit was teaching them and thought that the individual was pretending to be infected for the purpose of the teaching. 4.1.8 Perception and behavior/practice Abstinence Female participants in all three regions said, ‘Abstinence is not commonly practiced in the community as a whole.’ They added that, ‘There might be a few young people who abstain.’ The female OSY interviewee from Dire Dawa said abstinence was not common but that she practiced abstinence. In contrast, the female ISY interviewee from Dire Dawa said that many people were abstaining and that she preferred abstinence for herself. The female discussants and the OSY interviewee from Jijiga said, ‘Abstinence is not commonly practiced among the youth in particular and in the community in general.’ However, both mentioned that they used abstinence to protect themselves from HIV infection. In Jijiga, female discussants commented that Somali girls practiced abstinence more frequently than girls from other ethnic groups. Male participants, in all three regions, said, ‘Abstinence is not practical in the youth.’ The reasons mentioned included the statement that, ‘The youth is in a fire age and want to try and taste sexual pleasure.’ Moreover, they suggested that those who were considering marriage wanted to have sexual intercourse before deciding. In Jijiga, in contrast to views of the females, the male youth said, ‘Abstinence is impractical even in Somali girls.’ One of the reasons given was that a female would suspect her boyfriend of being unfaithful if he failed to have a sexual relationship with her. Moreover, the boys thought that if they did not have sexual intercourse with their girlfriends, that the girls would leave them. Male ISY discussants from Bahir Dar pointed out the existence of a few purposeful and intelligent young people who abstained from sexual intercourse. One–to-one relationships (faithfulness) One-to-one relationships were not practiced commonly by the youth. Females and males tended to stay with a partner for a maximum of 2-6 months and then, for various reasons, to start alternative relationships. Multiple partners were common for both males and females. However, one of the female interviewees from Dire Dawa felt that there were behavioral changes in this regard. In Jijiga, all the female participants said that faithfulness was uncommon. In Jijiga, the female OSY discussants said, ‘The usual practice is to have two friends at the same time, one is for love and the other is for financial advantages [money etc.].’ 64 In contrast to the statements above, in Bahir Dar, many female participants said that faithfulness was becoming common practice; however, a few ISY discussants opposed this idea. Furthermore, the female OSY interviewee said, ‘This preventive method faithfulness works only for religious people.’ Young males in Dire Dawa and Bahir Dar said that faithfulness was not common and that when it happened it only lasted for a few months; subsequently, additional partners were found. One reason for this behavior was that the young males felt that having multiple partners was a sign of ‘pride and superiority’. Nevertheless, the male interviewees said, ‘The youth is now changing its behavior and is becoming faithful.’ Condom use In the three regions, participants said that condoms were available from bars, small shops, the Family Guidance Association of Ethiopia (FGAE) clinics, anti-AIDS clubs and pharmacies. The price was very cheap (ETB 0.25 for three condoms); in some places condoms were provided free-of-charge. In Dire Dawa, most of the youth did not commonly use condoms because they ‘trusted each other’. Although they were not completely sure, they thought that FSWs always used condoms. This belief was mentioned persistently by the youth from the three regions. In the community, condom use varied with type of sexual relationship. In all three regions, it was usual for males visiting FSWs to use condoms; however, there was a tendency for FSWs to allow sex without a condom if higher prices were paid. Males who had one girlfriend did not usually use condoms and said, ‘We trust each other.’ The female OSY discussants from Dire Dawa said, ‘We have less power to decide on condom use, because of their [the males’] status.’ The OSY discussants from Jijiga added that the Somali and Moslem communities considered that condoms were haram (forbidden). All male participants said that condoms were available and that the price was reasonably low. In Jijiga, however, condoms were not sold in Somali owned shops. The male discussants said, ‘The majority of the youth, especially school students do not use condoms.’ They felt that condoms were more useful to FSWs. The male OSY interviewee from Dire Dawa felt that condom use was increasing. The male ISY interviewee from Jijiga pointed out that most Moslems did not use condoms. The male ISY discussants from Jijiga said, ‘The Somalis think that condoms are part of the cultures of other ethnic groups such as the Amhara [i.e. non-Somalis].’ 4.1.9 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex Risk groups All female participants said that the youth (male and female) and FSWs were at high risk for HIV. The male participants also included other groups, such as farmers, drivers and their assistants, businessmen, street children and the uniformed services. Circumstances/factors contributing to unprotected sex The female youth mentioned drug use (including khat and local alcohol) and watching ‘dirty movies’ (pornographic films) as factors that provoked the youth to practice unprotected sex. Commonly, the youth was involved in unstable sexual relationships. At the beginning of a sexual relationship (days 1 to 15), they might use condoms; however, later on they would have unprotected sex because the sexual partners started to trust each other. Nevertheless, in general, these relationships lasted for a maximum of six months and broke up easily. Subsequently, both partners would have alternative sexual friends and the pattern would begin again. Unemployment and lack of recreational facilities were given, amongst others, as reasons for this kind of behavior. The male youth mentioned drug use (including khat, alcohol and hashish) and watching pornographic films as factors contributing to the practice of risky sex. Commonly, after taking drugs or watching pornographic films, a male youth would visit a FSW or other casual partner. On rare occasions, a male youth would visit his girlfriend, if she were available. The ISY male discussants from Jijiga also mentioned a tendency for young males to establish sexual affairs with female newcomers. In relation to risky sex, group 65 sex (i.e. practicing sexual intercourse in a group on a single girl through violence) was also mentioned by the group discussants from Jijiga. Types of drugs commonly used by youth in the study areas Khat, alcohol (including local drinks) and shisha were mentioned by the female discussants from Dire Dawa as the types of drugs used commonly by the youth. It was reported that after taking drugs the male youths were often too ‘out of their minds’ to remember to use condoms. Although use of drugs was common practice amongst the boys, very few girls used them. Male discussants from the three cities mentioned the same types of drugs as the females. Drug use was said to prompt the males to visit FSWs and predisposed them to having sex without a condom. Some young males explained that different species of khat had different effects on the individual (e.g. some increased sexual desire). Commercial sex work Female participants in all three cities said that commercial sex work was very common. There were many bars, nightclubs and local houses selling drinks; all of which favored the practice. The female discussants in Jijiga commented that commercial sex work was never practiced amongst the Somalis. According to the males, drivers, soldiers, daily laborers, and married and older men visited FSWs. It was also pointed out that FSWs had boyfriends (lovers) with whom they did not use condoms. Usually, these boyfriends were young people. Although FSWs were said to use condoms more often than other people, street-based sex workers engaged in unprotected sex when they were offered higher prices. In Bahir Dar, it was mentioned that girls from rural areas were considered to be free of HIV/AIDS and consequently, were often exposed to unprotected sex; participants said that these girls were often forced to have sex without a condom. Male youths were said to visit FSWs only on rare occasions, after they had taken drugs. 4.1.10 Perceived risk behaviors and behavioral change According to female participants, young females had a particular fear of contracting HIV. In general, the FGDs indicated that the male youth often seemed to behave unthinkingly and forgot about HIV, especially after taking drugs including khat. In the past, most of the male youth did not even want to accept the existence of HIV; however, in recent times, a few of the youth had started to change their behavior (e.g. they were using condoms and being faithful). The two female interviewees from Jijiga said, ‘We will continue to practice abstinence until we get married.’ Both of them claimed to be virgins. In Bahir Dar, the female discussants said that youths perceived that they were at risk; however, behavioral change was not observed. The female OSY interviewee said, ‘There is good risk perception as well as some behavioral change amongst the youth.’ Several male participants said that all the youth seemed to fear HIV/AIDS but still chose to participate in unprotected sex. In contrast, the male ISY interviewee from Jijiga said, ‘The youth [including himself] does not fear HIV/AIDS and there is no change in behavior.’ His ideas were supported by all the male discussants. Nevertheless, the youth reported that FSWs were showing significant changes in their behavior by using condoms. 4.1.11 Participation in anti-AIDS clubs According to the female participants, in recent times, the youth had started to participate in anti-AIDS clubs. Female discussants from Dire Dawa and Jijiga commented that participants in anti-AIDS clubs seemed to have better behavior than the uninvolved youth. For example, anti-AIDS club participants were providing care for PLWHA. In Bahir Dar, participants mentioned that anti-AIDS clubs were important sources of information on HIV/AIDS. Nevertheless, it was pointed out that the messages transmitted by the clubs were of limited value. In Dire Dawa, the female discussants pointed out that there were still youths who made fun of anti-AIDS club programs. 66 Almost all the males said, ‘There are encouraging activities by the anti-AIDS clubs.’ Anti-AIDS clubs were operating in all kebeles in the three cities; they were providing care and support for PLWHA, and peer and community education. 4.1.12 Suggestions to avert the spread of HIV/AIDS Expansion of the activities of anti-AIDS clubs and better employment opportunities were suggested as ways of averting the spread of HIV/AIDS. Additionally, all participants mentioned expansion of recreational facilities. In Dire Dawa, OSY discussants suggested a ban on the screening of pornographic films by video houses and the closure of bars and nightclubs. In Jijiga, suggestions included expansion of libraries and involvement of religious leaders. The female OSY interviewee in Jijiga suggested evaluation of the effects of anti-AIDS clubs. In Bahir Dar, male participants strongly advocated the involvement of parents and the need for open communication. Continuous efforts to teach the community, expansion of VCT services and establishment of youth centers were also suggested. Furthermore, the male ISY in Jijiga also suggested that society’s ‘role models’ should show positive behavior. 4.2 Akaki Textile Factory workers 4.2.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS Modes of transmission Male and female discussants and interviewees from the Akaki factory mentioned unprotected sex and contaminated sharp materials as means for the transmission of HIV infection. Methods of prevention The discussants listed the three major preventive methods (abstinence, faithfulness and condom use). The male individual interviewee did not mention abstinence but was able to list faithfulness, condom use and avoidance of behaviors, such as drug use, that increase the risk for unprotected sex. The female individual interviewee could only mention faithfulness amongst the preventive methods. 4.2.2 Relationship between HIV infection and other STIs The factory workers were able to mention most of the common STIs such as gonorrhea, syphilis and chancroid. They said that affected individuals sought treatments from clinics. They commented that HIV infection was incurable while STIs had drugs to treat them. 4.2.3 Misconceptions about HIV/AIDS, HIV transmission and condom use The factory workers raised the misconception that condoms carry the HIV virus. The observed difference in quality of condoms available on the market was mentioned amongst the reasons for their suspicion. Cheap condoms, which were available widely, were said to have the virus (for example, they mentioned Hiwot Trust condoms). In contrast, condoms such as Durex were said to be expensive and of high quality. Observations by the youth and the elderly indicated that they were overwhelmed by this kind of misconception. The elderly thought that HIV was the curse of God and did not think that it could be prevented. The male interviewee also mentioned this misconception. He thought that this misconception had contributed to the spread of HIV. The male interviewee also pointed out that Hiwot condoms had a bad odor while Durex condoms had a good odor; he ranked Hiwot condoms as third class. A further misconception was mentioned by a female discussant; she said that eating eggs from a chicken that had swallowed a used condom was believed to transmit HIV infection. 67 4.2.4 Stigma and attitudes towards PLWHA In contrast with previous years, when there was marked discrimination against PLWHA, the factory workers said that there was now a positive attitude towards PLWHA; moreover, they appreciated the care and social support provided in the factory for PLWHA. This concept was also revealed by the in-depth interviews. One of the female discussants expressed her concerns regarding stigma. She said that three years previously she herself had been discriminated against and stigmatized. She had been suffering from tuberculosis and had developed ‘almaz balechira’ (herpes zoster). She remembered that her workmates would not shake hands with her. For this reason, she decided to take an HIV test; the result was negative. At the time of the study, her social relationships had normalized. The woman also mentioned a case of a man whose wife had died previously due to HIV/AIDS. When the man died, he had skin lesions and because of this many people refused to give routine care to his dead body; eventually, the man’s brother provided care for the body. 4.2.5 Voluntary counseling and testing All participants from the factory were aware of the existence of VCT services; however, although they were interested in being tested, they said that the cost was too high. There was no VCT service in the factory. 4.2.6 Influence of knowledge, educational status and religion on behavior Knowledge and educational status Both discussants and interviewees felt that, in the majority of cases, educated people who had knowledge about HIV/AIDS had better opportunity to protect themselves because they knew the preventive methods. However, the male interviewee added that most of the factory workers were uneducated and hence careless about using preventive methods. Nevertheless, male discussants said that risky behavioral practices were th observed amongst individuals who had completed 12 Grade but were then unemployed. In contrast, the female discussants and interviewee explained that higher educational status did not guarantee the practice of safe behavior. In fact, the females pointed out that educated men were not practicing safe sex; these individuals were able to engage in this risky behavior because they had higher incomes and could afford to pay higher prices for sex. Religion All discussants and interviewees highlighted the contribution of religion to the prevention of HIV/AIDS. Religions (i.e. Orthodox Christianity, Islam and the Protestant faith) were said to participate in teaching the community about faithfulness (one-to-one) and abstinence. All of these religions were said to condemn sexual intercourse before marriage and extramarital sex. 4.2.7 Contribution of information sources to increased knowledge and behavioral change Sources of information Participants listed the following sources of information about HIV/AIDS: radio, television, leaflets, newspapers and drama. Radio messages were preferred for their wide coverage of the population and power in influencing people’s behavior. In addition, television programs that presented PLWHA were found to be effective in influencing behavior. Participants felt that, in recent times, families had started to discuss HIV/AIDS more openly. The male interviewee also mentioned that HIV was discussed in schools and amongst friends. Both the discussants and the interviewees revealed that there was no active anti-AIDS club in their work place; however, they spoke about some of the activities that happened in Akaki town. 68 4.2.8 Perception and behavior/practice Abstinence The male interviewee believed that none of the youth but about half of unmarried people practiced abstinence. Similarly, the female discussants and interviewee believed that abstinence was not a common practice amongst factory workers or the wider community. One of the discussants was advising her daughter and her daughter’s boyfriend to take HIV tests and to make sure that the results were negative before they started to have sexual intercourse. One-to-one (faithfulness) The male discussants thought that only 25-50% of unmarried people were practicing abstinence. Moreover, they estimated that about 25% of married people were unfaithful to their partners. One reason given for not complying with the ‘one-to-one’ preventive method was that having multiple sexual partners was considered to be a sign of pride and superiority, especially by males. The male interviewee also revealed that faithfulness did not seem to be practiced amongst the factory workers. According to the female discussants and interviewee, feelings towards faithfulness were mixed; it was felt that more females than males practiced faithfulness. The female interviewee said, ‘I am married and faithful to my husband.’ However, she said, ‘This [faithfulness] is not commonly practiced among the factory workers.’ Condoms Male and female discussants and interviewees revealed that condoms were available, in the factory and in the shops. The condoms were very cheap. Condoms were supplied to the factory by the FGAE. Reportedly, the factory workers did not use condoms with their regular partners; however, they used condoms with other partners. Some participants felt that condoms were more useful to FSWs and the youth than to factory workers. When condoms were not used it was said to be the result of a lack of awareness or the use of drugs, such as alcohol. According to the male interviewee, condoms were used by the educated and unmarried but married people did not use them. One of the reasons for not using condoms was that people did not like to be seen buying or possessing condoms. In particular, they were concerned that other people would think they had condoms because they were unfaithful to their partners. 4.2.9 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex Risk groups The factory workers mentioned that the following groups were at high risk for HIV: drivers, the youth (both males and females) and sometimes farmers who were visiting urban areas to buy goods and sell farm produce. Discussants and interviewees noted that there were only a few FSWs around the factory area (contrasting with the situation in Addis Ababa). According to the male participants, only a few young factory workers visited these FSWs. Circumstances contributing to unprotected sex Unemployment, alcoholic beverages, khat and films that aroused sexual desire were mentioned as factors predisposing individuals to unprotected sex. Participants commented that khat and alcohol were accessible in the area. At the end of each month, the workers received their salaries; at this time, consumption of alcohol increased and subsequently workers visited FSWs. 4.2.10 Perceived risk behaviors and behavioral change It was mentioned that people had started to be afraid of HIV/AIDS. This was ascribed to the mass media coverage. It was believed that there was behavioral change amongst the factory workers. However, all participants felt that the number of individuals dying from HIV/AIDS had increased. When the slow changes 69 of behavior were considered alongside the rapid spread of the disease, participants felt that a great deal of behavioral change was still needed. 4.2.11 Suggestions to avert the spread of HIV/AIDS Participants suggested various ways to reduce the spread of HIV/AIDS, including: education of the community (especially the youth) about the preventive methods; expansion of VCT services, including the provision of services in the factory; and instigation of legal action against illegal video houses. Legal action against infected persons who had deliberately infected their partners by not disclosing their HIV status was also mentioned. 4.3 Truckers 4.3.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS Modes of transmission The discussants and the interviewee mentioned only unprotected sex and contaminated sharp materials as means for the transmission of HIV infection. One of the discussants said that sharing blankets used by an infected person could transmit HIV. Methods of prevention The discussants and the interviewee listed the three prevention methods. However, among the FGD participants the older ones opposed the use of condoms as a method of prevention, especially for truck drivers, because condom use encouraged people to have sexual affairs outside their marriages. Nevertheless, teaching the youth about condoms was felt to be very important. 4.3.2 Relationship between HIV and other STIs The truck drivers were able to mention most of the common STIs, such as gonorrhea, syphilis and chancroid. They also explained the relationships of HIV infection with STIs. They said that both HIV and STIs were transmitted through unprotected sexual intercourse. Moreover, they said that STIs were treatable but HIV/AIDS was not. The discussants said that for treatment of STIs, the truckers visited Kazanchis Health Center (previously called Borchele) in Addis Ababa or other health centers, hospitals or private clinics. The truckers commented that, in the past, health professionals talked extensively about STIs. However, they felt that, ‘In recent years, nobody talks about STIs except HIV/AIDS.’ 4.3.3 Misconceptions about HIV/AIDS, HIV transmission and condom use Amongst other misconceptions, the truckers mentioned that sharing blankets could transmit HIV and that condoms were produced specifically for people practicing oral and anal sex. Additionally, the misconception that condoms spread HIV, rather than preventing the infection, was said to exist amongst some of the truckers. Some of these misconceptions were said to be common amongst the older truck drivers. 4.3.4 Stigma and attitudes towards PLWHA The truckers commented that there was no way to know whether a driver was infected or not. However, they said that there were several infected drivers. When someone was seriously sick or had died, families including the sick person hid the real cause, particularly when the cause was HIV/AIDS. Instead, they 70 explained that the cause was a lung disease or ‘a disease from wind’. Because of this behavior it was always difficult to know the extent of the HIV/AIDS problem in the truckers’ community. They also said that the existing problem was so huge that they did not have adequate capacity to help all the chronically sick HIV infected drivers. It was said that, nowadays, when a driver dies of AIDS, nobody remembers to help his family. Most drivers’ families lived in rented houses; when the wage earner died, his family suffered. According to the discussants, stigmatization of PLWHA had decreased; however, the interviewee mentioned that the truckers were not willing to drink or sleep together with PLWHA. 4.3.5 Voluntary counseling and testing All participants were aware of the existence of VCT services. However, although they wanted to be tested, the cost of tests was said to be too high (ranging from ETB 50-200/test). In addition, they felt that they did not have time to be tested because they were very busy. They also explained that they had no information, e.g. official government recommendations, as to the reliability of HIV testing at VCT centers. These points were considered to be barriers to taking HIV tests. 4.3.6 Influence of knowledge, educational status and religion on behavior Knowledge and education Knowledge about HIV/AIDS was said to be helpful in preventing the spread of HIV/AIDS. However, participants commented that educational status did not necessarily protect people from acquiring HIV/AIDS. The interviewee mentioned that he had seen educated people who were infected with HIV. Religion All participants accepted the contribution of religion to the prevention of the spread of HIV/AIDS. However, the interviewee was skeptical about the current practices and doubted their impact. He believed that religious leaders should be trained and provided with adequate knowledge on HIV/AIDS, so that they could provide effective teaching on HIV/AIDS to their followers and the community. 4.3.7 Contribution of information sources to increased knowledge and behavioral change The truckers mentioned radio, television, leaflets and newspapers as sources of information on HIV/AIDS. They believed that TV messages were effective ways to influence behavior. However, they commented that the time allocated to HIV/AIDS messages on TV was very short and full of advertisements. When discussing convenience, TV and radio programs were considered less useful because not all trucks had radios and truckers did not commonly watch TV programs. It was also said that truckers did not often read newspapers because driving was tiring and people were not accustomed to reading newspapers. The interviewee suggested that peer group education was the most appropriate source of information for truckers (i.e. trucker to trucker education). 4.3.8 Perception and behavior/practice Abstinence Participants mentioned that very few (if any) truckers practiced abstinence. One of the truckers said, ‘We are too old too abstain.’ One-to-one (faithfulness) The participants agreed that ‘one-to-one’ relationships were relatively impossible in the case of truckers, particularly because truckers were away from their families for long periods of time. 71 Condom use Condoms were available widely. According to the discussants, most of the truckers used condoms. However, one of the discussants said that condom use was low after drinking alcohol. Moreover, the interviewee said that condom use was low amongst the truckers. The interviewee attributed this to a lack of knowledge and low levels of demand for condoms by FSWs working in peripheral parts of Ethiopia. Compared with FSWs based in peripheral areas, he believed that FSWs working in the central part of Ethiopia were better at asking males to use condoms. 4.3.9 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex Risk groups The truck drivers mentioned that the following groups were at high risk for HIV: drivers, teachers, soldiers, the youth and health workers. All participants said that commercial sex workers were abundant along the Ethio-Djibouti route and were found in all of the small towns. They said that the lives of the FSWs depended on the presence of truckers. Because many of the FSWs were young and beautiful they always had clients. It was also mentioned that FSWs followed the movement of soldiers and camps. Circumstances and types of drugs Alcoholic drinks and khat were said to be the most commonly used drugs amongst the drivers. Khat use followed by alcohol consumption was said to be associated with unprotected sexual intercourse. 4.3.10 Perceived risk behaviors and behavioral change Most truckers feared HIV/AIDS and yet not all of them protected themselves. The truckers referred to HIV/AIDS as ‘the land mine’ or ‘the explosive’. There was mixed feeling as to whether behavioral change had occurred amongst truckers. The discussants felt that there were some behavioral changes amongst the truck drivers although the number of HIV/AIDS cases had increased. In contrast, the interviewee said that there was no behavioral change and that most drivers visited FSWs. 4.3.11 Participation in anti-AIDS clubs The discussants and interviewee revealed that there were no active anti-AIDS clubs for the truckers. However, they explained that a proposal for strengthening intervention programs amongst the truckers had been submitted to the National HIV/AIDS Prevention Secretariat. 4.3.12 Suggestions to avert the spread of HIV/AIDS Participants suggested various ways to reduce the spread of HIV/AIDS, including: reduction of the number of FSWs; expansion of VCT services; provision of care for PLWHA; and elimination of nightclubs and red-light houses. When the discussants and the interviewee were asked to comment on trends in the numbers of AIDS cases, they said that the number of cases was increasing. 4.4 Intercity bus drivers and minibus drivers 4.4.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS Modes of transmission Almost all of the participants knew about HIV/AIDS and the major routes of transmission. The intercity bus driver interviewee included mother-to-child transmission, which was not identified by the discussants. 72 Methods of prevention Among the preventive methods, ‘one-to-one’ relationships and condom use were mentioned. However, none of the drivers included abstinence among the preventive methods. 4.4.2 Misconceptions about HIV/AIDS, HIV transmission and condom use The misconception that the lubricant in condoms carries the HIV virus was mentioned. Some assumed HIV to be a kind of biological warfare. Others said, ‘HIV infection has increased since people started to use condoms.’ In addition, it was mentioned that there were some people who believed that, ‘There is no AIDS.’ Moreover, others considered the epidemic to be ‘a punishment from God’. These misconceptions had contributed to the spread of HIV/AIDS. 4.4.3 Stigma and attitudes towards PLWHA The participants expressed a positive attitude towards PLWHA; all of them were willing to take care of PLWHA. 4.4.4 Voluntary counseling and testing Although they had not attempted to take HIV tests, the participants were aware of VCT services. 4.4.5 Influence of knowledge, educational status and religion on behavior Knowledge and educational status Although knowledge about HIV/AIDS and educational status were contributing to behavioral change amongst the drivers, not all educated people had changed their behavior. Religion The discussants and interviewee highlighted the role of religion in behavioral change. The minibus driver said attending church ceremonies helped much more than condom promotion advertisements because he thought that promotion of condoms encouraged people to engage in multiple partnerships. 4.4.6 Contribution of information sources to increased knowledge and behavioral change Mass media Participants mentioned various sources of HIV/AIDS information, including: radio, television, mini-media and printed materials. Pamphlets, newsletters and mini-media available at the bus station were mentioned and discussed. Television and radio interviews with PLWHA were considered to be the most effective ways of influencing people’s behavior. Radio was considered to be the most appropriate and important source of information on HIV/AIDS, especially for drivers. However, television was said to be more helpful than radio in influencing people’s behavior; in particular, television dramas were mentioned as being powerful influences. Interpersonal communication Participants mentioned interpersonal communication with health professionals, teachers, parents and friends as sources of HIV/AIDS information. However, from the perspective of the discussants and interviewees, interpersonal communication was not considered to be the most important source of information. 73 4.4.7 Perception and behavior/practice Abstinence Concerning the current practice of the three preventive methods by the intercity bus and minibus drivers, abstinence was said to be almost impossible. One of the discussants said that abstinence was a possible practice for only a few individuals. Faithfulness (one-to-one) Intercity bus drivers mentioned that ‘one-to-one’ relationships had become common practice. Moreover, incidence of marriage had increased. Nevertheless, both types of drivers mentioned that it was difficult to maintain faithfulness by couples. It was pointed out that most drivers had multiple sexual partners. Condom use Participants said that condoms were available everywhere. They believed that the use of condoms had increased, especially when partners were not married. 4.4.8 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex Risk groups Participants mentioned that the following groups were at high risk for HIV: drivers, the youth (including students), government employees, females and soldiers. Participation in commercial sex work was said to be common amongst young females. Factors and circumstances for unprotected sex Alcohol and drug (khat and hashish) use were mentioned amongst the factors contributing to unprotected sex. When drug use was coupled with alcohol consumption, unprotected sexual intercourse was likely to follow. The drivers explained that drinking alcohol after chewing khat increased sexual desire and promoted the occurrence of unprotected sex. The minibus driver interviewee associated HIV/AIDS with poverty and said, ‘It is the poor who are affected.’ 4.4.9 Perceived risk behaviors and behavioral change People’s awareness of HIV/AIDS had increased and almost all people feared HIV/AIDS. However, according to the minibus drivers, degree of behavioral change was not impressive. In fact, the minibus drivers said that there was no change in people’s behavior even though they knew that AIDS killed. Many of the drivers associated the lack of behavioral change with the nature of their work, which introduced them to many young girls and women. However, a different view was mentioned by one of the discussants. He said that there was behavioral change amongst drivers and that this resulted from observations that a number of drivers had suffered from and died of AIDS. Condom use had increased. Moreover, condoms were being used with regular partners and when having sexual intercourse with FSWs. 4.4.10 Participation in anti-AIDS clubs The intercity bus and minibus drivers were not participating in any type of anti-AIDS activity and were not members of anti-AIDS clubs. 4.4.11 Suggestions to avert the spread of HIV/AIDS Participants suggested various approaches to reducing the spread of HIV/AIDS, including: the provision of job opportunities; expansion of health education and VCT services; and the control of illegal video houses. 74 In addition, participants suggested that girls should be taught to dress decently (i.e. to wear clothes that covered provocative parts of their bodies). They felt that the way some girls dressed was too attractive and tempting for males. Participants also suggested using drivers’ associations to approach and teach drivers about HIV/AIDS. 4.5 Pastoralists 4.5.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS Modes of transmission Almost 50% of participants (discussants and interviewees) had basic knowledge of HIV transmission. The most frequently mentioned modes of transmission were: sexual intercourse and the use of contaminated sharps. Female pastoralists were observed to have inadequate knowledge about modes of HIV transmission. Methods of prevention Nearly all the males and a few female discussants were able to list the three major preventive methods. However, most female discussants did not mention abstinence or condom use and the female interviewee did not mention abstinence. When asked how often the preventive methods were practiced, it was said that abstinence had become a common practice; in the past, abstinence was considered almost impossible. However, the female discussants agreed that abstinence was very difficult in practice. All discussants and interviewees (males and females) pointed out that faithfulness was practiced more commonly than in previous years; this change in behavior was due to increased awareness and fear of HIV/AIDS. 4.5.2 Relationship between HIV and other STIs Participants were able to name the most common STIs. The female interviewee explained that people visited traditional healers when suffering from STIs. In contrast, when people were infected with HIV, they visited modern health institutions. 4.5.3 Misconceptions about HIV/AIDS, HIV transmission and condom use The misconception that condoms carry the virus and transmit HIV infection was common amongst the pastoralists. In addition, because the pastoralists did not know how to use condoms, they had various fears relating to condom use; these included a fear that the condom would break during sexual intercourse. Female pastoralists also feared that condoms would slip off into the vagina and would be retained in the reproductive tract, causing serious reproductive problems. One female discussant said that she believed that condoms could break during sexual intercourse and be retained in the uterus where babies were conceived. As pointed out by the participants, these kinds of misconceptions had implications for the spread of HIV infection. 4.5.4 Influence of knowledge, educational status and religion on behavior Knowledge and educational status The role of education and knowledge about HIV/AIDS in reducing the risk for HIV infection was discussed. With the exception of the male discussants, all participants mentioned that knowledge and educational status had positive implications for behavioral change. According to the male discussants, educational status did not seem to affect people’s sexual behavior. The male discussants supported their idea by pointing out that they had seen educated people with AIDS. 75 Religion All discussants and interviewees clearly stated the advantages of involving religious leaders in the prevention of HIV/AIDS, in particular, because the religious leaders had high levels of credibility and acceptance amongst the community. 4.5.5 Contribution of information to increased knowledge and behavioral change Mass media Almost all discussants and interviewees said that they had little access to the mass media; several reasons were given. Televisions were available only in the towns. Therefore, unless the pastoralists were visiting urban areas, there was no chance for them to watch TV programs. They also pointed out that radios were not available in many of the households. Furthermore, even when radios were available, people were not keen to listen to the programs because of language barriers; radios were not utilized properly. Because most pastoralists were illiterate, printed media was not utilized. Interpersonal communication Participants mentioned that interpersonal communication was the main source of HIV/AIDS information for the pastoralist communities; for example, friends, health workers, family members, teachers, community health committees and NGO workers (e.g. workers for Save the Children–USA) were used as sources of information. 4.5.6 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex Risk groups Participants believed that there were no high-risk groups for HIV in their rural areas because there were no bars or FSWs. However, the male discussants mentioned the youth as a risk group. In urban areas, participants identified FSWs, drivers, merchants and soldiers as high-risk groups. Factors and circumstances Amongst factors contributing to the practice of unprotected sex, use of drugs (such as khat and alcohol) was mentioned. In the rural areas, according to the male discussants, the community (Aba Geda) had closed local bars selling alcohol. 4.5.7 Voluntary counseling and testing The male discussants and interviewee had heard about VCT; however, they said that the services were not available in their areas. 4.5.8 Perception and behavior/practice Participants revealed that multiple sexual partnerships were very common in the area. According to the Geda system, a man could have three or four sexual partners and similarly, his wife could have a sexual partner with the knowledge of her husband. However, in recent times, fear of HIV/AIDS had encouraged people to start protecting themselves, particularly by limiting numbers of sexual partners. Many of the female participants had never seen a condom or if they had seen a condom, it was during health education. Almost all said that they had never seen PLWHA. However, they suspected HIV/AIDS when they saw individuals with the signs and symptoms. Participants believed that there was behavioral change amongst the pastoralists. 76 4.6 Farmers 4.6.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS Mode of transmission Knowledge about the transmission of HIV varied; modes of transmission mentioned ranged from sexual intercourse to the sharing of needles, safety pins and blades. Kissing, breathing and close contact were also mentioned. The male discussants gave further explanations as to how close contact and kissing could transmit the virus. They explained that through kissing and shaking hands it was possible transmit the virus if there were lesions, wounds or cuts on the body parts that were in contact. Methods of prevention Concerning knowledge of the preventive methods, all participants emphasized the sharps (needles, blades etc.) that were shared with family members and neighbors. When the females were asked about the preventive methods, none of them could name all three preventive methods; however, some female discussants and the female interviewee mentioned faithfulness and VCT before marriage. 4.6.2 Relationship between HIV and other STIs Female farmers could not easily name the different types of STIs; the female discussants mentioned only syphilis and gonorrhea. However, the male discussants and male interviewee were able to mention the commonest STIs, such as gonorrhea, syphilis and chancroid. They explained that people visited traditional healers for treatment of STIs. Traditional healers were the first choice for STI treatment because people wanted to keep their infections a secret. When they were asked about the relationship between STIs and HIV infection, they said that both were transmitted through sexual intercourse. Moreover, they highlighted the fact that STIs were treatable while HIV/AIDS was not. 4.6.3 Misconceptions about HIV/AIDS, HIV transmission and condom use Various misconceptions were discussed. Amongst these the major misconceptions were the transmission of HIV infection through eating raw meat, raw eggs, bananas, oranges, tomatoes and sugar cane. Raw meat was said to cause the disease because people who were infected might have handled it and there might have been contact with blood. Similarly, sugar cane could be contaminated during cutting because it could come into contact with blood from cuts on the hands of the workers. It was thought that chickens bought from urban areas were infected with the virus because they swallowed condoms; consumption of raw eggs from these chickens was thought to transmit the virus. Raw eggs from chickens that had fed on the wastes of an HIV/AIDS patient were also thought to carry the infection. In addition, both males and females mentioned transmission of HIV through breathing, sleeping together and by close contact such as shaking hands. The male interviewee mentioned the misconception that condoms transmit the virus. He also believed that HIV/AIDS was an expression of ‘God’s anger’ because of people’s misbehavior in sexual acts. 4.6.4 Stigma and attitudes towards PLWHA The participants, especially the females, stated that they were not willing to take care of PLWHA. This was because they did not understand how HIV was transmitted. However, the males believed that they should help PLWHA. It was explained that there was discrimination and stigma attached to PLWHA. The majority of people did not want to mix themselves and their families with PLWHA. Stigma was not limited to the person who was affected by HIV/AIDS but also to his/her family and people who were providing care. Some participants gave examples of these attitudes and stigma that were derived from their own observations. 77 4.6.5 Voluntary counseling and testing The participants knew that young people whose marriages were arranged by their parents could get tested for HIV. They explained that parents had started to demand HIV test results before they arranged marriages. This practice had expanded in some families over the last two years. In addition, testing for HIV after reunion and after separation for long periods of time was mentioned. However, people were not aware of VCT services, which were provided to any person who wanted to be tested. 4.6.6 Influence of knowledge, educational status and religion on behavior Knowledge and education Both male and female participants explained that education and knowledge about HIV/AIDS were useful in changing an individual’s behavior. The females commented that educated people and those with knowledge were in a better position to protect themselves from acquisition of HIV/AIDS. Conversely, the males explained that HIV/AIDS was killing both the educated and the uneducated. They believed that the disease was not specifically a disease of the uneducated. They also mentioned that although HIV/AIDS was a disease of the urban areas, nowadays the disease had started to affect rural people. Participants believed that although HIV affected both educated and uneducated groups, it affected more of the uneducated group and those without knowledge. Religion Discussants and interviewees mentioned that religious leaders (in mosques and churches) had started to teach people about HIV/AIDS. The leaders preached about faithfulness and avoidance of premarital sex. Participants believed that all religions were very useful in the prevention of HIV/AIDS, as long as the followers adhered to the doctrines and the word of God. 4.6.7 Contribution of information to increased knowledge and behavioral change Mass media Amongst the sources of information on HIV/AIDS, the majority of discussants mentioned radio. Some said that the radio messages were clear and that they preferred radios to other sources of information. Other participants said that people were not serious enough and did not listen to radio messages, adding that people would rather listen to music. In addition, the majority of households did not have radios. Interpersonal communication The major sources of information in the villages were students who were attending schools. The students taught their families and the community about HIV/AIDS (how it was transmitted and how it could be prevented). Some students presented their messages in the form of dramas, shown to the community once a month, especially during vacations (when the schools were closed). Discussants and interviewees commented that people were interested when they attended this kind of presentation. Some parents rewarded the students with money so that the students would continue their efforts. The female interviewee clearly remembered the story of a drama that she had attended. For a few of the farmers who could read and write, leaflets and posters were the other sources of information; however, distribution of leaflets was limited to the offices of peasant associations. The male discussants and interviewee mentioned that people who had died as a result of HIV/AIDS were points of discussion in the community; they felt that this somehow helped the community to become aware of HIV/AIDS and encouraged them to take care of themselves. When the participants were asked if there were any organized anti-AIDS activities, they said that there were none in the villages. 78 4.6.8 Perception and behavior/practice Abstinence Abstinence was said to be common amongst rural youngsters. However, the discussants and interviewees did not know whether abstinence could prevent the acquisition of HIV infection. Faithfulness Discussants said that faithfulness was the most important preventive method. However, they also mentioned that polygamy was common and an accepted practice in the community. The female discussants said that males were responsible for not accepting and breaking up ‘one-to-one’ relationships. Condom use According to the discussants and interviewees, farmers did not use condoms. Amongst the reasons given, it was said that there was a very low level of knowledge about condoms. 4.6.9 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex Risk groups The discussants and interviewees mentioned that youngsters (15-25 years old), especially the males, were at risk of acquiring HIV infection. The high-risk groups listed by the males included merchants, the uniformed services, students, teachers, drivers and FSWs. They explained that most of these groups moved from place to place and were exposed to HIV/AIDS. Amongst the groups, participants considered that merchants were at the highest risk because they were highly mobile and frequently visited towns. There were no FSWs in the area. However, because men were free to move from place to place they could go to towns and visit FSWs. The female participants mentioned that after drinking alcohol, the men might have unprotected sex with FSWs and then transmit HIV to their wives. 4.6.10 Factors and circumstances contributing to unprotected sex According to the participants there were no drugs in the area. Although khat was widely used by both males and females, it was not considered to be a drug. Its potential role in the spread of HIV/AIDS was not recognized. Khat was used to stimulate people to work. They said that, in the rural areas, it was not common practice to drink alcohol after chewing khat. In fact, the male discussants and interviewee mentioned that sexual desire was very low after chewing khat. 4.6.11 Perceived risk behavior and behavioral change The risk perception of the rural people concentrated on materials, such as sharps, that were considered dangerous in relation to HIV transmission; they also included those described in Section 4.6.3. People tried to avoid these materials. They said, ‘Borrowing materials such as sharps from neighbors is being abandoned.’ They added, ‘When we can not have a new blade, we boil or burn and use it [the old blade].’ The male interviewee said that people perceived their risks in relation to their previous risky behaviors, as they did not know whether they were infected or not. They also perceived their risks from educational information they received. Rather than trying to use condoms, farmers preferred to remain in ‘one-to-one’ relationships. This was related to misconceptions regarding condom use. Participants felt that there were changes in behavior amongst the farmers. For example, previously when a man died his brother had to marry his sister-in-law; in recent times this practice had decreased. Polygamy was also decreasing. Participants also said that people had become accustomed to HIV testing before marriage. Although condoms were available in the shops and community health posts, many people did not 79 like to use condoms. According to the male discussants, students, merchants and drivers used condoms. Discussants had seen individuals returning from the towns after acquiring HIV/AIDS and becoming sick; these individuals had died in their respective villages. People in the villages had learnt that these individuals had died of AIDS and they had started to take HIV/AIDS seriously. On various occasions, these situations were points of discussion and debate. 4.6.12 Suggestions to avert the spread of HIV/AIDS Participants suggested various ways to reduce the spread of HIV/AIDS, including the use of students, volunteers, health workers, teachers and religious leaders to increase awareness and knowledge of HIV/AIDS in the community. They also suggested that each individual and family, and the government should take action against HIV/AIDS and should teach the rural community about HIV/AIDS. 4.7 Female sex workers (bar-based, home-based and street-based) 4.7.1 Knowledge about modes of transmission and prevention methods for HIV/AIDS Modes of transmission The home-based interviewee was aware of the presence of HIV/AIDS. However, she was not able to mention the three major modes of transmission. Instead, she associated HIV transmission with deep kissing and with the breakage of condoms. Similarly, the bar-based interviewee mentioned that transmission was by blood and wounds. In contrast, home-, bar- and street-based discussants mentioned unprotected sexual intercourse and sharp materials that were contaminated with blood. Methods of prevention All participants mentioned that condoms were the most important preventive method for FSWs. They did not mention abstinence or faithfulness, which obviously would not work in their situations. All of them focused on and explained: their skills in negotiating with clients for condom use; their decisions when clients refused to use condoms; and other precautions related to condom use. 4.7.2 Relationship between HIV and other STIs With the exception of the home- and bar-based interviewees (both of whom were illiterate), all the participants were able to mention the commonest STIs (gonorrhea, syphilis and chancroid). The majority explained that HIV infection exposed the body to STIs by weakening the body defense mechanism. Some participants (especially the home- and street-based discussants) clarified this idea by mentioning the white blood cells of the body, which were the targets of the virus. They also said that there was a tendency for ‘transformation of STIs to HIV/AIDS’; all discussants and groups mentioned this belief. Participants said that FSWs visited traditional healers and used mineral water for treatment of HIV/AIDS; in contrast, they used health institutions in the case of STIs. One of the reasons given for this behavior was that STIs were treatable and curable while HIV/AIDS was not. 4.7.3 Misconceptions about HIV/AIDS, HIV transmission and condom use The misconception that the ‘condom has the virus’ was mentioned, particularly by the discussants. However, although this thinking existed in the community, especially amongst males, it was explained that the FSWs relied on condoms. Therefore, unlike the other target groups, they were not worried about the misconception. They believed that condoms were protective. They said that if condoms were not protective, ‘All female sex workers would have died or become sick.’ 80 Some discussants said, ‘HIV/AIDS is present only in radio and televisions.’ When asked what this meant, they said that nowadays FSWs were at less risk than other groups because they regularly used condoms. 4.7.4 Stigma and attitudes towards PLWHA The majority of participants said that they had positive attitudes towards PLWHA. The street- and bar-based discussants mentioned that some of them were already helping their friends. However, one street-based discussant said that since discovering her friend’s HIV status, she was not happy to eat or share clothes with her. Some participants expressed concerns that they had been identified as high risk for HIV/AIDS and were stigmatized as if they were ‘AIDS themselves’. 4.7.5 Voluntary counseling and testing None of the participants had been tested for HIV. Nevertheless, all of them were aware of the existence of VCT services. The majority of FSWs were afraid of ‘what will happen after they hear the results’. The street-based discussants said that the cost of the test was now very low; for example, it cost ETB 10 at the Kazanchis Health Center (previously called Borchele). However, they did not dare to get tested. 4.7.6 Influence of knowledge, educational status and religion on behavior Knowledge and educational status Almost all FSWs believed that knowledge and education contributed significantly in influencing a person’s behavior. They appreciated that knowledge of condom use had helped them to protect themselves. The majority of the street-based girls said that education about AIDS was included in formal classroom teaching th (at 4 Grade and above). However, the street-based girls also explained that even women without any formal education could have knowledge about HIV/AIDS and could take appropriate precautions; knowledge was available if a woman listened to the radio or took advice from a person who was knowledgeable about HIV/AIDS. However, the bar-based discussants said that education had no major impact, especially on FSWs because of their behavior and work related risks. Religion The majority of FSWs did not explain the role of religion in protecting people from risky behaviors; this was because of their lifestyles. Some of them believed that God would continue to protect them until they had alternatives to sex work. 4.7.7 Contribution of information to increased knowledge and behavioral change Mass media Radio and television were the major media sources of HIV related information for the FSWs, especially for the bar-based FSWs. Some literate participants also read leaflets and other printed materials. Interpersonal communication The street-based FSWs did not mention any of the mass media but mentioned the advice that they received from health workers, NGO workers and other individuals. They also mentioned discussions with other FSWs. The bar-based interviewee said that she was no longer interested in listening to the mass media. When she was asked why, she said that the messages from radio and television frustrated her greatly, so she had decided to stop listening to/watching the programs. 81 4.7.8 Perception and behavior/practice The majority of FSWs perceived that they were in a job that continuously exposed them to HIV infection. All said that they were using condoms with their clients. They explained that condoms were available everywhere and were cheap. The majority bought and kept condoms; some were provided with free-of-charge condoms. The FSWs preferred the condoms that they bought themselves to those provided by clients because they believed that some men pierced the tips of the condoms. One FSW said that the quality of condoms supplied by clients was poor because the clients carried the condoms in their back pockets. Participants also mentioned that most clients were willing to use condoms but that some men did not like them. In all of these situations the FSWs said, ‘We do not accept sex without condoms.’ In contrast, FSWs said that sexual intercourse with lovers was performed without condoms. Nevertheless, it seemed that only a few FSWs actually had unprotected sex with their lovers or ‘boyfriends’. 4.7.9 HIV risk groups and circumstances/factors contributing to the practice of unprotected sex Risk groups FSWs mentioned the youth, especially students, as a high-risk group for HIV. They said this group was at high risk because it did not protect itself. Most discussants and interviewees also mentioned married people as a risk group. Moreover, street-based FSWs also mentioned schoolteachers because they had multiple sexual partners amongst their female students. None of the FSWs mentioned that FSWs were one of the risk groups. Factors and circumstances FSWs mentioned that commonly used drugs included khat, alcohol, hashish and shisha. Most FSWs chewed khat and drank alcohol. Some also used hashish, especially the street-based girls. A few of them mentioned that excessive drinking exposed them to unprotected sex. Therefore, they tended to control the amount they drank when a client offered them alcoholic drinks. The street-based girls preferred to use small hotels rather than big government hotels when they went out with their clients. In small hotels, when clients tried to force them to have sexual intercourse without a condom, the owners of the hotels helped them. However, in big hotels, it was very difficult to get assistance even if they cried for help. 4.7.10 Perceived risk behaviors and behavioral change FSWs had a strong fear of HIV/AIDS. They felt that they had changed their behavior. The majority believed that they were protecting themselves by using condoms. However, they expressed their concerns that a few FSWs were not changing their behavior and continued to practice unprotected sex when offered better pay. They also pointed out that some males did not protect themselves and asked to have sex without condoms. A few FSWs did not use condoms with their lovers or ‘boyfriends’. 4.7.11 Participation in anti-AIDS clubs Almost none of the FSWs were participating in anti-AIDS clubs. Participation only seemed to occur in situations where there were NGO activities. 4.7.12 Suggestions to avert the spread of HIV/AIDS FSWs suggested various ways of reducing the spread of HIV/AIDS, including: continuity of anti-AIDS activities; involvement of religious leaders in the provision of health education; creation of job opportunities to provide alternative employment for FSW; and the provision of training and financial loans to FSW so that they could engage in small-scale income generating activities. 82 5 Discussion Results are discussed in relation to other local literature; qualitative results were used to strengthen and clarify the quantitative findings. The qualitative data show clearly that the behavioral surveillance survey was successful in opening and developing a dialogue on HIV/AIDS amongst the study respondents. 5.1 Knowledge about HIV/AIDS 5.1.1 Awareness Awareness of the existence of HIV/AIDS was high (>90%) amongst all target groups, irrespective of gender and region. This finding supported the results of the Ethiopia Demographic and Health Survey (CSA 2001), which showed high levels of awareness of HIV/AIDS amongst the general population (96 and 85% for males and females, respectively). Moreover, qualitative data showed that awareness of HIV/AIDS was high even in rural communities. In comparison with previous studies of rural communities in Ethiopia, this was an encouraging finding; for example, according to Ismail et al. (1995) awareness of HIV/AIDS was only 74% in a rural community in the Gondar region. 5.1.2 Preventive methods A previous study in the major cities of Ethiopia indicated that about 94% of males and 84% of females (15-49 years old) had knowledge of the preventive methods (Mehret et al. 1996). In this study, about 67% of FSWs, over 45% of all youth and over 56% of other groups combined could mention the three major methods of preventing HIV infection. Amongst the FSWs, knowledge about preventive methods was highest in Dire Dawa and lowest in Gambella town. Knowledge of preventive methods was higher in the in-school youth (ISY) than in the out-of-school youth (OSY). However, only one of every two youths could name all three preventive methods. Uniformed services respondents had better knowledge of preventive methods than the other groups studied; over 73% of ground force and air force respondents were able to mention the three major methods correctly. Compared with other target groups, the rural populations had less knowledge of the preventive methods. Less than 25% of the pastoralists and farmers knew the three preventive methods. The lowest level of preventive knowledge (1.8%) was found amongst the female farmers of Butajira. In general, findings amongst the rural population were of a similar magnitude to the 28% reported by CSA (2001). However, it is important to note that the CSA (2001) and Mehret (1996) assessed knowledge of preventive methods by determining the proportion of individuals who knew two or more of the three preventive methods. In contrast, the BSS assessed knowledge of preventive methods by assessing the proportion of respondents who could correctly identify all three preventive methods. Nevertheless, irrespective of the differences in methodology, knowledge about the preventive methods was very low amongst the rural populations, particularly amongst the female farmers. As the great majority of Ethiopia’s population lives in rural areas, the very low knowledge levels observed amongst the rural population groups studied needs serious consideration. Most respondents knew that male condoms existed. In contrast, many were unaware that female condoms existed, presumably because female condoms were not available on the market and because female condoms were not actively promoted. Respondents who knew about male condoms also knew where to obtain them. For most of the respondents, it took less than 30 minutes by foot to obtain a condom. Data from focus group discussions (FGDs) and individual in-depth interviews (IDIs) supported the quantitative findings relating to access to condoms; FGD and IDI participants commented that condoms were available and could be obtained at a reasonable price. These results contrasted with the findings of an earlier study by Mehret et al. (1996), which reported that availability of condoms was low outside of Addis Ababa. 83 5.1.3 Misconceptions about HIV/AIDS About 50% of OSY and a slightly over 50% of ISY were able to identify the misconceptions correctly. The OSY in the Harari, SNNPR and Somali regions had the least misconceptions about HIV/AIDS; in contrast, youth in Addis Ababa and the Afar region had the most misconceptions. Misconceptions (such as ‘mosquito bites can transmit HIV infection’) were widespread amongst FSWs, particularly in Addis Ababa, and the Amhara and Oromia regions. Despite high levels of HIV/AIDS interventions in Addis Ababa, FSWs working in the city had many misconceptions about HIV/AIDS. Pastoralists and farmers had more misconceptions than any other target group. Both quantitative and qualitative data confirmed this finding. Misconceptions amongst farmers included the beliefs that raw eggs laid by a chicken that had swallowed a used condom and raw meat could transmit HIV infection. Different sets of misconceptions existed within each target group. The qualitative study revealed additional misconceptions; for example, that ‘the lubricant in condoms carries the virus.’ Despite high levels of awareness of the existence of HIV/AIDS and relatively good knowledge of the preventive methods, the presence of widespread misconceptions should be of concern to all individuals and organizations involved in the fight against HIV/AIDS. Some misconceptions related to stigma whilst others raised serious questions about the extent of people’s knowledge of HIV/AIDS, in particular the depth of the understanding they require to protect themselves. 5.1.4 Comprehensive knowledge Measures of comprehensive knowledge give a better picture of the level of understanding about HIV/AIDS, especially regarding the modes of transmission. Knowledge of preventive methods was markedly greater than comprehensive knowledge about HIV/AIDS. With the exception of male ISY (15-19 years old), less than 40% of respondents in each target group were considered to have comprehensive knowledge about HIV/AIDS. The level of comprehensive knowledge was lower in females than in males. Female farmers had the lowest level of comprehensive knowledge. This important finding should help program planners to focus on decreasing the level of misconceptions and increasing knowledge on HIV/AIDS transmission mechanisms. As demonstrated by the qualitative results, presence of widespread misconceptions affects protective behavior and thereby, weakens efforts to curtail the spread of HIV infection. 5.1.5 Stigma and discrimination Results showed high levels of stigma relating to HIV/AIDS. In fact, the majority of the respondents showed at least one stigmatizing attitude towards people living with HIV/AIDS (PLWHA). Even amongst the youth, around 97.3% of 15- to 19-year-old OSY and around 96.4% of 20- to 24-year-old OSY expressed stigmatizing attitudes towards PLWHA. Amongst OSY, females were slightly less likely than their male counterparts to have stigmatizing attitudes towards PLWHA. Although focus group discussions and in-depth interviews revealed that level of stigma had decreased amongst the youth, stigma against PLWHA was still a major problem. Considerable discrimination against PLWHA was reported amongst FSWs, with as few as 10% of FSWs responding positively to all questions relating to stigma and discrimination. Proportion of respondents with stigmatizing attitudes varied between the target groups, ranging from 99.4% in male pastoralists to 55.7% in truckers. Quantitative and qualitative results indicated that although there were individuals with accepting attitudes towards PLWHA, there were also those who showed extreme stigma and discrimination towards PLWHA (e.g. female farmers). These findings support those of Kifle (2001) who found that most respondents (>18 years old) in Dire Dawa showed at least one form of stigma towards PLWHA. Stigma and discrimination stand out as significant challenges to the prevention and control of HIV/AIDS in Ethiopia. The presence of a high level of stigma facilitates the spread of HIV/AIDS, not least by its effects on some of the prevention packages such as VCT. 84 5.2 General risk and sexual behavior 5.2.1 Drug and alcohol use Drug and alcohol use were examined because of their potential roles in predisposing individuals to the practice of unprotected sex. There are few previous studies reporting levels of drug and alcohol use in Ethiopia. In 1997, Alem showed that over 50% of the adult population of Butajira (n = 10,468) had ever used khat and about 50% were khat chewers at the time of the survey; amongst users, 17.4% used khat every day. In the same study, Alem showed that 23% of the adult population used alcohol 23% (36 and 15% for males and females, respectively). A more recent study, in the Zeway area of Ethiopia, indicated that 32% of adolescents and adults (>15 years old) currently chewed khat (Belew et al. 2000). In this study, relatively low levels of regular drug and/or alcohol use were observed amongst most target groups. Nevertheless, there were differences between the groups and subgroups. For example, regular drug use (mainly khat) and alcohol consumption were higher amongst the OSY than the ISY. Younger respondents were less likely than older ones to have consumed alcohol in the week before the survey or to have used drugs. Qualitative data showed that drug use was higher when youths were unemployed or had completed high school but not yet found a job. Amongst most adult populations, very low levels of regular drug and alcohol use were reported, particularly amongst the uniformed services. These results need further investigation, to determine whether there was under-reporting of drug and alcohol use. In contrast, levels of regular drug and alcohol use were very high amongst FSWs. Over 70% of FSWs drank alcohol regularly. This could be explained by the fact that most of the FSWs were working in bars and in establishments where local alcoholic drinks were sold. As clients came to these establishments, FSWs were almost always invited to have a drink. Results indicated that the combination of khat and alcohol was a major risk factor for unprotected sex. In this respect, the customary behavior of khat chewers (revealed by the qualitative study) was of particular interest as it was common practice for khat chewers to break the effects of khat chewing by drinking alcohol (a practice often called chebbssi). Nevertheless, overall there was very little alcohol drinking following khat use, particularly amongst the rural population. 5.2.2 Premarital sex Amongst 15- to 19-year-old youth, almost twice as many OSY (35 and 29% of males and females, respectively) as ISY (19 and 13% of males and females, respectively) reported that they were sexually active. These results agreed with the findings of several previous studies amongst in- and out-of-school adolescents (Abate 1999; Berhane et al. 2000; Eshetu et al. 1997; Fantahun and Chala 1996). Amongst the older group of OSY (20-24 years) nearly 75% of males and 60% of females were sexually active. Results of the BSS complemented the finding of a recent study by Taffa et al. (2002), which examined sero-prevalence amongst the youth in Addis Ababa; prevalence of HIV-1 was found to be 13-times higher amongst OSY than ISY (0.3 and 5.3%, respectively). The proportion of sexually active individuals was higher amongst OSY in Gambella, Beneshangul-Gumuz and Tigray than amongst the youth in other regions. It was difficult to explain these differences between regions, In general, however, results indicated that level of sexual activity amongst the youth was increasing. Qualitative data indicated that reasons for this trend included the expansion of illegal video houses showing erotic films, increased use of drugs and unemployment. 5.2.3 Non-commercial sex partners and numbers of sexual partners During the previous 12 months, greater proportions of OSY than ISY had had sexual partners. Amongst the 15- to 19-year-olds, 35.1 and 17% of OSY and ISY, respectively, reported having one or more sexual partners. Over 35% of 20- to 24-year-old OSY reported having one or more sexual partners. The proportion of youth with one or more sexual partner was higher than that observed in Dubti (Afar region) where 9% of OSY was found to have had more than one sexual partner during the previous 12 months (Assefa 2002). 85 Moreover, a study in four regional cities (Addis Ababa, Awassa, Bahir Dar and Dire Dawa) by Mehret et al. (1996) showed that comparatively small proportions of 20- to 24-year olds (14.5 and 3.9% for males and females, respectively) had had more than one non-regular sexual partner in the previous 12 months. Almost half of the sexually active OSY in Tigray, Beneshangul-Gumuz and Gambella had more than one partner in the last year. The percentage reporting multiple sexual partners in the last year was higher in OSY than in ISY. Amongst OSY, more males than females had more than one sexual partner in the last year. Amongst the adult population groups (uniformed services, transport workers, rural populations and factory workers), almost a third reported having more than one sexual partner during the previous 12 months. Amongst all married adults, 33% reported having extramarital sex during the previous 12 months. Data highlight the fact that marriage in itself is not a guarantee of protection from HIV infection unless faithfulness is practiced consistently. 5.2.4 Commercial sex partners and non-regular sex partners Commercial sex was most common amongst the uniformed services, particularly the ground forces. Amongst those who were sexually active, 76% of ground force and 21% of air force respondents reported having commercial sex partners in the previous 12 months. Moreover, about 20% of them reported having non-regular sex partners. This behavior is likely to be related to the high mobility of the ground forces and the long duration of time they spend away from their families. Amongst drivers and their assistants, around 13% had commercial sex partners and around 10% had non-regular sex partners. These results are comparable to those of Mehret et al. (1996) who studied urban populations of Ethiopia and found that 18% of males and 5% of females had non-regular sex partners in the previous year. Only a small proportion (1%) of factory workers had commercial sex partners in the previous 12 months but about 8% had non-regular partners. The low level of commercial partners may have resulted because of interventions by the Ethio-Netherlands AIDS Research Project (ENARP) in the area. Less than 1% of pastoralists and none of the farmers reported having had any commercial sex partners. Over 12% of pastoralists but only 0.2% of farmers (one farmer) reported having non-regular sex partners in the previous 12 months. Qualitative data indicated that commercial sex partners were uncommon amongst the youth. However, the youth frequently had non-commercial partners and a significant proportion did not use condoms. 5.2.5 Condom use and unprotected sex A substantial proportion of youth did not use condoms with their non-commercial partners. Consistent condom use during the previous 12 months was lower amongst the OSY than ISY and lower amongst female than male youth. Amongst the adult population, unprotected sex was practiced despite high levels of knowledge about the preventive methods of HIV infection. Unprotected sex occurred most often amongst the uniformed services and minibus drivers. Alarmingly, about 27% of FSWs did not use condoms the last time they had sex with a non-paying partner. In contrast, only 3% of FSWs did not use condoms the last time they had sex with a paying client. The relatively low use of condoms with non-paying partners probably occurred because the FSWs trusted their non-paying partners; these men were often regular partners of the FSWs and most were considered to be the women’s lovers. Data from FGDs revealed that most street-based FSWs had lovers with whom they did not use condoms. The qualitative data also indicated that FSWs working in peripheral areas of Ethiopia and those coming from rural areas were unable to negotiate for condom use. In a study of FSWs in small towns in northwest Ethiopia, it was reported that the rate of unprotected sex was 2- to 3-times higher in those who were illiterate than literate (Degu 2002), indicating that poorly educated FSWs were less able to negotiate for condom use. In the same study, it was noted that FSWs who used condoms less frequently, felt that they didn’t need to use condoms when having sex with farmers coming from remote rural areas. 86 5.2.6 History of STIs and treatment seeking behavior In general, prevalence of STI symptoms (genital discharge or ulcers/sores) was low. Amongst the youth, STI symptoms were reported (in the previous 12 months) by only 4, 5 and 2% of the younger OSY, older OSY and ISY, respectively. Similarly, the prevalence was only 5.8% amongst the adult group respondents. Nevertheless, the level of STIs was higher than that reported previously in Ethiopia (Mehret et al. 1996; CSA 2001); for example, CSA (2001) reported a prevalence of 1.4%. In part, this difference may have occurred because the CSA survey included much larger groups of the rural population. 5.3 HIV testing and exposure to interventions 5.3.1 HIV testing Very few of the study participants reported ever having taken an HIV test. With the exception of the uniformed services, amongst whom 20% had been tested, in other groups less than 11% had ever been tested for HIV. Qualitative data revealed that the majority of people had not taken HIV tests because of high costs, fear of stigma and the lack of VCT services. Although direct comparison between the BSS and previous studies is difficult, the quantitative and qualitative results of this study indicated that levels of HIV testing were higher than the 1% (of the population) reported previously by the CSA (2000b). Despite this possible trend towards an increase in HIV testing, the practice of VCT was still very low. Nevertheless, the majority of respondents (over 76%) reported that they would be willing to undergo VCT in the future. In general, VCT services were exceedingly inadequate considering the scale of the HIV problem in Ethiopia. 5.3.2 Media interventions In order of increasing importance, the major sources of information on HIV/AIDS were printed media, television and radio. These data agree with a recent report from Addis Ababa, which revealed that the most common sources of information about HIV/AIDS were radio and television followed by anti-AIDS clubs (Cherie 2002). With the exception of farmers and pastoralists, coverage of HIV media messages was high amongst the various population groups included in this study. The majority of respondents commented that messages regarding HIV/AIDS were clear. Amongst FSWs, condom use was associated with exposure to one or more of the types of media in the previous 12 months. Knowledge about the preventive methods increased with exposure to media information sources. In adult groups (the uniformed services, factory workers, drivers and rural respondents), knowledge about preventive methods, and condom use with commercial partners were associated with exposure to the media. Qualitative results indicated consistently that radio and television were the major sources of information on HIV/AIDS; moreover, these information sources were often considered very useful. These findings were encouraging as they confirmed the important role of the media in increasing knowledge about the preventive methods of HIV and in influencing positive behavior, such as condom use. 5.4 Relationships between knowledge, sexual behavior and perception of risk Amongst the youth, condom use was positively associated with knowledge about the three preventive methods. Most of the youth who were aware that condom use protects against HIV transmission had used a condom the last time they had sex in the previous 12 months. As shown by Zemenfes (1996), knowledge that condoms protect was more likely to be associated with the use of condoms than with other preventive behaviors such as abstinence or faithfulness. Most youth respondents perceived themselves to be at no or 87 low risk of HIV infection; this was even true amongst the subgroup of youth who had had unprotected sex in the previous 12 months. The majority (85%) of FSWs perceived themselves to be at no or low risk of HIV infection because they used condoms. Qualitative data indicated that none of the FSWs perceived themselves to be amongst the high-risk groups. However, the quantitative survey showed that nearly 67% of FSWs who practiced unprotected sex at their last commercial sex encounter and about 74% of those who used condoms inconsistently with paying clients during the previous 30 days perceived themselves to be at moderate risk for HIV infection because of their risky behavior. The majority (80-95%) of other adult population groups perceived their risk of HIV infection to be nil or low. Relatively higher perception of risk was observed amongst some uniformed service personnel and minibus drivers (16.5 and 11%, respectively); these individuals perceived themselves to be at moderate or high risk of HIV infection. In all target groups, the majority of respondents perceived themselves to be at low risk for HIV infection. Even amongst those who did not use condoms, particularly with non-commercial partners, individuals perceived themselves to be at low risk because they trusted their partners. Interestingly, qualitative data revealed that the FSWs perceived themselves to be at low risk for HIV infection because they used condoms consistently with commercial partners. Moreover, FGDs and IDIs, revealed multiple factors underlying high risk behavior including suspicion that condoms carried HIV, unemployment and loss of hope, and the combination of drug and alcohol use. 5.5 Limitations to the study • The segmentation method of selection of OSY was applied based on the number of households reported by the 1994 census (CSA 1998). Since the household numbering was not updated there were problems in identifying the selected households. • The sensitive nature of the questions may have affected the level of honesty with which respondents gave their answers. • The timing of the survey coincided with the completion of classes and final exams for 12th graders (ISY) and this made the mapping difficult and time consuming. 88 6 Conclusions and recommendations 6.1 Conclusions Knowledge of the three major preventive methods was reasonably good. However, almost half the respondents were unable to name all three preventive methods. Moreover, there was a knowledge gap amongst the rural population groups. Condoms were accessible and not too expensive but major misconceptions existed about condoms. Misconceptions about HIV/AIDS existed amongst all the population groups. However, levels of misconceptions were higher amongst the underprivileged groups, such as the farmers and pastoralists. Because of misconceptions about HIV/AIDS, comprehensive knowledge was very low in all groups. Therefore, in addressing knowledge, misconceptions should be considered. There was a high level of stigma and discrimination; this existed in various forms. Stigma and discrimination were worst amongst the rural population groups, particularly amongst the females. Stigma and discrimination remain a challenge to HIV/AIDS control and prevention efforts in Ethiopia. In the previous 12 months, very few youth or farmers had reportedly had commercial sex; in contrast, commercial sex was common amongst the uniformed services. There were high levels of premarital sex amongst the youth. Number of sexual partners was higher amongst the out-of-school youth (OSY) than the in-school youth (ISY), and amongst males than females. A considerable proportion of the adult population groups had had more than one sexual partner in the previous 12 months. About one in three married respondents reported that they had had extramarital sex in the previous 12 months. All these sexual behaviors provided opportunities for the spread of HIV/AIDS. Most of the sexually active youth had unprotected sex with non-commercial partners, particularly the OSY. A substantial proportion of FSWs had unprotected sex the last time they had sex with their non-paying partners. With the exception of FSWs, condom use and consistent condom use were lower in females than in males. The coverage of VCT services was found to be limited and the proportion of respondents who reported that they had ever had an HIV test was very low. High cost, lack of access and unknown reliability appeared to be barriers to VCT for respondents. Nevertheless, many respondents commented that they were willing to undergo VCT in the future. Considerable proportions of youth and FSWs used drugs (mostly khat and shisha) and alcohol. Risk perception for HIV infection was low. Even FSWs did not perceive themselves to be at risk for HIV infection. With the exception of the ISY, exposure to community interventions, other than mass media messages, was low amongst all population groups. 6.2 Recommendations 6.2.1 Policy and advocacy level • Sustained political commitment and involvement of leaders is needed at all levels to support behavioral change and decrease stigmatization and discrimination. • Governmental, non-governmental and other bilateral organizations need to promote the establishment and running of recreational facilities and libraries, and focus on the provision of employment opportunities for the youth. • The media has to continue its efforts: to address both ISY and OSY; to reach the rural population (especially through radio programs); to help the general population to develop positive attitudes towards PLWHA; and to build comprehensive knowledge on HIV/AIDS (including minimization of misconceptions). 89 • Cognizant of regional variation, decision makers at higher government levels should pay special attention to some of the regions that had low scores for comprehensive knowledge and lacked intervention activities, such as the Afar, Gambella and Somali regions. • Parents, religious organizations, governmental and non-governmental organizations need to be mobilized to influence public opinion on HIV/AIDS and related high-risk behaviors. • Comprehensive HIV/AIDS prevention and control interventions and job creation should be targeted at youth (15-24 years old), particularly the females. 6.2.2 Information, education and communication/behavioral change communication (IEC/BCC) • Misconceptions were widespread in all target groups. Mass media and IEC activities should address misconceptions to enhance behavioral change. • Current IEC needs to be evaluated with a view to adapting the country strategy for BCC in order to enhance behavioral change. • Anti-AIDS clubs, which were found to be of great value in terms of improving knowledge, attitudes and practice, have to be strengthened amongst the ISY and need to be expanded to OSY. • Parents should be involved in HIV/AIDS-related intervention activities. They should be enabled and encouraged to participate. Encouragement of open communication between parents and their children will help to reinforce behavior. 6.2.3 Program level • Increased awareness and expansion of VCT services are required to promote and sustain behavioral • • • • • • • • 90 change. The VCT services should be more accessible to the community, the uniformed services and the mobile population groups. Awareness of pregnant mother-to-child transmission (PMTCT) of HIV needs to be increased; moreover, services reducing the risk for PMTCT need to be initiated and made widely available. HIV/AIDS intervention programs should extend to the rural communities (i.e. to pastoralists and farmers) and special strategies should be designed to increase access of these communities to the mass media; moreover, alternative methods that are appropriate to rural areas, such as out-reach services, should be used. Increased involvement of FSWs is needed to address their needs in intervention activities; this may be accomplished through expansion of FSW forums and provision of vocational training. Emphasis should be given to discouraging drug and alcohol use amongst the youth. Some of the intervention activities could be conducted in schools by integration with the activities of school clubs. If appropriate measures are not taken at this stage, drug and alcohol use may lead to serious problems. Promotion of abstinence and decreasing the magnitude of premarital sex amongst the youth should be given priority. In addition, promotion of other preventive methods should be targeted and individualized. Promotion of condoms should continue for all sexually active individuals. Negotiation skills should always be a priority in training. In particular, females should be encouraged to demand condom use and should be protected against violence. Establishment of programs promoting the use of condoms, particularly programs targeting FSWs, should be a high priority. Governmental and non-governmental institutions operating in the region could organize these programs; moreover, health workers, volunteers and peer groups could facilitate implementation of the programs. Programs designed to control HIV/AIDS transmission should aim to bring about behavioral change and focus on the promotion of safer sex. Intensive IEC programs, which take into account the heterogeneous characteristics of the population, should be developed. These programs should aim to delay sexual debut and should include age appropriate information on HIV transmission and prevention, and the support services available. • Control programs for sexually transmitted infections (STIs) that are provided by health institutions need to be strengthened to include youth friendly services, early diagnosis and treatment. • Peer education relating to sex education has an important role in reaching ISY and OSY, as well as other target groups. Accordingly, locally developed, culturally appropriate educational materials should support IEC activities. • Target specific strategies and interventions should be designed for the groups that are mobile such as drivers (taxi drivers, intercity bus drivers and truckers) and the uniformed services. • In the uniformed service personnel and their families, promotion of VCT through increased access and education, continued promotion of condoms and an emphasis on consistent condom use are recommended. In addition, extension of IEC services to the community around uniformed services camps and specifically to FSWs and female youth should be useful. • An enabling environment or environmental intervention (e.g. control of illegal video showing houses and nightclubs) is required. 91 References Abate S. 1999 Determinants of high-risk sexual behavior for HIV/AIDS among out of school youth in Addis Ababa Ethiopia. MPH thesis, Department of Community Health, Addis Ababa University, Addis Ababa, Ethiopia. Addis Ababa Regional Health Bureau. 1999. HIV/AIDS in Addis Ababa. Background, projections, impacts and interventions. City Administration Health Bureau, Addis Ababa, Ethiopia. Assefa T. 2002. Sero-prevalence of HIV-1 infection among antenatal care attendees and determinants of high-risk behavior among different populations in Dubti town Afar Region. MPH thesis, Department of Community Health, Addis Ababa University, Addis Ababa, Ethiopia. Alem A. 1997. Mental health in rural Ethiopia: studies on mental health distress, suicidal behavior and use of khat and alcohol. PhD dissertation, Department of Psychiatry, Umea University, Sweden. Belew M., Kebede D., Kassaye M. and Enquosellassie F. 2000. The magnitude of khat use and its association with health, nutrition and socio-economic status. Ethiopian Medical Journal 38:11-26. Berhane F., Berhane Y. and Fantahun M. 2000. Health problems and services preferences of school adolescents in Addis Ababa. MPH thesis, Department of Community Health, Addis Ababa University, Addis Ababa, Ethiopia. Cherie A. 2002. Perceived sufficiency and usefulness of IEC materials and methods on HIV/AIDS among high school youth in Addis Ababa. MPH thesis, Department of Community Health, Addis Ababa University, Addis Ababa, Ethiopia. CSA (Central Statistical Authority). 1998. The 1994 Population and Housing Census of Ethiopia. Analytical report. CSA, Addis Ababa, Ethiopia. CSA (Central Statistical Authority). 2001. Ethiopia Demographic and Health Survey –June 2000. CSA, Addis Ababa and Marco International Inc., USA. Degu G. 2002. Knowledge and practice of condom in preventing HIV/AIDS infection among commercial sex workers in three small towns of northwestern Ethiopia. Ethiopian Journal of Health Development 16(3): 277-286. Eshete H. and Sahlu T. 1996. The progression of HIV/AIDS in Ethiopia. Ethiopian Journal of Health Development 10(3): 179-190. Eshetu F., Zakus D. and Kebede D. 1997. The attitude of students, parents and teachers towards the promotion and provision of condoms for adolescents in Ethiopia. Ethiopian Journal of Health Development 11(1): 7-16 Fantahun M and Chala F. 1996. Sexual behavior, and knowledge and attitude towards HIV/AIDS among out of school youth in Bahir Dar town northwest Ethiopia. Ethiopian Medical Journal 34(4): 233-242. Gebresellassie S. 1988. National KAPB study on HIV/AIDS Addis Ababa. Unpublished report. GFRE (Government of the Federal Republic of Ethiopia). 1998. Policy on HIV/AIDS of the Federal Republic of Ethiopia. GFRE, Addis Ababa, Ethiopia. GFRE (Government of the Federal Republic of Ethiopia). 2000. Establishment of HIV/AIDS Prevention and Control Council. Discussion paper presented at the consensus-building workshop held at Addis Ababa, Ethiopia, 10-11 February 2000. Ismail S., H/Giorgis F., Legesse D., Alemu E., Regassa K., Abdella M. et al. 1995. Knowledge, attitude and practice on high risk factors pertaining to HIV/AIDS in a rural community. Ethiopian Medical Journal 33(1): 1-13. Kebede D., Aklilu M. and Sanders E. 2000. The HIV epidemic and the state of its surveillance in Ethiopia. Ethiopian Medial Journal 38: 283-302. Khodakevich L., Mehret M., Negassa H. and Shanko B. 1990. Projections on the development of HIV/AIDS epidemics in Ethiopia. Ethiopian Journal of Health Development 4(2): 191-195. Kifle Y. 2001. Social stigma attached to HIV/AIDS and its determinants. MPH thesis, Department of Community Health, Addis Ababa University, Addis Ababa, Ethiopia. Lester F.T., Ayehunie S. and Zewdie D. 1988. Acquired immunodeficiency syndrome: seven cases in an Addis Ababa Hospital. Ethiopian Medical Journal 26(3): 139-45. Mehret M., Mertens T.E., Carael M. et al. 1996. Baseline for the evaluation of an AIDS Programme using prevention indicators: a case study in Ethiopia. Bulletin of the World Health Organization 74(5): 509-516. Mekonnen Y., Jegou R., Medley G. et al. 1999. Predicting the course of the HIV/AIDS epidemic in Addis Ababa and its potential demographic input. Abstract presented at the First International Conference on HIV/AIDS in Ethiopia held at Addis Ababa, Ethiopia, November 1999. Ethiopian Medical Journal 37(Suppl. 1): 111. MoH (Ministry of Health). 1995. National HIV/AIDS update. Ethiopian Journal of Health Development 9(1): 63-66. 92 MoH (Ministry of Health). 1998. AIDS in Ethiopia. Background, projections, impacts, intervention. 2nd Edition. MoH, Addis Ababa, Ethiopia. MoH (Ministry of Health). 1999a. Strategic framework for the national response to HIV/AIDS in Ethiopia for 2000-2004. MoH, Addis Ababa, Ethiopia. MoH (Ministry of Health). 1999b. Summary. Federal level multi-sectoral HIV/AIDS strategic plan 2000-2004. MoH, Addis Ababa, Ethiopia. MoH (Ministry of Health). 1999c. Summary. Regional multi-sectoral HIV/AIDS strategic plans 2000-2004. MoH, Addis Ababa, Ethiopia. MoH (Ministry of Health). 2000. AIDS in Ethiopia. 3rd Edition. MoH, Addis Ababa, Ethiopia. MoH (Ministry of Health). 2001. Health and health related indicators. Planning and Programming Department, MOH, Addis Ababa, Ethiopia. MoH (Ministry of Health). 2002. AIDS in Ethiopia, 4th edition. MoH, Addis Ababa, Ethiopia. NAPCC (National AIDS Prevention and Control Council). 2000. National HIV/AIDS Control Program (in Amharic). NAPCC, Addis Ababa, Ethiopia. Negassa H., Kefenie H., Khodakevich L. et al. 1990a. Profile of AIDS cases in Ethiopia. Ethiopian Journal of Health Development 4(2): 213-217. Negassa H., Khodakevich L., Kefenie H. et al. 1990b. Surveillance on AIDS cases in Ethiopia. Ethiopian Journal of Health Development 4(2): 107-113. PRB (Population Reference Bureau). 2000. World population data sheet. PRB, Washington DC, USA. Taffa N., Sundby J., Holm-Hansen C. and Bjune G. 2002. HIV prevalence and socio-cultural contexts of sexuality among youth in Addis Ababa, Ethiopia. Ethiopian Journal of Health Development 16(2): 139-145. Tegbaru B., Fisseha B., Tessema Z. and Fontanet A. 1999. The prevalence of HIV-1 among visa applicants between 1993 and 1999 in Addis Ababa, Ethiopia. Abstract presented at the First International Conference on HIV/AIDS held at Addis Ababa, Ethiopia, November 1999. TGE (Transitional Government of Ethiopia). 1993. Health Policy of the Transitional Government of Ethiopia. TGE, Addis Ababa, Ethiopia. TGE (Transitional Government of Ethiopia). 1995. Health sector strategy. TGE, Addis Ababa, Ethiopia. Tsega E., Mengesha B. and Nordenfelt E. 1988. Serological survey of human immunodeficiency virus infection in Ethiopia. Ethiopian Medical Journal 26(4): 179-184. UNAIDS (United Nations Program on HIV/AIDS). 1998. On the global HIV/AIDS epidemic. UNAIDS, Geneva, Switzerland. Zemenfes D. 1996. HIV/AIDS awareness, knowledge and practice in patients with sexually transmitted diseases. Ethiopian Medical Journal 34(1): 25-32. Additional resources For more information, see the following technical guidelines: FHI (Family Health International). 2000. Behavioral Surveillance Surveys (BSS): guidelines for repeated behavioral surveys in populations at risk for HIV. FHI, USA. 350 pp. 93 Annexes Annex 1. Sample sizes for study populations (respondents) and sites Region Tigray Afar Amhara Oromia Somali Beneshangul-Gumuz SNNPR Gambella Harari Addis Ababa Dire Dawa AC Uniformed services Total Sample size Category OSY 1220 OSY 1220 Truckers-1 400 OSY 1220 ISY 1100 FSWs 350 OSY (Nazareth & Borena) 2440 ISY 1100 FSW (Nazareth & Borena) 700 Pastoralists 850 OSY 1220 ISY 1100 OSY 1220 OSY 1220 FSW 350 Farmers 850 OSY 1220 FSWs 350 OSY 1220 ISY 1100 OSY 1220 ISY 1100 FSWs 600 Truckers -2 600 Intercity bus 600 Minibus 600 Factory workers 600 OSY 1220 ISY 1100 FSWs 350 Ground forces – Eastern Front 1250 Air force 622 30,312 N.B. OSY = out-of-school youth; ISY = in-school youth; FSWs = female sex workers; Truckers–1 = Ethio Djibouti corridor truck drivers and their assistants; and Truckers–2 = truck drivers and their assistants from all of the other five routes leading in and out of Addis Ababa. 94 Annex 2A. BSS indicators for ISY Amhara Oromia M F Total M BSS indicators n= 569 n= 568 n= 1137 Knowledge of HIV prevention methods F Percentage Harari Somali Totall M n= n= 526 530 n= 1056 75.7 74.1 74.9 75.3 72.6 No incorrect beliefs about 63.3 65.0 64.1 HIV/AIDS Comprehensive knowledge about AIDS F Addis Ababa Dire Dawa National Total M F Total M F Total M F Total M F Total n= n= 465 471 n= 936 n= 510 n= n = 509 1019 n= n= n= n= n= n= n= n= 74.0 54.2 51 52.6 66.3 64.7 65.5 49.6 47.4 48.5 51.9 47.5 At least one stigmatizing attitude towards PLWHA 88.9 99.5 94.2 Ever had sexual intercourse 517 545 1062 502 498 1000 n= 3089 76.3 50.7 63.5 60.7 59.4 60.1 69 64.4 68.9 61.7 65.3 53.8 26.2 39.5 87.6 76.6 82.1 61.9 56.3 59 85.3 73.5 79.4 69.7 60.7 65.2 49.7 31.4 15.3 23.3 68.4 43.2 55.8 38.1 34.5 36.3 62.0 48.0 54.9 50.4 39.7 45.0 98.5 99.1 98.8 100 99.8 99.9 99.6 99.8 99.7 85.5 97.2 91.5 98.0 98.6 98.3 94.9 99 96.9 22.1 16.2 19.2 30.0 32.5 31.3 18.9 11.0 15.0 13.3 5.9 11.2 2.0 19.3 8.2 13.8 19.3 12.8 16.0 Had sexual intercourse in the last 12 months (% of ever had sex) 48.4 67.4 56.4 46.2 58.7 52.7 42.0 67.3 51.4 48.6 66.7 54.1 37.9 72.7 43.5 49.5 75.6 57.2 46.1 64.6 53.5 Condom use with last non-commercial partner (% of those who had sex in the last 12 months) 54.1 22.6 39.2 47.9 321.7 38.7 75.8 50.0 69.9 75.8 50 66.0 81.8 50.0 73.3 75.0 58.1 69.2 64.2 40.2 52.4 Consistent condom use (% of those who had sex in the last 12 months) 87.9 35.7 72.3 48.6 42.4 45.6 92.0 96.2 94.1 84.0 60.0 77.1 85.0 75.0 83.3 85.7 82.4 82.4 79.2 64.4 73.6 Ever had HIV test 8.1 3.4 3.6 2.2 4.5 5.6 2.6 1.8 4.5 3.4 4.0 5.1 6.6 3.8 1.7 1.9 4.3 9.6 4.4 4.3 6.5 4.9 60 1.0 3121 6210 95 96 Annex 2B. BSS knowledge indicators and components for ISY Amhara BSS indicators Ever heard of STIs Ever heard of HIV/AIDS Using condom correctly at all times can protect from HIV (Yes) Abstaining from sexual intercourse can protect from HIV (Yes) Having one uninfected faithful partner can protect from HIV (Yes) Healthy looking people can spread HIV (Yes) Sharing meals can spread HIV (No) Mosquito bite can spread HIV (No) Eating uncooked egg laid by a chicken that has swallowed used condom can spread HIV (No) Eating raw meat prepared by an HIV infected person can spread HIV (No) Drinking local hard liquor or eating hot pepper can protect from HIV (No) Willingness to share meal with HIV positive person (No) Oromia M F Total M n= 569 n= 568 n= 1137 98.6 99.8 99.6 99.8 81.9 F Total Percentage Harari Somali M F M F Total n= n= n= 526 530 1056 n= 465 n = n= 471 936 n= 510 n= n= 509 1019 99.1 99.8 97.3 99.2 98.3 100 100 100 95.9 75.6 85.7 100 99.2 99.6 95.7 91.0 93.3 99.8 99.8 99.8 78.3 80.1 81.0 84.3 82.7 58.7 53 55.9 92.8 94.9 93.8 94.1 90.6 92.3 96.1 97.4 96.7 81.9 Addis Ababa F F n= 3089 n= n= 3121 6210 96.3 99.1 97.7 100 100 100 97.4 97.0 97.2 100 100 100 96.9 99.9 94.0 95.5 99.8 99.9 82.5 59.5 70.9 65.8 69.4 67.6 70.3 61 65.7 73.8 68.1 71.0 92.5 97.2 94.9 95.7 92.7 94.2 92.1 88.6 90.3 99.6 97.6 98.6 94.4 93.5 94.0 96.0 94.2 95.1 95.5 97.9 96.7 90.6 60.3 75.5 93.2 94.7 94.0 89.0 75.3 82.2 93.5 87.0 90.1 90.1 86.0 87.6 81.3 84.5 78.9 36.9 57.8 96.1 84.3 90.2 83.0 89.9 86.5 92.4 79.5 86.0 86.7 77.9 82.4 95.6 97.7 96.7 86.3 97.4 91.9 97.6 87.7 92.6 93.9 96.7 95.3 98.8 96.3 97.6 98.0 98.4 98.0 94.9 95.8 95.4 78.9 71.5 75.2 86.9 80.8 83.8 67.0 67.0 67.1 91.6 92.0 91.9 74.3 64.4 69.2 94.0 93.0 93.5 82.3 77.9 80.1 44.8 43.3 44.1 66.0 50.2 59.0 69.9 37.2 53.4 86.7 88.2 87.4 53.4 52.3 52.8 80.9 76.1 78.5 66.4 58.0 62.2 63.6 80.8 72.2 68.6 63.4 66.0 84.7 62.3 73.5 73.3 75.0 74.2 59.8 48.1 53.8 75.5 82.9 79.2 70.5 68.7 69.6 91.9 94.8 93.2 91.6 96.0 93.8 98.9 91.5 95.2 94.3 91.9 93.1 95.4 93.6 94.4 96.2 97.8 97.0 94.6 94.3 94.5 19.7 16.4 18.1 46.0 4.7 13.8 31.7 22.7 10.6 5.3 7.7 8.4 13.3 n= n= 517 545 Total M F n= 1062 n= 502 15.6 11.8 5.8 Total National n= n= 498 1000 8.0 M Dire Dawa M 20.2 Total 7.1 Total 16.0 14.7 continued... Annex 2B. BSS knowledge indicators and components for ISY (continued...) Amhara Oromia M F Total M F Total n= 569 n= 568 n= 1137 n= n= n= 526 530 1056 BSS indicators Willingness to buy food from an HIV positive shopkeeper/food seller (No) 37.2 26.5 31.9 27.8 42.6 35.2 If member of family became ill with HIV, would respondent want it to remain a secret (Yes) 17.3 13.9 15.6 22.2 12.9 17.6 Willingness to care for male relative infected with HIV (No) 3.3 3.9 3.6 2.9 4.0 3.4 Willingness to care for female relative infected with HIV (No) 3.7 3.4 3.5 4.6 4.2 4.4 An HIV infected student should be allowed to continue school (No) 79.2 98.8 89.0 83.2 95.8 89.6 An HIV infected teacher should be allowed to continue teaching (No) 13.6 19.8 16.7 10.5 6.6 8.4 PLWHA should be quarantined (Yes) 13.7 4.6 9.2 19.8 8.7 14.2 HIV positive woman can transmit the virus to her unborn child (Yes) 93.8 91.9 92.9 90.1 89.6 89.9 Knows the existence of ARV* for PMTCT** (% of above) 21.8 19.0 20.4 24.7 14.5 19.0 HIV positive mother can transmit the virus to her baby through breastfeeding (Yes) (% of those who knew PMTCT) 64.8 73.7 69.3 69.6 67.5 68.6 Note: *ARV = antiretrovirals;**PMTCT = pregnant mother-to-child transmission Percentage Harari Somali M F Total n= 465 n = n= 471 936 M F Total n= 510 n= n= 509 1019 Addis Ababa M F n= n= 517 545 Dire Dawa Total M F n= 1062 n= 502 Total National M F Total n= n= 498 1000 n= 3089 n= n= 3121 6210 14.9 30.4 22.7 30.8 20.1 25.5 25.5 39.5 32.7 25.7 19.5 22.6 27.5 30.0 28.7 27.7 21.7 24.7 9.3 37.0 23.2 13.8 18.2 16.0 23.3 22 22.8 18.9 20.9 19.9 12.9 9.2 11.1 3.6 3.1 3.3 2.1 4.0 3.1 3.4 5.2 4.3 4.7 4.9 4.8 13.1 9.6 11.4 4.7 2.6 3.6 2.7 3.7 3.2 4.6 4.2 4.4 5.6 4.6 5.1 86.9 85.6 86.2 94.9 95.9 95.4 76.4 94.3 85.6 93.6 95.4 94.5 85.5 94.5 90.0 13.3 17.6 15.5 3.5 2.8 3.1 9.7 4.8 7.2 11.0 23 17.1 10.4 12.5 11.4 14.0 20.1 17.1 5.9 2.8 4.3 4.8 3.3 4.1 7.2 5.9 11.1 7.2 91.2 76.2 83.7 84.7 80.3 82.5 86.5 89 87.7 90.8 94 92.5 89.6 87.1 88.3 26.2 21.1 23.5 12.3 10.9 11.6 29.7 7.6 19.0 5.7 7.2 20.2 14.2 17.2 70.3 76.0 73.2 72.1 72.0 72.0 58.4 64.0 61.2 68.1 72.2 70.2 4.6 9 74.1 81.5 77.8 9.1 97 98 Annex 2C. BSS indicators for younger OSY M Tigray F Total n= 300 Knowledge of HIV prevention methods 85.3 39.0 62.2 44.3 42.3 43.3 62.8 65.8 64.3 No incorrect beliefs about HIV/AIDS 52.0 18.3 35.2 32.0 47.3 39.8 Comprehensive knowledge about AIDS 44.7 10.0 27.3 At least one stigmatizing attitude towards PLWHA Ever had sexual intercourse Had sexual intercourse in the last 12 months (% of ever had sex) Condom use with last non-commercial partner (% of those who had sex in the last 12 months) Ever had HIV test n= 600 n= n= 309 317 n= 626 M n= 301 Amhara F Total BSS indicators Consistent use of condoms (% of those who had sex in the last 12 months) n= 300 M Afar F Total n= n= 313 614 Percentage Oromia M F Total n= n= 585 585 n= 1170 M n= 302 Somali F Total Beneshangul-umuz M F Total M SNNPR F Total n= n= 299 601 n= 300 n= 302 n= 602 n= 210 n= n= 240 450 53.2 52.1 52.6 33.1 40.5 36.8 60.3 29.8 45.0 53.3 42.5 47.6 38.5 37.4 37.9 46.8 38.6 42.7 47.0 22.7 34.9 42.7 49.3 46.0 66.2 49.6 57.3 23.6 26.5 25.1 28.9 30.7 29.5 31.6 25.0 28.3 22.2 15.7 19.0 26.7 19.9 23.0 37.6 28.8 32.9 98.0 84.6 91.9 99.3 97.7 98.5 98.6 100 99.3 99.0 99.3 99.1 99.7 96.0 98.0 98.7 81.7 91.3 99.0 99.6 99.3 35.0 22.0 28.5 28.8 35.3 32.1 26.2 23.0 24.6 33.5 34.9 34.2 27.8 27.8 27.8 30.0 20.9 25.4 25.2 22.9 24.0 79.0 42.4 64.9 74.2 56.3 64.2 46.8 43.1 45.0 61.7 64.2 63.0 44.0 61.4 52.7 65.6 30.2 54.2 73.6 67.3 70.4 73.2 61.5 71.0 50.0 30.0 38.9 67.6 44.8 57.6 59.5 53.0 56.0 60.5 66.7 64.0 61.0 60.9 61.0 51.4 64.9 58.1 63.6 36.4 59.1 2.3 1.6 2.0 47.6 21.4 32.7 1.7 0.3 1.0 55.6 39.6 44.4 6.1 3.2 4.6 36.4 37.7 37.1 1.6 3.8 2.7 31.6 58.3 46.5 4.4 4.3 4.4 47.5 0.7 34.8 43.9 3.8 2.2 44.4 6.3 43.2 43.8 4.2 5.1 continued... Annex 2C. BSS indicators for younger OSY (continued…) M Gambella F Total Harari M F Total M Percentage Addis Ababa F Total M Dire Dawa F Total M National F Total BSS indicators n= 302 n= 302 n= 604 n= 301 n= 303 n= 604 n= 421 n= 405 n= 826 n= 276 n= 294 n= 570 n= 3607 n= 3660 n= 7267 Knowledge of HIV prevention methods 25.8 25.8 25.8 76.7 50.5 63.6 53.2 44.7 49 55.4 49.7 52.5 54.7 44.6 49.6 No incorrect beliefs about HIV/AIDS 45.4 22.8 34.1 91 59.4 75.2 33.5 26.4 30 43.1 44.6 43.9 47.8 37.5 42.6 Comprehensive knowledge about AIDS 15.6 10.6 13.1 70.8 36.0 53.3 18.3 17.3 17.8 31.5 35.0 33.3 31.3 23.1 27.2 At least one stigmatizing attitude towards PLWHA 94.9 100 97.4 99.3 99.0 99.2 96.6 98.5 97.5 97.4 97.6 97.5 98.2 96.3 97.3 Ever had sexual intercourse 62.3 45.4 53.8 28.9 30.7 29.8 39.7 30.1 35 41.7 20.7 30.9 34.7 29.2 31.9 Had sexual intercourse in the last 12 months (% of ever had sex) 67.6 54.0 61.8 46.0 40.9 43.3 62.3 48.4 56.4 60.9 62.3 61.4 62.5 53.7 58.5 Condom use with last non-commercial partner (% of those who had sex in the last 12 months) 38.5 21.5 32.2 100 56.4 78.5 62.8 33.9 51.6 65.7 28.9 52.8 60.2 45.3 53.7 28.6 1.7 15.4 2.5 23.5 2.1 70.7 2.0 19.8 6.1 51.4 4.0 50 3.4 19.6 10.1 39.7 6.7 23.5 5.1 13.2 1.4 22.5 3.2 42.5 2.8 30.6 3.8 37.4 3.3 Consistent use of condoms (% of those who had sex in the last 12 months) Ever had HIV test 99 100 Annex 2D. BSS knowledge indicators and components for younger OSY M Tigray F Total M Afar F Total M Percentage Amhara Oromia F Total M F Total M Somali F Total BSS indicators n= 300 n= 300 n= 600 n= 309 n= 317 n= 626 n= 301 n= 313 n= 614 n= 585 n= 585 n= 1170 n= 302 n= 299 Ever heard of STIs 69.3 50.7 60.0 68.9 67.5 68.2 89.0 82.1 85.5 85.8 87.9 86.8 73.5 Ever heard of HIV/AIDS Using condom correctly at all times can protect from HIV (Yes) 99.7 82.3 91.0 96.1 95.0 95.5 98.7 98.7 98.7 97.9 98.3 98.1 n= 601 Beneshangul-Gumuz M F Total n= 300 n= 302 n= 602 39.8 56.7 53.7 23.2 38.4 95.4 83.3 89.4 99.0 96.0 97.5 92.7 54.3 73.5 57.9 68.5 63.3 77.4 72.0 74.6 68.7 71.8 70.3 42.7 42.1 42.4 65.3 49.0 57.1 Abstaining from sexual intercourse can protect from HIV (Yes) 93.0 67.3 80.2 71.5 63.1 67.3 83.1 87.5 85.3 76.9 73.5 75.2 69.9 79.3 74.5 94 60.3 77.1 Having one uninfected faithful partner can protect from HIV (Yes) 96.0 63.0 79.5 68.9 73.5 71.2 87.4 88.2 87.8 79.3 79.0 79.1 86.1 77.6 81.9 94.7 52.6 73.6 Healthy looking people can spread HIV (Yes) 78.0 58.7 68.3 66.7 70.1 68.7 66.8 77.6 72.3 68.9 61.0 65.0 62.3 41.1 51.7 86.3 71.2 78.7 Sharing meals can spread HIV (No) 82.7 61.3 72.0 60.5 76.7 68.7 81.1 79.9 80.5 80.5 78.8 79.7 71.2 58.2 64.7 77.3 68.5 72.9 Mosquito bite can spread HIV (No) 69.3 33.3 51.3 55.3 67.8 61.7 62.1 47.9 54.9 72.3 62.2 67.3 68.2 53.7 61.1 59.3 74.5 66.9 Eating uncooked egg laid by a chicken that has swallowed used condom can spread HIV (No) 40.8 14.2 28.8 18.5 34.6 26.6 23.9 19.1 21.5 53.6 31.1 42.3 53.5 35.7 45.3 35.4 37.6 36.5 Eating raw meat prepared by an HIV infected person can spread HIV (No) 37.5 31.6 34.8 33.7 56.1 45.0 49.5 55.7 52.6 53.6 40.5 47.0 42.0 50.2 45.8 44.4 35.2 39.9 Drinking local hard liquor or eating hot pepper can protect from HIV (No) 80.3 74.1 77.5 61.6 79.0 70.2 79.5 71.2 75.2 86.4 85.2 85.8 89.9 90.0 89.9 89.6 76.9 83.3 Willingness to share meal with HIV positive person (No) 46.2 27.9 37.9 62.0 41.0 51.3 39.1 45.6 42.4 50.6 68.8 59.7 41.3 49.8 45.3 54.9 54.1 54.5 continued... Annex 2D. BSS knowledge indicators and components for younger OSY (continued...) Percentage Tigray Afar Total Amhara M F Total Somali M F M F M F M F BSS indicators n= 300 n= 300 n= 600 n= 309 n= 317 n= 626 n= 301 n= 313 n= 614 n= 585 n= 585 n= 1170 n= 302 n= 299 Willingness to buy food from an HIV positive shopkeeper/food seller (No) 72.6 60.3 67.0 68.4 34.9 51.5 51.8 57.2 54.5 50.6 68.8 59.7 34.0 If member of family became ill with HIV, would respondent want it to remain a secret (Yes) 24.7 21.9 23.4 53.5 29.6 41.5 27.3 22.3 24.8 33.7 24.5 29.1 Willingness to care for male relative infected with HIV (No) 33.4 13.4 24.4 18.2 13.6 15.9 13.3 12.5 12.9 9.8 Willingness to care for female relative infected with HIV (No) 32.4 15.0 24.5 22.6 13.6 18.1 12.8 11.3 12 An HIV infected student should be allowed to continue school (No) 65.6 46.6 57.0 71.4 80.4 75.9 93.2 86.2 An HIV infected teacher should be allowed to continue teaching (No) 31.1 16.6 24.5 20.2 18.6 19.4 23.0 PLWHA should be quarantined (Yes) 26.8 25.1 26.0 52.2 38.2 45.2 HIV positive woman can transmit the virus to her unborn child (Yes) 71.0 85.4 77.7 80.8 91.0 Knows the existence of ARV* for PMTCT** (% of above) 17.8 5.2 11.6 4.2 HIV positive mother can transmit the virus to her baby through breastfeeding (Yes) (% of those who knew PMTCT) 62.9 78.4 70.0 59.9 71.0 2.2 Total Oromia Total Beneshangul-Gumuz Total M F n= 300 n= 302 n= 602 47.8 40.4 54.9 51.4 53.2 43.8 35.7 40.0 65.0 30.0 47.7 16.9 13.3 35.8 19.7 28.3 5.7 25.2 15.3 10.1 14.4 12.3 36.5 20.1 28.9 11.4 24.5 17.9 89.8 82.4 85.9 84.1 68.1 69.9 68.9 75.4 56.9 66.3 20.2 21.6 19.2 20.2 19.7 30.9 28.1 29.6 22.6 24.5 23.5 27.8 32.0 30.0 37.0 28.4 32.7 31.6 35.7 33.5 33.0 40.0 36.5 86.0 83.8 78.3 81.0 75.7 81.0 78.4 88.9 83.5 86.4 65.3 65.5 65.4 3.1 15.7 15.3 15.5 16.8 14.2 15.4 8.6 4.8 11.3 12.1 11.7 65.6 62.3 63.1 62.7 62.5 70.8 66.6 72.9 88.8 80.3 56.6 84.8 70.5 n= 601 6.9 Total Note: *ARV = antiretrovirals; **PMTCT = pregnant mother-to-child transmission. continued... 101 102 Annex 2D. BSS knowledge indicators and components for younger OSY (continued…) Percentage SNNPR M F Total Gambella Harari Addis Ababa Dire Dawa National M F Total M F Total M F Total M F Total M F BSS indicators n= n= n= 210 240 450 n= 302 n= 302 n= 604 n= 301 n= 303 n= 604 n= 421 n= 405 n= 826 n= 276 n= 294 n= 570 n= n= 3607 3660 n= 7267 Total Ever heard of STIs 95.2 90.4 92.7 79.1 66.9 73 91.7 85.8 88.7 87.2 87.9 87.5 81.2 82.7 81.9 79.8 71.1 75.5 Ever heard of HIV/AIDS Using condom correctly at all times can protect from HIV (Yes) Abstaining from sexual intercourse can protect from HIV (Yes) Having one uninfected faithful partner can protect from HIV (Yes) Healthy looking people can spread HIV (Yes) Sharing meals can spread HIV (No) Mosquito bite can spread HIV (No) Eating uncooked egg laid by a chicken that has swallowed used condom can spread HIV (No) Eating raw meat prepared by an HIV infected person can spread HIV (No) Drinking local hard liquor or eating hot pepper can protect from HIV (No) Willingness to share meal with HIV positive person (No) Willingness to buy food from an HIV positive shopkeeper/food seller (No) 99.0 99.6 99.3 98.7 93.7 96.2 100 98.0 99.0 96.7 97.8 97.2 99.3 97.6 98.4 98.1 94.4 96.5 68.1 58.8 63.1 34.1 45.7 39.9 81.1 70.0 75.5 77.4 65.7 71.7 60.0 55.1 57.9 66.6 60.6 63.6 81.0 71.7 76.0 78.8 53.3 66.1 95.7 75.9 85.8 71.0 69.9 70.5 83.7 66.7 74.9 81.0 70.1 76.8 82.4 67.5 74.4 76.5 58.6 67.5 93.0 72.3 82.6 76.0 72.3 74.2 80.4 62.6 71.2 83.1 70.7 75.5 78.1 64.2 70.7 63.9 46.7 55.3 96.0 83.5 89.7 71.5 67.4 69.5 62.7 54.8 58.6 72.4 63.4 67.9 92.4 85.8 88.9 80.1 61.3 70.7 97.3 84.8 91.1 80.8 75.3 78.1 72.1 84.7 77.2 79.4 74.1 76.8 85.7 83.3 84.4 76.2 50.0 63.1 95.3 73.9 84.6 50.1 42.0 46.1 85.1 72.4 78.6 69.8 59.4 64.5 63.9 53.6 58.4 65.8 20.5 43.7 80.7 67.3 74.1 43.5 23.2 33.5 44.9 55.1 50.1 47.6 34.9 41.3 61.1 61.9 61.5 56.7 43.1 50.1 54.5 52.2 53.3 50.6 41.2 46.0 51.5 74.9 63.5 48.8 48.4 48.6 96.2 93.3 94.6 80.9 71.0 76.1 97.3 94.9 96.2 86.0 79.5 82.8 89.4 89.5 89.5 85.0 82.2 83.6 23.1 27.6 25.5 36.9 57.6 47.0 31.2 22.2 26.8 33.4 39.4 36.4 36.5 25.8 31.0 35.5 37.5 36.5 36.5 42.3 39.6 31.3 67.8 49.1 51.5 36.4 44.0 49.1 56.6 52.8 43.1 30.3 36.5 45.5 47.6 46.6 continued... Annex 2D. BSS knowledge indicators and components for younger OSY (continued…) Percentage SNNPR M F Harari Addis Ababa Dire Dawa National M F Total M F Total M F Total M F Total M BSS indicators n= n= n= 210 240 450 n= 302 n= 302 n= 604 n= 301 n= 303 n= 604 n= 421 n= 405 n= 826 n= 276 n= 294 n= 570 n= n= 3607 3660 n= 7267 If member of family became ill with HIV, would respondent want it to remain a secret (Yes) 23.6 32.6 28.4 37.9 33.2 35.6 20.9 21.5 21.2 28.7 29.3 29.0 33.6 15.0 24.1 33.6 24.8 29.2 Willingness to care for male relative infected with HIV (No) 10.1 10.0 10.1 27.5 35.3 31.3 3.0 7.1 5.0 13.5 13.9 13.1 17.5 13.6 15.5 14.1 14.6 14.4 Willingness to care for female relative infected with HIV (No) 7.7 17.4 30.0 23.6 4.0 7.7 5.9 15.2 11.6 13.4 17.9 15.0 16.4 14.1 13.1 13.6 An HIV infected student should be allowed to continue school (No) 89.9 85.8 87.7 52.3 70.7 61.3 97.3 94.9 96.2 82.1 82.8 82.4 83.6 86.1 84.8 79.9 79.3 79.6 An HIV infected teacher should be allowed to continue teaching (No) 5.8 13.8 10.1 18.5 37.1 27.5 2.3 11.4 6.9 19.7 22.2 20.9 19.0 25.1 22.1 16.2 19.7 17.9 PLWHA should be quarantined (Yes) 14.9 14.2 14.5 36.2 48.8 42.3 6.1 8.0 22.1 20.5 21.3 13.5 15.3 14.4 24.6 24.7 24.7 HIV positive woman can transmit the virus to her unborn child (Yes) 83.7 93.7 89.0 50.3 65.4 57.7 73.4 82.5 77.9 80.1 80.1 80.1 90.1 80.8 85.4 76.4 80.4 78.4 4.1 9.5 7.3 8.4 19.0 6.5 12.9 17.5 11.6 14.5 56.3 70.2 63.1 62.0 75.6 69.0 62.8 75.1 68.9 7.9 Total Gambella 7.8 Knows the existence of ARV* for PMTCT** (% of above) 19.0 48.7 35.7 18.5 7.0 11.9 59.7 HIV positive mother can transmit the virus to her baby through breastfeeding (Yes) (% of those who knew PMTCT) 82.7 64.4 85.8 75.8 51.0 76.7 63.5 Note: *ARV = antiretrovirals; **PMTCT = pregnant mother-to-child transmission 7.0 30.5 71.7 77.3 F Total 103 104 Annex 2E. BSS indicators for older OSY Percentage Tigray M F BSS indicators n= 305 Knowledge of HIV prevention methods No incorrect beliefs about HIV/AIDS Comprehensive knowledge about HIV/AIDS At least one stigmatizing attitude towards PLWHA Ever had sexual intercourse Total Afar Amhara M F Total M M n= n= 295 600 n= 240 n= 248 n= 488 n= n= 288 279 86.6 60.0 73.5 51.9 41.3 46.6 73.7 77.1 75.3 55.4 31.5 43.7 47.3 40.9 44.1 52.1 24.4 35.8 97.7 77.0 Had sexual intercourse in the last 12 months (% of ever had sex) Condom use with last non-commercial partner (% of those who had sex in the last 12 months) Consistent condom use (% of those who had sex in the last 12 months) Ever had HIV test F Total M F Total M n= 567 n= n= 585 572 n= 1157 n= 300 n= 299 n= 599 n= 298 n= 302 n= 600 n= n= n= 305 260 565 65.6 55.2 60.5 38.3 63.5 50.9 71.8 45.0 58.3 70.5 51.9 61.9 55.0 54.1 54.7 54.2 42.7 48.5 61.0 35.1 48.1 53.4 58.9 56.2 69.2 68.1 68.7 34.7 23.5 29.1 42.2 48.4 45.3 43.2 29.4 36.4 26.3 27.4 26.9 36.9 25.8 31.3 52.5 43.8 48.5 83.0 91.6 99.6 96.0 97.8 98.6 100 99.3 99.3 98.6 99.0 99.7 96.5 99.1 99.0 74.8 86.8 98.4 98.8 98.6 42.0 59.8 71.5 66.8 69.3 73.0 40.9 57.3 72.5 64.5 68.5 60.3 71.2 65.8 89.9 85.4 87.7 74.4 60.8 68.1 75.7 47.6 66.0 68.4 41.8 55.4 60.7 38.6 52.9 56.1 55.3 55.7 61.3 59.2 60.2 83.2 32.9 58.6 66.5 65.2 66.0 68.4 59.4 66.7 46.1 24.2 37.5 53.8 43.9 51.3 66.5 43.6 55.8 55.9 62.3 59.2 62.1 54.7 60.2 71.1 61.0 66.8 34.3 40.0 35.4 51.3 9.6 34.8 47.8 35.0 44.5 44.0 30.5 37.7 38.7 51.6 45.5 42.2 44.8 42.9 59.3 38.6 50.6 5.9 2.8 4.4 5.1 12.5 7.3 5.9 6.7 3.4 11.7 7.6 6.9 9.9 F SNNPR M 5.8 Total BeneshangulGumuz Somali Total 4.4 F Oromia 6.3 6.1 5.9 6.3 F 8.1 Total 7.5 continued... Annex 2E. BSS indicators for older OSY (continued...) Gambella Percentage Addis Ababa Harari Dire Dawa National M F Total M F Total M F Total M F Total M F Total BSS indicators n= 300 n= 301 n= 601 n= 306 n= 305 n= 611 n= 290 n= 310 n= 600 n= 286 n= 284 n= 570 n= 3503 n= 3454 n= 6957 Knowledge of HIV prevention methods 39.7 39.2 39.4 85.0 49.5 67.3 59.7 50.3 54.8 68.9 55.6 62.3 65.0 53.7 59.4 No incorrect beliefs about HIV/AIDS 54.7 32.6 43.6 93.5 64.9 79.2 46.6 34.5 40.3 62.6 54.9 58.8 59.2 46.6 53.0 Comprehensive knowledge about HIV/AIDS 25.7 17.3 21.5 80.1 33.1 56.6 29.3 20.0 24.5 48.6 41.9 45.3 43.2 30.1 36.7 At least one stigmatizing attitude towards PLWHA 91.6 97.3 94.0 99.7 99.7 99.7 97.5 96.3 96.9 98.2 97.9 98.0 98.1 94.7 96.4 Ever had sexual intercourse 93.0 86.4 89.7 66.7 46.6 56.6 71.4 43.5 57.0 67.1 50.4 58.8 74.2 60.2 67.3 Had sexual intercourse in the last 12 months (% of ever had sex) 71.0 55.8 63.6 48.5 35.2 43.1 57.0 53.3 55.6 61.5 48.3 55.8 64.6 49.3 57.8 Condom use with last non-commercial partner (% of those who had sex in the last 12 months) 61.6 28.5 46.9 91.5 57.4 80.1 60.3 35.6 50.0 62.3 39.1 53.6 63.6 45.5 56.6 Consistent condom use (% of those who had sex in the last 12 months) Ever had HIV test 45.9 2.0 21.5 2.3 35.1 2.2 72.3 2.0 13.3 9.8 53.2 5.9 42.7 6.4 22.6 17.9 35.2 12.3 30.6 6.9 14.5 3.5 24.4 5.2 45.5 5.7 30.7 7.4 39.8 6.6 105 106 Annex 2F. BSS knowledge indicators and components for older OSY Tigray BSS indicators M n= 305 F Total n= n= 295 600 Afar M n= 240 F n= 248 Total n= 488 Amhara M n= 288 F n= 279 Total n= 568 Percentage Oromia M n= 585 F n= 572 Total n= 1157 Somali M n= 300 F n= 299 Total n= 599 Beneshangul-Gumuz M n= 298 F n= 302 Total n= 600 Ever heard of STIs 74.8 79.0 76.8 84.9 68.3 76.5 97.6 93.5 95.6 94.4 93.0 93.7 91.0 67.9 79.5 89.3 64.9 77.0 Ever heard of HIV/AIDS Using condom correctly at all times can protect from HIV (Yes) Abstaining from sexual intercourse can protect from HIV (Yes) Having one uninfected faithful partner can protect from HIV (Yes) Healthy looking people can spread HIV (Yes) Sharing meals can spread HIV (No) Mosquito bite can spread HIV (No) Eating uncooked egg laid by a chicken that has swallowed used condom can spread HIV (No) Eating raw meat prepared by an HIV infected person can spread HIV (No) Drinking local hard liquor or eating hot pepper can protect from HIV (No) Willingness to share meal with HIV positive person (No) 99.7 95.6 97.7 95.0 91.9 93.4 100 98.6 99.3 98.5 97.7 98.1 99.3 96.7 98.0 98.7 98.7 98.7 93.8 77.6 85.8 68.2 67.2 67.8 82.7 82.1 82.4 79.0 72.4 75.7 54.3 65.6 59.9 77.2 73.8 75.5 92.1 79.7 86.0 73.6 59.9 66.6 90.3 91.0 90.7 81.9 76.4 79.2 67.3 93.6 80.5 93.6 61.6 77.5 96.4 76.9 86.8 78.7 63.6 70.9 95.8 90.7 93.3 86 84.4 85.2 93.7 92.6 93.2 91.9 64.2 78.0 77.4 68.5 73.0 74.9 63.6 69.1 83.4 86.4 84.8 75.6 65.6 70.6 74.3 50.2 62.3 91.3 89.1 90.2 83.9 78.6 81.3 65.3 71.3 68.2 93.8 88.2 91 84.3 80.2 82.3 85.7 82.3 84.0 79.9 72.8 76.3 76.4 45.8 61.3 58.6 62.8 60.8 66.7 62.4 64.6 76.9 66.1 71.6 81.0 75.9 78.5 69.1 81.5 75.3 53.0 16.0 35.2 19.8 28.3 24.1 38.5 21.5 30.2 59.7 33.6 46.9 62.1 52.9 57.6 46.6 35.2 40.9 43.8 30.5 37.4 42.3 59.3 50.8 45.8 61.5 53.5 63.5 41.7 52.8 55.4 51.6 53.5 40.5 30.2 35.3 84.5 79.8 82.3 67.8 79.6 73.7 90.3 89.5 89.9 91.3 83.0 87.2 94.0 92.7 93.4 91.2 84.6 87.8 48.0 24.1 36.5 40.1 29.6 34.9 29.2 34.2 31.6 32.8 48.5 40.5 24.2 37.7 30.8 40.1 37.6 38.9 continued... Annex 2F. BSS knowledge indicators and components for older OSY (continued...) Tigray BSS indicators M n= 305 F Total n= n= 295 600 Afar M n= 240 F n= 248 Total n= 488 Willingness to buy food from an HIV positive shopkeeper/food seller (No) 70.7 53.5 62.5 48.5 31.0 39.7 If member of family became ill with HIV, would respondent want 41.9 24.3 33.1 it to remain a secret (Yes) 27.0 18.4 22.9 Willingness to care for male relative infected with HIV (No) 31.6 11.3 21.8 13.7 15.0 14.3 Willingness to care for female relative infected with HIV (No) 34.2 10.6 22.9 10.6 12.8 11.7 An HIV infected student should be allowed to continue school (No) 69.7 53.9 62.1 67.0 80.1 73.5 An HIV infected teacher should be allowed to continue teaching (No) 24.0 17.0 20.6 10.6 22.6 16.6 PLWHA should be quarantined (Yes) 21.5 20.6 21.0 36.6 32.9 34.7 HIV positive woman can transmit 71.8 88.5 80.1 the virus to her unborn child (Yes) 77.3 91.1 84.0 Knows the existence of ARV* for PMTCT** (% of above) 21.3 12.8 16.9 5.5 7.0 6.3 HIV positive mother can transmit the virus to her baby through breastfeeding (Yes) (% of those who knew PMTCT) 67.1 81.9 74.2 76.2 66.1 71.1 Note: *ARV = antiretrovirals; **PMTCT = pregnant mother-to-child transmission Amhara M n= 288 F n= 279 Total n= 568 Percentage Oromia M n= 585 F n= 572 Somali Total n= 1157 M n= 300 F n= 299 Total n= 599 Beneshangul-Gumuz M n= 298 F n= 302 Total n= 600 47.6 41.1 44.4 47.2 65.8 56.4 21.1 34.9 27.9 36.1 38.3 37.2 26.7 21.1 24.0 30.9 26.7 28.8 48.7 25.3 37.1 42.9 24.2 33.4 4.5 5.8 5.2 7.3 15.9 11.5 22.1 12.1 17.2 5.1 17.1 11.1 7.3 6.2 6.7 8.0 13.1 10.5 20.5 11.8 16.2 6.8 16.1 11.5 91.3 95.3 93.3 85.2 83.4 84.3 78.9 81.7 80.2 86.4 53.0 69.6 10.4 10.9 10.7 6.3 9.3 20.1 13.1 16.7 8.8 20.1 19.3 19.7 20.0 18.5 19.2 24.2 18.0 19.1 17.7 28.2 23 89.3 86.2 87.7 86.1 83.4 84.8 95.6 82.8 89.1 90.6 78.5 84.5 23.0 17.7 20.4 22.4 19.1 20.8 13.4 5.0 21.4 29.9 25.4 58.5 65.1 61.6 67.2 71.7 69.4 75.5 93.4 84.3 12.2 9.6 18.8 13.9 74.1 88.9 81.6 continued... 107 108 Annex 2F. BSS knowledge indicators and components for older OSY (continued…) Percentage SNNPR Gambella Harari Addis Ababa Dire Dawa National M F Total M F Total M F Total M F Total M n= n= n= n= n= n= n= n= n= n= n= BSS indicators 305 260 565 300 301 601 306 305 611 290 310 n= 600 n= n= 286 284 Ever heard of STIs 98.0 97.3 97.7 94.7 79.4 87.0 95.4 88.9 92.1 94.8 92.9 93.8 88.1 91.2 89.6 91.5 84.1 87.8 Ever heard of HIV/AIDS Using condom correctly at all times can protect from HIV (Yes) Abstaining from sexual intercourse can protect from HIV (Yes) Having one uninfected faithful partner can protect from HIV (Yes) Healthy looking people can spread HIV (Yes) 99.7 99.6 99.6 99.7 99.0 99.3 99.7 100 99.0 97.2 97.1 97.2 96.9 99.3 98.1 98.6 97.7 98.1 81.3 66.9 74.7 44.0 60.8 52.4 88.6 72.5 75.5 75.9 70.6 73.2 74.1 63.0 68.6 75.0 70.4 72.7 86.6 78.8 83.0 85.0 75.0 80.0 98.7 80.3 85.8 79.3 71.0 75.0 91.3 74.6 83.0 89.9 77.2 83.6 91.1 78.1 85.1 87.0 66.4 76.7 93.8 72.1 82.6 87.6 77.4 82.3 88.5 68.7 78.6 85.4 76.1 80.8 80.7 77.3 79.1 73.3 60.8 67.1 98.0 86.2 92.1 83.1 78.4 80.7 81.8 64.1 73.0 80.9 71.4 76.2 Sharing meals can spread HIV (No) 91.8 93.1 92.4 90.3 72.4 81.4 97.7 88.2 93.0 87.2 81.0 84.0 81.1 90.5 85.8 85.8 81.5 83.7 Mosquito bite can spread HIV (No) Eating uncooked egg laid by a chicken that has swallowed used condom can spread HIV (No) Eating raw meat prepared by an HIV infected person can spread HIV (No) Drinking local hard liquor or eating hot pepper can protect from HIV (No) Willingness to share meal with HIV positive person (No) Willingness to buy food from an HIV positive shopkeeper/food seller (No) If member of family became ill with HIV, would respondent want it to remain a secret (Yes) 90.5 91.2 90.8 83.0 62.8 72.9 96.4 81.3 88.9 56.6 44.5 50.3 86.7 81.7 84.2 77.0 68.3 72.7 75.3 49.8 63.6 69.2 32.2 50.8 85.6 71.1 78.4 52.1 33.6 42.5 56.7 57.1 56.9 57.4 39.1 48.4 77.0 62.5 70.3 62.2 43.0 52.6 56.7 52.1 54.4 55.7 39.5 47.3 55.2 73.8 64.6 55.4 48.5 52.0 94.7 95.8 95.2 81.6 82.9 82.2 99.3 92.8 96.1 90.8 86.0 88.3 91.3 90.1 90.7 89.4 86.7 88.1 13.5 14.7 14.0 46.0 36.1 41.0 27.5 23.9 25.7 18.4 30.6 24.7 24.9 25.9 25.7 30.5 33.6 32.0 24.0 31.3 27.4 25.8 50.7 38.2 49.5 36.1 42.8 40.8 43.2 42.0 30.0 28.7 29.3 59.4 56.4 57.9 19.1 25.5 22.0 28.4 26.2 27.3 17.4 21.6 19.5 27.7 25.9 26.8 40.1 10.3 25.0 31.5 23.0 27.3 F Total M F Total n= n= n= n= 570 3503 3454 6957 continued.. Annex 2F. BSS knowledge indicators and components for older OSY (continued…) Percentage SNNPR Gambella Harari Addis Ababa Dire Dawa M F Total M F Total M F Total M F Total M n= n= n= n= n= n= n= n= n= n= n= BSS indicators 305 260 565 300 301 601 306 305 611 290 310 n= 600 Willingness to care for male relative infected with HIV (No) 5.3 5.4 5.3 19.7 22.5 21.1 3.0 9.8 6.4 9.9 Willingness to care for female relative infected with HIV (No) 3.3 3.5 3.4 13.0 15.1 14.1 3.6 8.9 6.2 8.9 An HIV infected student should be allowed to continue school (No) 89.8 89.2 89.5 52.5 72.8 62.6 98.7 90.8 94.8 An HIV infected teacher should be allowed to continue teaching (No) 5.3 6.6 5.9 16.4 24.2 20.3 2.6 7.9 PLWHA should be quarantined (Yes) 11.5 7.3 9.6 24.1 40.6 32.3 5.6 7.2 HIV positive woman can transmit the virus to her unborn child (Yes) 82.6 91.9 86.9 62.2 67.4 64.8 77.0 Knows the existence of ARV* for PMTCT** (% of above) 16.3 47.9 31.7 21.0 6.0 13.2 HIV positive mother can transmit the virus to her baby through breastfeeding (Yes) (% of those who knew PMTCT) 74.7 84.2 79.0 67.2 81.2 74.2 Note: *ARV = antiretrovirals; **PMTCT = pregnant mother-to-child transmission. National Total M F Total n= n= 286 284 n= n= n= n= 570 3503 3454 6957 11.0 10.5 11.6 9.2 10.4 11.8 12.7 12.2 9.0 11.6 9.2 10.4 11.4 10.8 11.1 87.6 83.4 85.4 89.2 92.2 90.7 82.0 79.8 80.9 5.2 12.4 19.3 16.0 11.2 23.8 17.5 13.0 17.4 15.2 6.4 16.3 15.3 15.8 11.2 8.2 20.8 21.5 21.1 78.7 77.9 84.0 89.0 86.6 93.1 86.2 89.6 83.0 83.7 83.3 62.1 6.3 14.7 6.7 10.5 20.2 11.5 16.0 22.2 15.8 19.0 84.9 71.5 77.3 54.3 75.4 65.2 68.6 72.3 70.5 69.6 77.2 72.4 33.9 8.9 F 9.7 109 110 Annex 3A. BSS indicators for FSWs Percentage Bahir Dar (n = 344) Nazareth (n = 338) Liben-Borena (n = 350) Awassa (n = 348) Gambellan (n = 301) Addis Ababa (n = 460) Dire Dawa (n = 346) Total (n = 2487) Knowledge of HIV prevention methods 75.9 68.0 68.9 71.8 45.2 59.6 76.9 66.7 No incorrect beliefs about AIDS 19.5 29.0 22.0 50.0 31.2 24.1 52.9 32.3 Comprehensive knowledge about AIDS 15.1 17.5 17.4 38.8 18.3 17.4 42.8 23.7 Condom use with last paying client 80.2 96.7 94.9 97.4 77.4 92.4 100 91.6 Consistent condom use with paying client in the last 30 days (% of above) 90.6 94.8 78.0 97.1 81.1 92.0 98.6 90.8 At least one stigmatizing attitude towards PLWHA 91.9 97.9 98.9 59.2 100 92.2 77.2 88.1 Women reporting an STI symptom in the last 12 months 5.2 4.1 6.9 8.3 6.3 2.4 1.7 4.9 Women seeking treatment for STIs (% of above) 88.9 78.6 82.6 100 84.2 45.5 83.3 83.5 Ever had HIV test 6.4 7.1 8.6 4.0 6.0 13.5 4.9 7.7 BSS indicators Annex 3B. BSS knowledge indicators and components for FSWs Bahir Dar (n = 344) Nazareth (n =338) Liben-Borena (n = 350) Awassa (n = 348) Ever heard of STIs 94.2 99.4 96.0 98.3 Ever heard of HIV/AIDS 98.3 100 99.4 99.7 Using condom correctly at all times can protect from HIV (Yes) 89.0 94.1 83.7 Abstaining from sexual intercourse can protect from HIV (Yes) 87.8 80.5 Having one uninfected faithful partner can protect from HIV (Yes) 88.7 Healthy looking people can spread HIV (Yes) Sharing meals can spread HIV (No) Percentage Gambella (n = 301) Addis Ababa (n = 460) Dire Dawa (n =346) Total (n = 2487) 93.0 91.1 96.5 95.3 99.3 92.4 100 98.2 94.0 73.1 82.2 82.1 85.5 78.6 86.8 67.8 70.7 84.7 79.3 82.8 84.9 79.0 71.4 76.1 78.3 80.1 79.4 76.3 72.0 83.0 69.4 78.9 77.7 76.9 74.7 79.9 65.4 77.3 78.1 74.6 88.7 76.8 Mosquito bite can spread HIV (No) 27.0 46.7 39.4 69.8 51.2 29.8 68.2 46.6 Eating uncooked egg laid by a chicken that has swallowed a used condom can spread HIV (No) 4.1 22.5 9.7 53.4 16.9 15.9 37.9 22.7 Eating raw meat prepared by an HIV infected person can spread HIV (No) 42.2 42.9 39.7 51.4 51.2 32.2 73.1 46.8 Drinking local hard liquor or eating hot pepper can protect from HIV (No) 68.0 81.7 79.1 94.0 79.4 69.6 93.1 80.2 Willingness to share meal with HIV positive person (No) 57.6 41.7 61.7 27.6 39.2 47.6 32.9 44.3 Willingness to buy food from an HIV positive shopkeeper/food seller (No) 67.4 74.6 76.6 49.4 52.8 72.0 42.2 62.7 If a member of family became ill with HIV, would respondent want it to remain a secret (Yes) 19.8 27.2 19.4 13.2 28.2 30.7 15.6 BSS indicators 22.3 continued.. 111 112 Annex 3B. BSS knowledge indicators and components for FSWs (continued…) BSS indicators Willingness to care for male relative infected with HIV (No) Bahir Dar (n = 344) Nazareth (n = 338) Liben-Borena (n = 350) 10.2 20.7 14.9 Willingness to care for female relative infected with HIV (No) 9.9 19.5 PLWLA should be quarantined (Yes) 63.4 89.9 HIV positive woman can transmit the virus to her unborn child (Yes) 80.8 Knows the existence of antiretrovirals for pregnant mother to child transmission (% of above) HIV positive mother can transmit the virus to her baby through breastfeeding (Yes) (% of women who know transmission to unborn baby) Percentage Awassa Gambella (n = 348) (n = 301) Addis Ababa (n = 460) Dire Dawa (n =346) (n = 2487) Total 8.3 11.3 18.3 7.5 13.3 17.7 8.0 12.6 18.7 13.0 14.4 92.3 32.2 100 66.3 40.8 68.5 79.6 86.9 87.1 83.1 78.9 90.2 83.6 7.9 7.4 8.9 24.1 3.2 8.5 5.4 9.5 81.7 87.0 87.5 87.8 88.8 84.6 79.2 85.1 Annex 4A. BSS indicators for uniformed services, transporter workers, factory workers and rural populations Percentage Uniformed services Transport workers Rural population Factory workers Ground forces M n= 1250 Air force M n= 622 Intercity bus M n= 537 Minibus taxi M n= 510 Truckers M n= 746 M n= 434 F n= 165 Total n= 599 M n= 408 Farmers F Total n= n= 390 798 M n= 350 Knowledge of HIV prevention methods 78.5 73.8 71.3 72.0 61.7 55.1 30.3 48.2 32.8 1.8 17.7 20.9 28.0 24.5 No incorrect beliefs about HIV/AIDS 39.7 58.1 41.7 40.4 63.0 31.3 29.7 30.9 17.2 15.6 16.4 37.1 21.2 29.2 Comprehensive knowledge about AIDS 33.5 48.1 31.1 32.9 42.8 21.4 12.7 19.0 8.8 0.3 4.6 11.7 9.1 10.4 At least one stigmatizing attitude towards PLWHA 93.3 71.2 58.7 61.7 55.7 78.8 82.8 79.9 96.3 98.6 97.4 99.4 99.1 99.3 Ever had sexual intercourse 98.2 92.6 91.0 86.2 95.6 89.2 93.3 90.3 58.1 79.7 71.3 91.1 91.4 91.1 Had sexual intercourse in the last 12 months (% of ever had sex) 85.6 84.4 82.9 67.8 81.9 79.1 70.8 76.7 97.7 90.0 93.5 88.5 73.9 81.2 Condom use with last commercial partner (% of those who had commercial partner in the last 12 months) 90.7 88.2 97.1 98.8 90.7 100 NA NA NA* NA NA 50.0** NA NA Consistent condom use with commercial partners (% of those who had commercial partner in the last 12 months) 80.4 78.8 91.4 91.5 84.1 66.7 NA NA NA* NA NA 50.0 NA NA BSS indicators Ever had HIV test *Farmers had no commercial partners. Pastoralists F Total n= n= 353 703 15.6 27.3 10.9 7.1 10.3 NA NA NA 1.2 0.3 0.8 3.2 0.6 1.9 **Only two pastoralists had commercial partners and one of them did not use condoms (50.0%) . NA = data not available/not applicable. 113 114 Annex 4B. BSS knowledge indicators and components for uniformed services, transport workers, factory workers and rural populations Percentage BSS indicators Ever heard of STIs Ever heard of HIV/AIDS Using condom correctly at all times can protect from HIV (Yes) Abstaining from sexual intercourse can protect from HIV (Yes) Having one uninfected faithful partner can protect from HIV (Yes) Healthy looking people can spread HIV (Yes) Sharing meals can spread HIV (No) Mosquito bite can spread HIV (No) Eating uncooked egg laid by a chicken that has swallowed used condom can spread HIV (No) Eating raw meat prepared by an HIV infected person can spread HIV (No) Uniformed services Ground Air forces force M M n= n= 1250 622 96.8 97.1 99.8 99.5 Transport workers Intercity Minibus bus taxi Truckers M M M n= n= n= 537 510 746 97.8 95.1 94.6 99.4 99.2 96.5 Factory workers Rural population M n= 434 94.9 96.8 F n= 165 95.8 98.8 Total n= 599 95.2 97.3 M n= 408 35.4 99.0 Farmers F n= 390 5.7 90.8 Total n= 798 20.9 95.0 M n= 350 92.6 99.4 Pastoralists F n= 353 89.2 99.4 Total n= 703 90.9 99.4 96.3 92.4 76.7 77.1 69.6 65.2 52.1 61.6 41.4 5.6 23.9 25.1 31.4 28.3 85.3 80.8 94.0 95.1 91.2 85.3 66.9 80.0 74.8 47.2 61.3 80.9 82.6 81.5 91.5 95.1 95.5 95.3 88.5 84.8 63.6 79.0 81.4 65.9 73.8 79.6 84.6 81.7 84.0 83.1 81.5 80.6 90.6 78.8 79.4 79.0 45.5 47.7 46.4 83.7 59.0 71.3 73.0 89.4 89.9 90.6 82.6 78.6 73.8 77.1 60.9 46.9 53.8 58.3 52.4 55.0 51.1 72.2 50.7 52.0 70.9 40.6 39.0 40.1 35 36.7 35.7 52.0 40.0 45.8 2.6 3.2 29.4 35.4 56.7 3.1 1.2 2.5 8.9 14.4 11.5 11.6 4.0 7.7 41.9 49.8 40.8 42.5 54.8 34.6 20.2 30.6 39.9 29.5 34.6 45.4 22.4 33.6 continued... Annex 4. BSS knowledge indicators and components for uniformed services, transport workers, factory workers and rural populations. Percentage Uniformed services Ground Air forces force M M n= n= 1250 622 Transport workers Intercity Minibus bus taxi Truckers M M M n= n= n= 537 510 746 BSS indicators Drinking local hard liquor or eating hot pepper can protect from 82.4 92.2 90.7 89.4 HIV (No) Willingness to share meal with 56.1 28.3 22.5 20.9 HIV positive person (No) Willingness to buy food from an HIV positive shopkeeper/food 68.0 48.8 17.6 39.5 seller (No) If member of family became ill with HIV, would respondent want 6.9 11.5 15.4 19.8 it to remain a secret (Yes) Willingness to care for male 14.0 4.4 3.4 4.2 relative infected with HIV (No) Willingness to care for female 13.8 4.5 3.4 5.1 relative infected with HIV (No) An HIV infected co-worker should be allowed to continue working 76.2 35.7 26.4 19.4 (No) PLWHA should be quarantined 64.5 23.9 13.7 12.8 (Yes) HIV positive woman can transmit 94.5 93.5 89.7 88.5 the virus to her unborn child (Yes) Knows the existence of ARV* for 6.2 15.0 19.0 18.4 PMTCT** (% of above) HIV positive mother can transmit the virus to her baby through 85.2 69.0 71.2 72.1 breastfeeding (Yes) Note: *ARV = antiretrovirals; **PMTCT = pregnant mother to child transmissions Factory workers Rural population Farmers F Total n= n= 390 798 M n= 350 Pastoralists F Total n= n= 353 703 M n= 434 F n= 165 Total n= 599 M n= 408 87.4 80.0 76.4 79.0 78.4 58.2 68.5 66.9 67.4 67.1 19.0 36.0 50.3 40.0 81.2 88.4 84.6 89.1 88.6 88.8 31.3 54.8 70.6 59.2 79.7 89.3 84.2 91.1 94.6 92.8 23.6 21.9 19.6 21.3 10.1 42.1 25.1 6.9 5.7 6.3 3.2 7.4 11.7 8.6 46.3 58.8 52.1 12.1 65.0 38.6 4.7 13.8 10.4 12.9 48.3 60.2 53.8 14.7 65.2 40.1 21.8 29.0 23.9 27.6 58.2 78.8 67.8 74.7 67.8 71.2 8.9 25.8 21.0 24.5 70.6 72.9 71.5 86.8 67.4 77.1 84.0 84.3 92.0 86.4 84.9 68.9 77.4 80.2 78.3 79.3 19.2 14.4 4.7 11.5 5.0 0.0 2.9 17.1 2.6 9.9 71.3 69.8 74.8 71.2 77.7 86.4 81.8 70.9 86.7 78.8 115 Annex 5A. Characteristics of the focus group discussants – youth in three regional cities, August 2002 Location Target group Number of participants Level of education (grade completed) Bahir Dar Bahir Dar OSY - males OSY - females 10 11 1–12 9–12 Bahir Dar ISY - males 11 7–12 Bahir Dar ISY - females 10 9–12 Dire Dawa OSY - males 12 7–12 Dire Dawa OSY - females 10 7–12+ Dire Dawa ISY - males 10 7–12 Dire Dawa ISY - females 10 7–12 Jijiga OSY - males 10 0–12 Jijiga OSY - female 11 6–12+ Jijiga ISY - males 10 7–12 10 7–12 Jijiga ISY - females N.B. OSY = out-of-school youth; and ISY = in-school youth Annex 5B. Characteristics of the individual in-depth interviewees – youth in three regional cities, August 2002 Age (years) Level of education (grade completed) OSY - male 18 10 Bahir Dar OSY - female 18 10 Bahir Dar ISY - male 19 10 Bahir Dar ISY - female 22 9 Dire Dawa OSY - male Not recorded Not recorded Dire Dawa OSY - female 20 12 Dire Dawa ISY - male 15 9 Dire Dawa ISY - female 17 10 Jijiga OSY - male 21 12 Jijiga OSY - female 21 12 Jijiga ISY - male 16 Location Target group Bahir Dar 19 Jijiga ISY - female N.B. OSY = out-of-school youth; and ISY = in-school youth 116 9 10 Annex 5C. Characteristics of the focus group discussants – adult population groups and female sex workers (FSWs), August 2002 Target group Age range(years) Educational status Factory workers – males Min. = 35 Max. = 48 Illiterate = 2 Grade 1-6 = 5 Grade 7-10 = 2 Grade 11-12 = 2 Factory workers – females Min. = 27 Max. = 45 Not asked 8 Akaki Textile Factory Truckers – males Min. = 35 Max. = 48 Illiterate = 5 Grade 1-6 = 3 Grade 7-10 = 3 11 Mojo Intercity bus drivers – males Min. = 20 Max. = 61 Grade 7-12 = 7 >Grade 12 = 1 8 Addis Ababa bus station Minibus drivers – males Min. = 23 Max. = 29 Grade 7-12 = 8 8 Addis Ababa Pastoralists – females Min. = 22 Max. = 55 Illiterate = 10 10 Borena Pastoralists – males Min. = 24 Max. =49 Illiterate = 6 Grade 1-6 = 3 9 Borena Farmers – females Min. = 24 Max. = 40 8 Butajira Farmers – males Min. = 22 Max. = 65 Min. = 16 Max. = 25 Illiterate = 5 Grade 1-6 = 1 Grade 7-12+ = 2 Illiterate = 7 Grade 1-6 = 3 Illiterate-12th Grade 10 Butajira 9 Addis Ababa 9 Addis Ababa 6 Addis Ababa FSW – bar-based FSW – home-based FSW – street-based Min. = 18 Max. = 30 Grade 1-12 Min. = 15 Grade 1-8 Max. = 18 Note: Min. = minimum age; Max. = maximum age. No. of participants 11 Location Akaki Textile Factory 117 Annex 5D. Characteristics of the individual in-depth interviewees – adult population groups and female sex workers (FSWs), August 2002 Age (years) Location Target group Butajira Farmers – male 27 Read/write Butajira Farmer – female Read/write Addis Ababa Intercity bus driver -male 30 40 Addis Ababa Minibus driver – male 35 27 36 34 34 35 20 25 12th Grade completed Akaki Factory worker – female Akaki Akaki Factory worker – male Trucker – male Borena Pastoralist – male Borena Pastoralist – female Addis Ababa FSW – home-based Level of education 12th Grade completed Not asked 12th Grade completed 12th Grade completed Read/write Illiterate Illiterate Addis Ababa FSW – bar-based Illiterate N.B. OSY = out-of-school youth; ISY = in-school youth; FSW = female sex worker. Annex 6. Definitions of indicators used in Ethiopian BSS Indicators appropriate for all target groups No. Indicator 1 Percentage of target group who correctly identify three effective means of protecting themselves from HIV infection (prompted). Correct answers: sex with one uninfected faithful partner, abstain from sex, use condoms correctly with all sex partners Indicators appropriate for adults (non-FSWs) No. Indicator 1. Number of non-regular partners during past 12 months (‘non-regular’ defined as non-spousal, non-cohabitational). 2. Percentage of target group with commercial partners during past 12 months (‘commercial partners’ refers to individuals who received money for sex). 3. Percentage of target group reporting condom use during most recent sex act with non-regular partner in last 12 months. 4. Percentage of target group reporting consistent condom use with non-regular partners over past 12 months. 5. Percentage of target group reporting condom use during most recent sex act with commercial partner in last 12 months. 6. Percentage of target group reporting consistent condom use with commercial partners over past 12 months. 7. Percentage of target group reporting unprotected sex with any non-regular or commercial sex partner during past 12 months. 118 Denominator Entire sample Denominator Entire sample Entire sample Number who had non-regular partner in last 12 months Number who had non-regular partner in last 12 months Number who had commercial partner in last 12 months Number who had commercial partner in last 12 months Entire sample (sexually active respondents only) Indicators appropriate for youth No. Indicator 1. Median age at first sex. 2. Percentage of target group with non-commercial partners during past 12 months. 3. Percentage of youth reporting condom use in most recent sex act with non-commercial partner in last 12 months. 4. Percentage of youth reporting consistent condom use with all non-commercial partners over past 12 months. 5. Percentage of youth reporting condom use in most recent sex act with commercial partner. 6. Percentage of youth reporting consistent condom use with commercial partners over past 12 months. 7. Percentage of youth reporting unprotected sex with any non-regular or commercial sex partner during past 12 months. Indicators appropriate for female sex workers No. Indicator 1. Percentage of FSWs reporting condom use during most recent sex act with client. 2. Percentage of FSWs reporting consistent condom use with clients during past 30 days. Denominator Entire sample Entire sample Number who had at least one non-commercial partner in last 12 months Number who had at least one non-commercial partner in last 12 months Number who had at least one commercial partner in last 12 months Number who had at least one commercial partner in last 12 months Entire sample Denominator Entire sample Entire sample 119 List of contributors to the BSS round I BSS project office staff Dr Frehiwot Berhane, Project Manager Ato Shibabaw Hiruy – Project administrator W/o Simret Fetahi – Project secretary and accountant Ato Moges Wolde Amanuel Ato Fassil Hailu Database managers Ato Kefene Asfaw, Statistician, Central Statistical Authority, Consultant Ato Girmay Medhin, Statistician, Institute of Pathobiology, Addis Ababa University, Consultant Ato Negusu Worku, FHI–Ethiopia AtoYared Kifle, Alemaya University Dr Negussie Deyessa, Department of Community Health Ato Addis Tesfaye, FHI–Ethiopia Supervisors and Region Coordinators No. 1 2 3 Region Tigray Afar Amhara 4 Oromia 5 SNNPR 6 7 8 9 10 11 12 13 Somali Harari Dire Dawa Beneshangul-Gumuz Gambella Addis Ababa Addis Ababa Addis Ababa 120 Supervisor Dr Aregawi Akililu Ato Tamrat Assefa Dr Mesfin Eshetu Ato Mohamed Jemal Sr Elfnesh Bekele Dr Admas Tefera Ato Ambaye Degefa Ato Mohamed Jemal Dr Alemayehu Negash Dr Tesfaye Umeta Ato Yared Kifle Dr Tewodros G/Michael Sr Elfnesh Bekele Dr Reta Ayele Ato Abiy Shewarega Ato Zemed Atta Ato Daniel Merid Coordinator Ato Hayelom Asefa Ato Shumye Molla Ato Tilahun Yimaldu Ato Amir Mohamed Ato Abraham Bongassie Dr Kesela Desalegn Ato Afework Adefris Ato Afendi Basha Ato Daniel Assefa Dr Miliyon Wondabeky Ato Mersha Worku Ato Alemayehu Tadesse Moderators and interviewers (qualitative study) Dr Aida Girma Sr Eden Kifle Dr Nesredin Jami Ato Tesfa Demelew Ato Mesganaw Lijalem Ato Ambaye Degefa Sr Yegomawork Gossaye Dr Hana Yilma Interviewers/Data collectors by region Tigray interviewers name No 1 2 3 4 5 6 Interviewers Hailemichael Atsebeha Letay G/Egziabher Eyasu Legese Senait Tesfaye Tewodros Kitaw Hareguwa Zenebe Afar interviewers name No 1 2 3 4 5 Interviewers Shimels Yimam S/R Sofia Seide S/R Elsa Melaku Abdu Hassen Kidafo Afkea Amhara interviewers name No 1 2 3 4 5 6 Interviewers Abeba Muche Asnakech Tilahun Biresaw Asaye Tigist Girma Welelaw Tesfahun Mengstu Alemu Dire dawa interviewers name No 1 2 3 4 5 6 Interviewers Meseret Abebe Abinet Yohannes Samuel Lakew Sinidu Gebeyehu Zinash Gebeyehu Meaza Ketema 121 Harer interviewers name No 1 2 3 4 5 6 Interviewers Mawerdi Ali Weinshet Getachew Awegichew Zweidu Restem Ali Tamir Asaminew Jemal Bule Nazreth interviewers name No 1 2 3 4 5 6 Interviewers Abeba Tsegaye Aweke Besibihat Etaferahu Mamo Henok Girma Mekasha Aman Momina Abdurkader Awassa interviewers name No 1 2 3 4 5 6 Interviewers Mekides Bekele Alem Kebede Misrak T/Engi Alemayehu Wendmu Manyahlshal Alem Birhan Tesfaye Gambella interviewers name No 1 2 3 4 5 6 Interviewers Shimeles Tamirat Almaz Gudeta Tsigei Kitesa Esayas Hordofa Mantegbosh Tekilu Emebet Amella Benshangul-gumuz interviewers name No 1 2 3 4 5 6 Interviewers Habtamu Hailu Eshetu Adnew Debritu Zewge Mergitu Tolossa Meselech Bugi Befekadu Shimels Borena interviewers name No 1 2 3 4 5 6 122 Interviewers Aden Hussen Kia Duba Godana Gababo Hana Taye Mulu Mamo Roman Mohammed Butagira interviewers name No 1 2 3 4 5 6 Interviewers Kurabachew Taye Dirshaye Demse Aklilu Girma Senayt Yadeta Nigatuwa Mulualem Shibire Bekele Somaliya interviewers name No 1 2 3 4 5 6 7 8 Interviewers Meseret G/Kiristos Abdulwhab Mohammed Mhoammed Ahmed Hindiya Usman Mebratu Adefrs Muhdin Haji Frehiwot Gizaw Safie Mengstu Addis ababa interviewers name No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Interviewers Amenti Djaleta Birhan Mohammed Mulualem Ayalew Rahel Mersha Yeneneh Gashaw Yewelsew Mengste Genet Haile Mekonen Beyene Habtemariam Gebru Jerusalem Kifle Degene Tegenu Frezer Asfaw Solomon Geda Gessese Demsse Sisay Hagos Selamawit Mesfin Addis Alemayehu Wasihun Tesfaye Mehret Wube Menen Simon Mifta Musema Gizaw Assefa Hana Hile Meaza Menkir Melak Yizengaw 123