HIV/AIDS, SRH, Gender and Life Skills

Course Title: HIV/AIDS, SRH, Gender and Life Skills

Course Owner: To be decided by the Senate

Course Code: To be decided by the department

Placement: 1st Year, 1st Semester

Credit Hour: 3 Cr Hrs. (5ECTS)

Pre-requisite: None

Course Description:

This course is one of the preliminary courses given to undergraduate students( regular,
weekend and summer) with a frame work of building their life skills, in order to
promote sexual health, protect them from contracting HIV and other sexually
transmitted diseases and empower them to live positive life taking gender issues into
considerations. It is further designed to equip students with knowledge, skills and
attitudes needed to prevent HIV and STIs and bring positive behavioral changes on self.

Objective of the Course:

The general objective of ‘HIV and AIDS, Sexual Reproductive Health, Gender and Life
Skills’ course is to equip students with knowledge, attitudes and skills needed to deal
with HIV, sexual and reproductive health, and gender related issues with positive living
skills, and promote the physical, mental, emotional, behavioral and social wellbeing of
self.

Grading System: As per the harmonized Curriculum and respective Universities Senate Legislation
Contents
List of Abbreviations and Acronyms............................................................................................................6
MODULE I....................................................................................................................................................7
1.1. Overview of HIV and AIDS............................................................................................................8
1.1.1. Defining Common Terminologies.........................................................................................8
1.1.2. Facts about HIV and AIDS.....................................................................................................9
1.1.3. Magnitude and Current Status of HIV and AIDS.................................................................11
1.2. Mode of Transmission...............................................................................................................16
1.2.1. Natural History or Course of HIV Infection.........................................................................16
1.2.2. Mode of HIV Transmission.................................................................................................18
1.3. Risk and Vulnerability................................................................................................................19
1.3.1. Definition of Risk and Vulnerability....................................................................................19
1.3.2. Vulnerable Groups and High Risk Population.....................................................................20
1.3.3. Identified Risk and Vulnerability Factors............................................................................20
1.4. Common Misconception on HIV and AIDS.................................................................................22
1.4.1. Common Origins of Misconceptions..................................................................................22
1.4.2. Correcting Common Misconception on HIV and AIDS.......................................................23
1.5. Prevention Methods..................................................................................................................24
1.5.1. Primary Prevention............................................................................................................24
1.5.2. Secondary Prevention........................................................................................................27
1.5.3. Tertiary Prevention............................................................................................................27
1.6. Stigma and Discrimination.........................................................................................................28
1.6.1. Definition of Stigma and Discrimination............................................................................28
1.6.2. Common Forms of Stigmatizing.........................................................................................29
1.6.3. Consequences....................................................................................................................31
1.7. HIV Counseling and Testing.......................................................................................................32
1.7.1. Need for Counseling for HIV..............................................................................................32
1.7.2. Advantage of Testing.........................................................................................................32
1.8. Treatment, Care and Support....................................................................................................32
1.8.1. Basic Care and Support for PLHIV......................................................................................33
1.8.2. ARV Treatment..................................................................................................................34
1.9. HIV and AIDS and People with Disability....................................................................................36
1.9.1. Definition...........................................................................................................................36
1.9.2. HIV and AIDS and People with Disability............................................................................36
 1.10. Major Impacts of HIV and AIDS..............................................................................................36
1.11. HIV and AIDS Intervention.....................................................................................................37
1.11.1. Responses to HIV and AIDS at a National Level..................................................................37
1.11.2. Responses to HIV and AIDS at Community Level...............................................................38
MODULE II.................................................................................................................................................39
2.1. Basic Concepts and Definitions..................................................................................................40
2.1.1. Human Sexual Intercourse Cycle........................................................................................41
2.1.2. Factors Influencing Human Sexuality.................................................................................45
2.1.4. Reproductive Health..........................................................................................................51
2.2. Basic Anatomy and Physiology of Reproductive Organs............................................................52
2.2.1. Male Reproductive Organ..................................................................................................52
2.2.2. Female Reproductive Organ..............................................................................................53
2.2.3. Puberty..............................................................................................................................57
2.3. Sexual and Reproductive Health Rights.....................................................................................58
2.4. Common Adolescent Sexual and Reproductive Health Problems..............................................60
2.5. Sexually Transmitted Infections.................................................................................................61
2.5.1. Definition and Magnitude..................................................................................................61
2.5.2. Types and Common Symptoms of Sexually Transmitted Infections..................................61
2.5.3. Mode of Transmission........................................................................................................63
2.5.4. Prevention.........................................................................................................................63
2.5.5. Importance of Early Diagnosis, Treatment and Partner Notification.................................64
2.5.6. Treatment..........................................................................................................................64
2.5.7. Consequences of STIs.........................................................................................................64
2.5.8. Complications of Untreated STIs........................................................................................65
2.6. Unintended Pregnancy..............................................................................................................67
2.6.1. Definition...........................................................................................................................67
2.6.2. Teenage Pregnancy............................................................................................................67
2.6.3. Causes................................................................................................................................68
2.6.4. Magnitude.........................................................................................................................68
2.6.5. Prevention.........................................................................................................................68
2.6.6. Consequences....................................................................................................................69
2.7. Abortion.....................................................................................................................................69
2.7.1. Definition...........................................................................................................................69
2.7.2. Complications of Abortion.................................................................................................69
 2.7.3. Types of Abortion...............................................................................................................70
2.7.4. Magnitude.........................................................................................................................70
2.7.5. Causes of Unsafe Abortion.................................................................................................71
2.7.6. Prevention.........................................................................................................................71
2.8. Components of SRH Services.....................................................................................................73
2.8.1. Family Planning..................................................................................................................73
2.8.2. Methods.............................................................................................................................75
2.9. Youth Friendly Services..............................................................................................................76
2.9.1. Why Focus on Adolescent and Young People?..................................................................76
2.9.2. Abortion and Youth in Ethiopia..........................................................................................77
2.9.3. Reasons Youth Fail to Receive RH Care Service..................................................................77
2.9.4. Approaches for Working with Youth Directly.....................................................................77
MODULE III................................................................................................................................................78
3.1. Introduction...............................................................................................................................79
3.1.1. Definition of Gender and Related Relevant Terminologies................................................79
3.1.2. Gender Vs. Sex...................................................................................................................81
3.1.3. Characteristics of Gender...................................................................................................82
3.1.4. Power.................................................................................................................................82
3.1.5. Gender and Sexual Reproductive Health...........................................................................84
3.1.6. Gender Role.......................................................................................................................86
3.1.7. Gender Needs....................................................................................................................87
3.1.8. Gender Equity and Equality...............................................................................................88
3.2. Concepts of Gender Violence....................................................................................................89
3.2.1. Gender Violence................................................................................................................89
3.2.2. Gender-Based Violence......................................................................................................90
3.2.3. Violence against Women...................................................................................................90
3.2.4. Intimate Partner Violence..................................................................................................91
3.2.5. Types of Gender-Based Violence.......................................................................................91
3.2.6. Causes of GBV....................................................................................................................95
3.2.7. Consequences of GBV........................................................................................................95
3.3. Gender Issues in Ethiopia..........................................................................................................96
3.3.1. Gender-Related Problems in Ethiopia................................................................................96
3.3.2. Status of Ethiopian Women...............................................................................................97
3.4. Interventions of GBV..................................................................................................................98
 3.4.1. Medical..............................................................................................................................98
3.4.2. Psychosocial.......................................................................................................................98
3.4.3. Legal...................................................................................................................................99
3.4.4. Empowerment...................................................................................................................99
MODULE IV..............................................................................................................................................103
4.1. Concepts of Life Skills...............................................................................................................104
4.2. Significance of Life Skills to Deal with HIV/AIDS and Other SRH Problems..............................105
4.3. Major Components of Life Skill................................................................................................105
4.3.1. Knowing and Living with Self...........................................................................................105
4.3.2. Intrapersonal Skills...........................................................................................................124
4.3.3. Interpersonal Skills...........................................................................................................141
List of Abbreviations and Acronyms
AIDS Acquired Immune Deficiency Syndrome

ANC Ante Natal care

ART Anti-Retroviral Therapy

ARV Anti-Retroviral

BCC Behavior Change Communication

CSA Central Statistical Agency

EDHS Ethiopian Demographic Health Survey

GBV Gender-Based Violence

HEIs Higher Education Institutions

HIV Human Immunodeficiency Virus

IUD Intra-Uterine Device

FMoH Federal Ministry of Health

MTCT Mother-to-Child transmission

PLHIV People Living with HIV

PMTCT Prevention of Mother-to-Child Transmission

RTIs Reproductive Tract Infections

SRH Sexual and Reproductive Health

STD Sexually Transmitted Diseases

STI Sexually Transmitted Infection

UNAIDS Joint United Nations Program on HIV and AIDS

VAW Violence against Women

VCT Voluntary Counseling and Testing

WHO World Health Organization

CHAPTER-I
 CHAPTER ONE
I. HIV and AIDS (12 hours)
Chapter objectives

At the end of this chapter, students will be able to:

 Distinguish the differences between HIV and AIDS;

 Explain the modes of HIV and AIDS transmissions and prevention methods;
 Describe risk and vulnerability factors related to HIV and AIDS;
 Describe stigma and discrimination that among HIVinfected people and its impact in HIV
transmission and prevention experience;
 Elucidate the importance of HIV testing in the prevention, treatment, care and other support
services;
 Discuss the major impacts of HIV and AIDS on different development sectors;

Contents
I.1. Overview of HIV and AIDS

Activity 1

Dear students, have you ever heard people talking about terms, HIV, AIDS and people with HIV and AIDS
patients? If yes, with one or two of your classmates, please discuss about the terms and write your
answers on the spaces given below before you proceed to read the text about the terms.

HIV:

AIDS:

People living with HIV:

AIDS patients:

I.1.1. Defining Common Terminologies

HIV: the Human Immunodeficiency Virus, a virus that weakens the body’s immune system, ultimately
causing AIDS.
Affected persons: Persons whose lives are changed in any way by HIV and AIDS due to the broader impact
of this epidemic.

AIDS: Acquired Immuno Deficiency Syndrome, a cluster of medical conditions and the most advanced stage
of HIV infection.This represents the late clinical stage of infection with the HIV, which most often results in
progressive damage to the immune and other organ systems, including the central nervous system. It occurs
when infection with HIV destroys the body’s natural protection ability from illness. HIV destroys the CD4 T
lymphocytes (CD4 cells) of the immune system, leaving the body vulnerable to life-threatening infections and
cancers. The immune system weakens to the point where it can be invaded by "opportunistic" infections
(other diseases) and certain cancers. Opportunistic infections may not cause problems to healthy people, but
may cause serious or even life-threatening problems to people who have AIDS.

AIDS patients: Are people whose resistance to diseases is severely destroyed by HIV, to the extent that their
bodies fail to resist even mild disease and different manifestations of diseases appear.

ART: The use of HIV medicines to treat HIV infection is called antiretroviral therapy (ART). It involves
taking a combination of HIV medicines (called an HIV regimen) every day

Vulnerability: Refers to socio-economic disempowerment and cultural context, work or livingsituations that
make students more susceptible to the risk of infection and situations which put children at greater risk of
being involved in child labor.

People infected with HIV: People with HIV are those who are infected with HIV but have no symptoms.
They show the following characteristics:
 They do not fall ill on the very day HIV invades their body because the virus needs some time to
reproduce itself in the human body.
 The immunity of the persons has not been severely attacked so no remarkable symptoms are apparent.
 During the second to fourth week after HIV has enters their bodies, these people may have certain
clinical manifestations, similar to flu-like symptoms such as a fever, muscular pain or a rash.
 They often look healthy and live and work just like those who are not infected.

I.1.2. Facts about HIV and AIDS

Many people see HIV and AIDS as they are the same; and therefore make an assumption that someone who is
HIV positive is to die soon. This is a wrong assumption. Thus, it is important to distinguish between HIV and
AIDS.
HIV is an acronym that stands for human immunodeficiency virusthat causes AIDS.

H: Human–The virus infects only human beings,

I: Immunodeficiency- The virus weakens the immune system, the infection protection
capacity, and increases the risk of infection,
V: Virus - It is a virus that attacks the body. Thus, after invading the human body, HIV
destroys the T- lymphocytes in human body system and is multiplied rapidly to the
extent that it becomes difficult for an individual to develop a vaccine to combat the
virus.

HIV weakens the human body’s immune system, making it difficult to fight infection. A person may live for
ten years or more after infection, much of this time without symptoms or sickness, although they can still
transmit the infection to others. Early symptoms of AIDS include: chronic fatigue, diarrhea, fever, mental
changes such as memory loss, weight loss, persistent cough, severe recurrent skin rashes, herpes and mouth
infections, and swelling of the lymph nodes. Opportunistic diseases such as cancers, meningitis, pneumonia
and tuberculosis may also take advantage of the body’s weakened immune system. Although periods of
illness may be interspersed with periods of remission, AIDS is almost always fatal.

AIDS is the acronym for the term acquired immunodeficiency syndrome.

A: Acquired means not inherited;
I: Immune stands for immune system;
D: Deficiency refers to deficiency of CD4+ cells in the immune system and
S: Syndrome represents a group of signs and symptoms that occur together and
characterize a particular abnormality.

AIDS creates a deficiency of CD4+ cells in the immune system and makes the individual to show the signs
and symptoms that characterize the disease. AIDS is the disease of the immune system due to infection with
HIV. Our blood contains white and red blood cells. Normally the white cells fight off and kill any germs
which enter our bodies. They do this by eating up the germs and by producing chemicals called antibodies
which kill them. In this way, our bodies fight off many different germs and we stay healthy. Sometimes we
have symptoms of illness when our white blood cells are fighting the germs, but usually the white cells win
and we recover. HIV weakens the immune system by entering and destroying our white blood cells. As more
and more white cells are killed, the body becomes less and less able to fight off the many germs which live
around and in our body all the time. After some years the white blood cells are seriously damaged and the
germs, which normally do not cause problems, can cause deadly disease.

Certain white blood cells, called T cells, perform a crucial role in protecting people from disease. Some of the
T cells are "helper" cells that signal other cells to do their jobs. HIV attacks and destroys the "helper" T cells.
When enough cells are destroyed, the immune system does not work anymore and the patient acquires AIDS.
Having AIDS is defined as having HIV and one or more opportunist infections. AIDS is a fast spreading
disease that does not yet have any cure. It does not discriminate people based on age, sex, color, level of
social status, and so forth. It is a disease which can stay in the body for a long time (3-20 years) without any
symptom.

Research is currently under way into vaccines, but none is viable yet. Antiretroviral drugs are available that
slow the progression of the disease and prolong life. HIV is a
fragile virus, which can only survive in a limited range of Note:

conditions. It can only enter the body through naturally moist When a person is infected with HIV, the
places and cannot penetrate unbroken skin. Prevention person is known as “HIV-infected.” When
an HIV infected person is tested and the
therefore involves ensuring that there is a barrier to the virus, result shows positive, the person is known
for example condoms or protective equipment such as gloves as “HIV Positive.”
and masks (where appropriate), and that skin-piercing
equipment is not contaminated; the virus is killed by bleach,
strong detergents and very hot water.

I.1.3. Magnitude and Current Status of HIV and AIDS

Activity 2

Do you have any information about the time HIV and AIDS was noticed in the world for
the first time? Please share information with your classmates before the instructor gives
you information.
I.1.3.1. B
rief History of HIV and AIDS
The origin of HIV has been a subject of scientific research and debate since the virus was identified in the
1980s. In 1981, a few cases of rare diseases were being reported among gay men but it wasnot until mid-1982
that scientists realized the 'disease' was also spreading among other populations such as heterosexuals and
injecting drug users. Inthe same year, the 'disease' was finally named AIDS. It was only in 1983 that the HIV
virus was isolated and identified by researchers at the Pasteur Institute in France.

I.1.3.2. Magnitude and Current Status of HIV and AIDS

Activity 3

Discuss with your classmates and answer the following questions before you proceed to read the
text

1. what is the current status of HIV and AIDS globally, regionally and nationally?
2. Which parts of the world do you think have high prevalence of HIV?
3. Which specific part of Ethiopia has high prevalence of HIV?

I.1.3.2.1.
Global HIV Statistics according to the Joint United Nations Program on HIV and AIDS in 2016
 19.5 million people were accessing antiretroviral therapy in 2016
 36.7 million [30.8 million–42.9 million] people globally were living with HIV in 2016

 1.8 million [1.6 million–2.1 million] people became newly infected with HIV in 2016
 1 million [830,000–1.2 million] people died from AIDS-related illnesses in 2016
 76.1 million [65.2 million–88.0 million] people have become infected with HIV since the start of the
epidemic
 35.0 million [28.9 million–41.5 million] people have died from AIDS-related illnesses since the start
of the epidemic
 In 2016, there were 36.7 million [30.8 million–42.9 million] people living with HIV.

- 34.5 million [28.8 million–40.2 million] adults

- 17.8 million [15.4 million–20.3 million] women (15+ years)
 - 2.1 million [1.7 million–2.6 million] children (<15 years)
 Around 53% [39–65%] of all people living with HIV had access to treatment.
 Worldwide, 1.8 million [1.6 million–2.1 million] people became newly infected with HIV in 2016.
 Since 2010, new HIV infections among adults declined by an estimated 11%, from 1.9 million [1.6
million–2.1million] to 1.7 million [1.4 million–1.9 million] in 2016.
 New HIV infections among children declined by 47% since 2010, from 300,000 [230,000–370,000] in
2010 to 160,000 [100,000–220,000] in 2016.
 AIDS-related deaths have fallen by 48% since the peak in 2005.
o In 2016, 1 million [830,000–1.2 million] people died from AIDS-related illnesses worldwide,
compared to 1.9 million [1.7 million–2.2 million] in 2005 and 1.5 million [1.3 million–1.7
million] in 2010.
o Tuberculosis remains the leading cause of death among people living with HIV, accounting for
around one in three AIDS-related deaths.

full source
I.1.3.2.2. Regional HIV and AIDS Data 2016

In 2016, there were 5,000 new infections per day. Out of these, 64% were in Sub-Saharan Africa, out of these
400 are among children below age 15 and 45 are among adults above 15 years old. Out of these about 37%
are among 15-24 years old.
Table 1: Regional HIV and AIDS Data

Region PLWHIV New HIV AIDS-Related Total No. of People

Infections Deaths Accessing ARV
Eastern and 19.4 million 790,000 420,000 11.7 million
Southern Africa

Asia and the 5.1 million 270,000 420,000 2.4 million

Pacific

Western and 6.1 million 370,000 310,000 2.1 million

Central Africa

Latin America 1.8 million 97,000 36,000 1.0 million

The Caribbean 310,000 18,000 9,400 162,000

Middle East and 230,000 16,000 11,000 54,400

North Africa

Eastern Europe 1.6 million 190,000 40,000 434,000

and Central Asia

Western and 2.1 million 73,000 18,000 1.7 million

central Europe
and North
America

full sourc
Figure 1: Eastern and Southern Africa Data on HIV and AIDS

I.1.3.2.3. National HIV Data

According to 2014 Ethiopia progress reports on HIV response, HIV and AIDS has been a major health issue
in Sub-Saharan Africa for more than three decades. According to EPP Spectrum modeling, 2014Ethiopia has
one of the lowest HIV prevalence rates in East Africa, but it was estimated that in 2013 still 793,700 people
were found to live with HIV HIV positve out of which 200,300 were children. As per the same modeling, the
pediatric HIV population in Ethiopia were mostly older children who were vertically infected in earlier years
when the coverage and effectiveness of prevention of mother to child transmission (PMTCT) in the country
was low and MTCT rates was high, i.e., there were163,800 HIV positive children, aged 5-14 years,in 2013.

There were approximately 45,200 AIDS related deaths in 2013 and about 898,400 AIDS orphans in the same
year. HIV adult prevalence is estimated at 1.5% in 2011, the year in which the last Ethiopian Demographic
Health Survey (EDHS) was conducted and reduced in to 1.1% in 2015. However prevalence varies according
to age, sex, and geographical location. According to the 2011 EDHS report, adult prevalence was almost
twice as high among females compared to among males at 1.9% versus 1.0% respectively.

The distribution of HIV prevalence also varies by age, peaking earlier in females in the 30-34 years age group
compared to 35-39 years in males. Looking at the younger age groups, it can be seen that young women have
a two to six fold higher HIV prevalence than young men (ranging from 15-17 years: 0% males vs. 0.2%
females to 20-22 years: 0.1% males vs. 0.6% females). Marked variation in urban rural prevalence is also
reported in the 2011 EDHS with urban areas showing a seven fold higher HIV prevalence compared to rural
areas (4.2% versus 0.6%).
Figure 2: Age and Sex Distribution of HIV Prevalence, EDHS 2011

The HIV epidemic in Ethiopia is becoming more concentrated in urban areas and along major transport
corridors. DHS 2011 data showshigh HIV prevalence in large towns including Addis Ababa, the regional
capital increasing from 2005 to 2011. Higher prevalence in Addis Ababa and large towns may be associated
with labor migration to large urban areas and large scale construction projects as well as a growing service
industry.

Variations in HIV prevalence were also observed among regions. According to the 2011 DHS,Gambella
region and urban administrations of Addis Ababa and Dire Dawa have the highest prevalence while SNNPR
and Oromia regions have the lowest prevalence (see Figure 3). However, due to their large population size,
Oromia, Amhara and SNNPR regions have the largest people living with HIV (PLHIV) population. Thus
although these regions have a lower HIV prevalence they still bear a significant proportion of theepidemic
burden. Overall the HIV epidemic prevalence in Ethiopia can be summarized as heterogeneous.

Figure 3: HIV Prevalence by Region (EDHS, 2011)

 It is not updated
I.2. Mode of Transmission

I.2.1. Natural History or Course of HIV Infection

 Seroconversion
People infected with HIV usually develop antibodies within four to six weeks after being infected but, it may
take as long as three months until antibodies develop. The period of time between when a person is infected
with HIVand when the antibody test result is positive is called the ‘window period.’ Unlike other diseases,
having antibodies for HIV does not indicate protection but indicates infection.

When a recently infected person develops antibodies that can be

measured using a laboratory test, seroconversion is occurring. Some Note:

people may experience a glandular illness (fever, rash, joint pains, and A person who tests HIV negative but
enlarged lymph nodes)at the time of seroconversion. who has engaged in behavior within
the past 3 months that places him or
HIV testing detects antibodies or antigens associated with HIV in whole
her at risk of HIV should be tested
blood, saliva or urine. A person, whose blood test results show HIV again in 3 months.
infection, is said to be seropositive or HIV positive. A person whose
blood test results do not show HIV infection is said to be sero-negative or HIV-negative,

 Asymptomatic HIV Infection

A person who is HIV infected but looks and feels healthy is asymptomatic. None of the physical signs or
symptoms that indicate HIV infection is present. Whether they have symptoms or not, people who are HIV
positive can still pass the virus to others. The duration of the asymptomatic phase varies greatly from person
to person. Some adults may develop symptoms of HIV as quickly as few months after primary infection;
others may take as long as 15 years or more to develop symptoms.

 Symptomatic HIV Infection

A person who has developed physical signs of HIV and report symptoms related to HIV is called
symptomatic. The immune system weakens and CD4 counts decreases during this phase.

The progression of HIV depends on the type of virus, and specific host characteristics including general
health, nutritional and immune status.
 AIDS

Almost all people who are HIV-positive will eventually develop HIV-related disease and AIDS, the end stage
of HIV infection. As HIV infection progresses, the CD4 count continues to decrease and the infected person
becomes susceptible to opportunistic infections. An opportunistic infection is an illness caused by micro-
organisms such as virus, fungus, bacteria or parasite that might not cause illness in a healthy person but will
cause illness in a person who has a weakened immune system. People with advanced HIVinfection suffer
from opportunistic infections of the lung, brain, eyes, and other organs; including other parasitic, viral and
fungi infections and some types of cancers.

Antiretroviral treatment (ART) and prophylaxis and opportunistic infections treatment help preserve CD4
cells, lowers viral load and prolong the time it takes for HIV to progress to the symptomatic phase and
ultimately to AIDS.

I.2.2. Mode of HIV Transmission

HIV, which causes AIDS, is transmitted through body fluids, in particular blood, semen, vaginal secretions

Activity 4

 List down what you know about HIV ways of transmissions and compare your note with the
person seated next to you.
 Discuss which one is the most common way of transmission and why.

and breast milk. It has been established that transmission takes place in four ways:
 Note:
1) Unprotected sexual intercourse with an infected partner (the most
common) The most common route of
HIV transmission is through
a. Unprotected vaginal, oral or anal sexual intercourse;and
sexual contact, especially
b. Direct contact with body fluid: semen, cervical and vaginal heterosexual intercourse.
fluids.
2) Blood and blood products; through
a. Receiving infected blood or blood products (infected transfusions) and transplantation of an
infected organ or tissue;
b. The use of contaminated injection (sharing needles, jewelry, IV drugs, or injury from
contaminated needles or other sharp objects);
c. Sharing cutting tools (using contaminated skin-piercing instruments, such as scalpels, needles,
razor blades, circumcision instruments); and
d. Contact with broken skin (exposure to blood through cuts or lesions).
3) Transmission from infected mother-to-child (MTCT) during
a. Pregnancy in the womb;
b. Labor and delivery;and
c. During breastfeeding.

People do not get infected with HIV through:

 Casual physical contact, coughing, sneezing and dry kissing, by sharing toilet and washing facilities,
by using eating utensils or consuming food and beverages handled by someone who has HIV;
 Everyday casual contact with HIV infected people at school, university, work, home, or anywhere
else;
 Contact with forks, cups, clothes, phones, toilet seats, or other things used by someone who is
infected;
 Eating food prepared by an HIV-infected person;
 Mosquitoes’ bites or other insect bites.

I.3. Risk and Vulnerability

 Activity 5

Certain groups of people are more vulnerable to HIV infection than others. Divide the class into
five groups and let them list down issues under each factor that make students vulnerable to HIV.
1. Which groups of people do you think are more exposed to the infection?
2. What factors make them more vulnerable? Describe as many as possible factors (biological,
personal, environmental, societal, and economic factors).

I.3.1. Definition of Risk and Vulnerability

 Risk

Risk: is defined as the probability that a person may acquire HIV infection. Certain behaviors create, enhance,
and perpetuate risk. Risk is the probability that a person will acquire infection and/or disease. Certain
individual behaviours (such as unsafe sex) increase such risk. Risk is also influenced by multiple factors,
including aspects of individuals’ physical and psychological development, sexual history, history of abuse,
ability to negotiate, awareness of sexuality-related issues, access to support, and membership of social
networks;
 Vulnerability

Vulnerability:is defined as a possibility of an individual to be exposed to HIV infection. It results from a

range of factors that reduce the ability of individuals and communities to avoid HIV infection. Vulnerability
forms the backdrop to risk-taking, and arises from the broader social, political and environmental factors that
provide the context in which people act, and influence the kinds of risks they take. These contextual factors
include political economy, inequalities and exclusions relating to gender, ethnicity and sexuality, and
legislative context. The existence or absence of health and education programmes, and their accessibility,
capacity, content and delivery, also influence sexual health

I.3.2. Vulnerable Groups and High Risk Population

Vulnerable populationsare groups of people who are particularly exposed to HIV infection in certain
situations or contexts, such as adolescents (particularly adolescent girls), orphans, street children, people in
closed settings (such as prisons or detention centers), people with disabilities, migrants and mobile workers.
High risk (or key) populations are defined as a group within a community with a high risk for HIV as the
result of their engagement in some form of high-risk behavior/activities. In some cases, the behaviors sexual
partners may put the high risk population at risk. High risk populations are diverse in Ethiopia and have not
been monitored over time or are not well defined. However, some studies such as regional HIV synthesis have
been conducted and identified region specific high risk groups. Based on the current available information, the
most-at-risk populations in the country include the following:

 Female sex workers

 Men who have sex with men
 Injecting drug users
 Uniformed forces(police and armed forces)
 Young women (aged 15-24)
 Long distance drivers
 Conflicting/disagreeing couples
 Prisoners
 University and college students
 Migrant laborers including cross-border and mobile populations etc.
 Factory and construction worker

I.3.3. Identified Risk and Vulnerability Factors

The behavior related risk factors for HIV in Ethiopia including in higher educational institutions (HEIs) are:
 Multiple and concurrent sexual partnership
 Early sexual initiation start and sexual experimentation
 Unsafe sexual practice
 Those who practice transactional and intergenerational sex
 Repeated episodes of sexually transmitted infection (STIs) and low treatment seeking behaviors
 Lack of adequate knowledge and skills to protect one-self
 Injecting drug users

The vulnerability factors for HIV in Ethiopia including in HEIs are:

1) Biological
 Sex
 Age
2) Personal
 Lack of proper self-concept and value
 Lack of parental guidance or support information age
 Lack of open communication with parents and peers
 Inadequate problem solving, coping and decision making skills
 Substance abuse: Use of alcohol or drugs can make one careless about practicing safer sex
 Addiction to materials or graphics or films (internet pornography, porn videos, etc.) that arouse
sexual feeling.
3) Environmental Factors
 Inadequate life skills building programs
 Lack of youth friendly service and supplies: including information and education, PMTCT
services and STI control and prevention services
 Lack of information on service availability
 Inadequate income generation activities
 Inaccessible and inadequate basic HIV service, such as counseling services
 In tourist destinations: tourists use students as sex workers through dealers
 Mobility to big cities, constructions areas, etc.
 Lack of awareness, concrete facts and knowledge related to HIV and other SRH issues
 Surrounding environment like bars, ‘shisha’ and ‘chat’ houses, dealers around university
compounds.
4) Socio-cultural
 Peer pressure
 Harmful traditional practices like early marriage, female genital mutilation abduction, women
inheritance, acceptance of premarital and extramarital sexual practices
 Lack of comprehensive knowledge about HIV and AIDS, sexual and reproductive health by
society
 Religion, Beliefs and laws that stigmatize and disempowering certain populations and act as
barriers to essential HIV prevention.

5) Economic
 Inappropriate use of money by students
  Financially deprived students who exchange sex for money -Due to extreme poverty, young
women engage in transactional sex with older men, young men with older women, while many
women are forced to support their family by selling sex, putting them at greater risk of HIV
infection.
 Women disproportionately bear the burden of poverty due to lack of control over resources.

I.4. Common Misconception on HIV and AIDS

Activity 6

 List down common misconception about HIV and AIDS.

 What are the causes of the misconceptions?
 What perpetuates the misconceptions?

I.4.1. Common Origins of Misconceptions

Many people have different misconceptions about HIV and AIDS. The misconceptions arise from simple
ignorance and misunderstandings about scientific knowledge regarding HIV infections to misinformation
propagated by individuals and groups with ideological stances that deny a causative relationship between HIV
infection and the development of AIDS.

Below is a list of some common misconceptions.

 HIV is the same as AIDS
 Sexual intercourse with a virgin will cure AIDS
 HIV antibody testing is unreliable
 Sexual intercourse with an animal will avoid or cure AIDS
 HIV can be spread through casual contact with an HIV infected individual
 HIV-positive individuals can be detected by their appearance
 HIV cannot be transmitted through oral sex
 HIV is transmitted by mosquitoes
 HIV can infect only homosexual men and drug users
 An HIV-infected mother cannot have children
 HIV cannot be the cause of AIDS because the body develops a vigorous antibody response to the virus
 Only a small number of CD4+ T-cells are infected by HIV, not enough to damage the immune system
  AIDS can be cured.
 People cannot get HIV from tattoos or body piercing
 Incorporate 2016 DHS findings
I.4.2. Correcting Common Misconception on HIV and AIDS

In the absence of a vaccine or cure, information and education are vital components forHIV and
AIDSprevention programs. Misconceptions may only prevail in the absence of information and increased
knowledge of the community. Hence, using media and other methods, misconceptions must be clarified.

Mainstreaming HIV and AIDS in the curriculum is one way to prepare students to have comprehensive
understanding about HIV and AIDS, demystify misconceptions and increase the capacity of students to take
the necessary precaution.

You Cannot Get HIVfrom:

 Touching someone who has HIV

HIV cannot survive outside of the body so you won’t get HIV from touching someone, hugging them
or shaking their hand.

 Sweat, tears, urine or feces of someone who has HIV

There is no HIV in an infected person’s sweat, tears, urine or feces.

 Insects
You cannot get HIV from insects. When an insect (such as a mosquito) bites you it sucks your blood –
it does not inject the blood of the last person it bit.

 Air
HIV cannot survive in the air so coughing, sneezing or spitting cannot transmit HIV.

 New or sterilized needles

New needles cannot transmit HIV because they havenot been in the body of an infected person. If used
needles are cleaned and sterilized properly they can’t transmit HIV either.

 Water
HIV cannot survive in water, so you will not get HIV from swimming pools, baths, shower areas or
from drinking water.

 Toilet seats, tables, door handles, cutlery, sharing towels

 HIV doesnot survive on surfaces, so you cannot get HIV from any of these.

 Musical instruments
HIV cannot survive on musical instruments. Even if it is an instrument that you play using your
mouth, it cannot give you HIV.

 Kissing
There is such a small amount of HIV in the saliva of an infected person that HIV cannot be passed on
from kissing. There is only a risk if you both have large open sores or bleeding gums and blood is
exchanged.

 Tattoos and piercings

There is only a risk if the needle used by the professional has been used in the body of an HIV-
infected person and not sterilized afterwards.

 ‘I've already been exposed to HIV. No further need for protection’

Repeated exposure to HIV may be necessary for active illness to progress. Different type of HIV can
be contracted aggravating the problem.

I.5. Prevention Methods

Activity 7

1) List down prevention methods one can use to protect oneself from HIV infection?
2) Which of the prevention method/s do you apply to protect yourself and others from the HIV
infection?
3) Describe the different prevention interventions to reduce the spread of HIV.

Thus far, there is no vaccine to prevent HIV infection and no cure for AIDS but it is possible to protect
oneself and others from infection. HIV prevention could be done by individuals as they acquire knowledge
about HIV and avoid any behavior that allows the entrance of HIV-infected fluids such as blood, semen,
vaginal secretions, and breast milk into a body. In addition,government or other concerned bodiescan
instituteprevention of HIV transmission. The following are examples of prevention programs.

I.5.1. Primary Prevention

The goal of primary prevention is to provide information and education regarding transmission of HIV for the
general population. Through this process, individuals will be enabled to determine whether they themselves
may be at risk. Once this has occurred they can be helped to substitute low-risk behaviors for those that are
high-risk.

 ABC

A: Abstinence from sexual intercourse (only method that is 100% effective)

B: Be faithful, Have only one mutually faithful uninfected sexual partner
C: Consistentand Correct use of male or female condom can greatly lower the chances
of transmitting HIV through sexual intercourse.
D discussion, diagnosise
Tips to use male condom

The ABC strategy promotes safer sexual behavior, reduces sexual partners and encourages loyalty to them,
and delays introduction of sexual activity. The implementation of ABC method differs among people who use
it. Because the spread of HIV can be limited by informed and responsible behavior, practical measures such as
condom usage are also important means of supporting behavior change within workplaces, health care as well
as educational institutions.

 Blood Screening

 Donation of blood and blood products, such as an organ or tissue, by an HIV-positive individual could
lead to HIV infection in the recipient.
 International guidelines state that all blood products must be tested for viruses such as HIV.
 High-income countries test and screen all blood products which will identify those that need to be
disposed of if they contain HIV.
 Some low-income countries lack the equipment to test all blood, so there have been some examples of
donated blood products containing HIV. However, this is still very rare and people who donate blood
are often asked questions that will help determine if they have been at risk of HIV infection in the past.
 Avoid sharing cutting tools (using contaminated skin-piercing instruments, such as scalpels, needles,
razor blades, circumcision instruments); and the use of contaminated injection (sharing needles,
jewelry, IV drugs, or injury from contaminated needles or other sharp objects).

 Prevention of Mother to Child Transmission

  Prevention of mother to child transmission (PMTCT) of HIV can reduce rates of transmission by 92-99%.
This primarily involves the use of a combination of antivirals during pregnancy and after birth in the infant
but also potentially include bottle feeding rather than breastfeeding. If replacement feeding is acceptable,
feasible, affordable, sustainable and safe, mothers should avoid breast-feeding their infants; however,
exclusive breast-feeding is recommended during the first months of life. If exclusive breast feeding is
carried out, the provision of extended antiretroviral prophylaxis to the infant decreases the risk of
transmission.
 Avoidance of unwanted pregnancies among infected mothers.
 Use of antiretroviral therapy.

1.5.1.4 Safer Sex Practice

 Delaying sexual initiation

 One to one
 Practicing safer sex includes using a condom unless one is in a relationship with a partner who does not
have HIV or other sex partners.
 If one has sex with someone who has HIV, it is important to practice safer sex and to be regularly tested
for HIV.
 Talking about one’s sexual history is important to find out behaviors that increase your partner’s or your
risk for HIV.

 Socio-Behavioral Change

 Social strategies do not require any drug or object to be effective, but rather require persons to change
their behaviors to gain protection from HIV. Some social strategies which people consider include:
sex education, life skill programs and comprehensive sexuality education provided at school reduce to
engage in high-risk behaviors.
 Laws criminalizing HIV transmission have not been found an effective way to reduce HIV risk
behavior, and may actually do more harm than good. 

 Voluntary Counseling and Testing

Populations which receive HIV counseling and testing are less likely to engage in behaviors with high risk of
contracting HIV so HIV testing is almost always a part of any strategy to encourage people to change their
behaviors to become less likely to contract HIV.

HIV testing is the gateway to HIV prevention, treatment, care and other support services.People’s knowledge
of their HIV status through HIV testing services is crucial to the success of the responses made by the
government and other collaborating partners. It is through testing that one would get serious medical, social
and psychological interventions.

 Male Circumcision

The World Health Organization (WHO) and Joint United Nations Program on HIV and AIDS (UNAIDS) both
recommended male circumcision as a method of preventing female-to-male HIV transmission. Whether it
protects against male-to-female transmission is disputed and whether it is of benefit in developed
countries and among men who have sex with men is undetermined. For men who have sex with men there is
some evidence that the penetrative partner has a lower chance of contracting. On the other hand, Women who
have undergone female genital mutilation have an increased risk of HIV.

 Pre-Exposure Prophylaxis

Pre-exposure prophylaxis (PrEP) is a way for an HIV-negative person who is at risk of HIV infection to
reduce their risk of becoming infected with HIV. It involves taking anti-HIV drugs on a regular basis. PrEP
provides only partial protection from HIV infection and is not intended to replace consistent condom use, new
needles or other ways of preventing HIV.PrEP is a new HIV prevention method. It involves an HIV-negative
individual taking anti-HIV drugs in an effort to reduce their risk of becoming infected with HIV. A person at
risk of infection needs to take anti-HIV drugs on a regular basis, starting from before being exposed to HIV
and continuing afterwards. A person using PrEP needs to take the drugs exactly as directed.

 Post-Exposure Prophylaxis

A course of antiretroviral medicine will be administered within 48 to 72 hours after exposure to HIV-positive
blood or genital secretions is referred to as post-exposure prophylaxis (PEP). Treatment is recommended for
example, after sexual assault to decrease the risk further. The duration of treatment is usually four weeks and
is associated with significant rates of adverse effects including: nausea, fatigue, emotional distress and
headaches.

I.5.2. Secondary Prevention

This is also called positive prevention. The most effective strategy to stem the spread of HIV will probably be
a combination of behavioral, biological, and pharmacological interventions. Counseling and related
behavioral interventions for those living with HIV infection can reduce behaviors associated with secondary
transmission of HIV. Each patient encounter offers the clinician an opportunity to reinforce HIV prevention
messages. Getting treated for HIV can help prevent the spread of HIV to people who are not infected.
Increased use of ART is associated with decreased community viral load and reduced rates of new HIV
diagnosis. Hence, early detection and treatment is essential to reduce transmission of HIV.

Consistent and effective use of ART resulting in a sustained reduction in viral load in conjunction with
consistent condom usage, safer sex and drug use practices, and detection and treatment of sexually transmitted
diseases (STDs) are essential tools for prevention of sexual and blood-borne transmission of HIV. 

Secondary prevention is concerned with individuals who are already positive for HIV antibodies. They may
possibly be symptomatic for ARC or AIDS. The goal is to prevent them from being repeatedly exposed to
HIV and from transmitting HIV.

I.5.3. Tertiary Prevention

Tertiary prevention is concerned with preventing as many of the disabling aspects of AIDS as possible. It is
called the "Living with AIDS Model," and the intent is to maximize the living potential of the person with
AIDS, or HIV infection.

This is about reduction of disability, complications, severity of cases and prompt rehabilitation. Focusing on
living is the needed attitude that helps prevent and manage some of the hopelessness and other transitional
affective responses for the person who is ill, for their significant others and for the professional working with
him or her. It is providing psycho-social support and help people with AIDS have positive attitude and live
with dignity.

Male condom utilization demonstration

I.6. Stigma and Discrimination

Activity 8
I.6.1.
 What do you think are the causes of stigma and discrimination against people living with
D
HIV/AIDS and their relatives such as families?
 What are the consequences of stigmatizing and discriminating PLWHIV?
 Please take some minutes and discuss with a student (s) sitting next to you practical cases you
know and then report your answer to the whole class.

efinition of Stigma and Discrimination

 HIV-Related Stigma

HIV related stigma refers to the negative beliefs, feelings, and attitudes towards people living with HIV,
groups associated with PLHIV (e.g. the families of people living with HIV) and other key populations at
higher risk of HIV infection, such as people who inject drugs, sex workers, men who have sex with men and
transgender people.

Stigma and discrimination are often directed towards these groups simply because others disapprove of their
behaviors. Stigma also varies depending on the dominant transmission routes in a country or region. In sub-
Saharan Africa, for example, heterosexual relationship is the main route of infection; as a result, the HIV-
related stigma in this region, is mainly focused on sexual disloyalty and sex work. These people are
increasingly marginalized, not only from society, but from the services they need to receive so as to protect
themselves from HIV. Stigma towards people living with HIV is a wrong act. This is because not everyone
had the virus from wrong behavior. Even if it comes from unaccepted sexual behavior, we are all human and
we all make unwise choices. We therefore have to accept them and love them, but we need to take care not to
engage in any risky behavior with them.

 HIV-Related Discrimination

HIV-related discrimination refers to the unfair and unjust treatment through act or omission of an individual-
based on his or her real or perceived HIV status. Discrimination in the context of HIV also includes the unfair
treatment of other key populations listed earlier (e.g.sex workers, people who inject drugs, men who have sex
with men, transgender people, people in prisons and other closed settings).

In some social contexts, it may be directed at women, young people, migrants, refugees, and internally
displaced people. HIV-related discrimination is usually based on stigmatizing attitudes and beliefs about
populations, behaviors, practices, sex, illness, and death. Discrimination can be institutionalized through
existing laws, policies, and practices that negatively focus on PLWHIV and marginalized groups, including
criminalized populations. In general, AIDS-related stigma and discrimination means prejudice, negative
attitudes, abuse and maltreatment directed at people living with HIV and AIDS. Many people with HIV and
AIDS are rejected by family, friends and community. They are treated poorly at the hospital and school. Even
at places of worship, worshippers refuse to sit by them.

As seen in the preceding paragraphs, people living with HIV and groups associated with them such as their
families and other key populations at higher risk of HIV infection (e.g. people who inject drugs, sex workers,
gays and transgender people) are at the high risk of HIV-related stigma and discrimination. In order to take
appropriate measures against the risk of these malpractices, it appears important to know the causes of the
practices.

I.6.2. Common Forms of Stigmatizing

Stigma against PLHIV remains a significant issue in Ethiopia. EDHS routinely include four attitudinal issues
determining stigmatizing attitudes among the general population. These include:
 needing to keep HIV in the family a secret
 unwillingness to care for an HIV-infected relative
 unwillingness to accept female person with HIV to serve as teachers, and
 Unwillingness to purchase vegetables or food from a PLHIV shopkeeper or other people infected with
the virus.

HIV and AIDS-related stigma can lead to discrimination, this can happen for example, when PLWHIV are
prohibited from travelling, using healthcare facilities, or seeking employment. The following are different
forms of HIV stigma and discrimination.

 Self-Stigma

Self-stigma or internalized stigma has an equally damaging effect on the mental wellbeing of people living
with HIV. The fear of discrimination breaks down confidence to seek help and medical care. Self-stigma and
fear of negative community reaction can hinder efforts to address the HIV epidemic and make people feel
silenced and shamefulof the virus.

A speech by a woman from Vietnam below gives a good illustration of self-stigma.

 "I am afraid of giving my disease to my family members-especially my youngest brother who is so
small. It would be so pitiful if he got the disease. I am aware that I have the disease so I do not touch
him. I talk with him only. I don’t hold him in my arms now.’’(ICRW, 2012)

 Governmental Stigma

A country’s discriminatory laws, rules and policies regarding HIV can alienate and exclude people living with
HIV from different social services, reinforcing the stigma surrounding HIV and AIDS.

 Healthcare Stigma

Healthcare professionals can medically assist someone infected or affected by HIV, and also provide life-
saving information on how to prevent it. However, often healthcare is not confidential, contains judgment
about a person’s HIV status, behavior, sexual orientation or gender identity. These views are often fuelled by
ignorance about HIV transmission routes among healthcare professionals. This prevents many people from
being honest to healthcare workers when they seek medical help and fear discrimination if they say they are
sex workers, have same-sex relations, or inject drugs.

 Employment Stigma

In the workplace, PLWHIV may suffer stigma from their co-workers and employers, such as social isolation
and ridicule, or experience discriminatory practices, such as termination or refusal of employment. Fear of an
employer’s reaction can cause a person living with HIV anxiety:
"It is always in the back of my mind, if I get a job, should I tell my employer about my HIV status?
There is a fear of how they will react to it. It may cost me my job; it may make me so uncomfortable
that it changes relationships. Yet I would want to be able to explain about why I am absent, and going
to the doctors." (HIV-positive woman, UK)

By reducing stigma in the workplace (via HIV and AIDS education, offering HIV testing, and minimizing the
cost of antiretroviral) employees are less likely to take days off work, and be more productive in their jobs.
This ensures people living with HIV are able to continue working.
 Community and Household Level Stigma

Community-level stigma and discrimination towards people living with HIV can force people to leave their
home and change their daily activities. People living with HIV found that stigma in family settings - in
particular avoidance, exaggerated kindness and being told to conceal one's status - actively contributed to
psychological distress. Stigma and discrimination can also take particular forms within community groups
such as key affected populations.

I.6.3. Consequences

The WHOindicates that fear of stigma and discrimination has been the main reason for people to become
reluctant to get tested, disclose their HIV status and take antiretroviral drugs. The epidemic of fear,
stigmatization and discrimination has undermined the ability of individuals, families and societies to protect
themselves and provide support and reassurance to those affected. This hinders, in no small way, efforts at
stemming the epidemic. It complicates decisions about testing, disclosure of status, and ability to negotiate
prevention behaviors, including use of family planning services.

Research has shown that stigma and discrimination undermine HIV prevention, treatment, and care efforts by
making people afraid to seek HIV information, services, and modalities to reduce actions raise suspicion
about their HIV status. Fear of stigma and discrimination, which can also be linked to fear of violence,
discourages people living with HIV from disclosing their status even to family members and sexual partners
and undermines their ability and willingness to access and adhere to treatment. Thus, stigma and
discrimination weaken the ability of individuals and communities to protect themselves from HIV and to stay
healthy if they are living with HIV.
The consequences of stigma and discrimination are wide-ranging. Some people are avoided by family, peers
and the wider community, while others face poor treatment in healthcare and educational settings, erosion of
their human rights, and psychological damage. These all limit access to HIV testing, treatment and related
services.

The PLWHIV stigma index indicates that roughly one in every eight people living with HIV is denied health
services because of stigma and discrimination. HIV-related stigma and discrimination exist worldwide,
although they manifest themselves differently across countries, communities, religious groups, and
individuals. The possible consequences of HIV-related stigma to be the following:
  loss of income and livelihood
 loss of marriage and childbearing options
 poor care within the health sector
 withdrawal of care giving in the home
 loss of hope and feelings of worthlessness
 loss of reputation/respect

I.7. HIV Counseling and Testing

Activity 9

 Have you ever undergone VCT?

 What is the benefit of knowing one’s HIV status?
 How is counseling and testing a safe thing?

Define counseling
I.7.1. Need for HIV Counseling

People who go to VCT centers will have pre-test and post-test counseling. They will be informed of the
process for HIV testing and counseling and of their right to decline testing. The counseling is confidential and
will be done with their consent. The counselor assesses their risks and mentally prepares them to accept their
results whatever it may be. Readiness to accept result is important after risk assessment so that those who get
tested have realistic ideas about what it means to be infected with HIV or being HIV negative.
Principles of counseling

I.7.2. Advantage of Testing

 Identify one’s HIV status;

 Provide quality services for individuals, couples and families;
 Based on their status, link individuals and their families to appropriate HIV treatment, care and
support, as well as HIV prevention services;
 Support the scale-up of high impact interventions to reduce HIV transmission and HIV-related
morbidity and mortality through
o the provision of ART,
o voluntary medical male circumcision,
 o prevention of mother-to-child transmission,
o pre-exposure prophylaxis and
o Post-exposure prophylaxis.

I.8. Treatment, Care and Support

Even though there is no cure for HIV until this point in life, with proper care and treatment, most people with
HIV can avoid getting AIDS and can stay healthy for a long time. The good news is that HIV and its
complications can often be treated. With proper treatment with antiretroviral drugs, most infected patients can
lead relatively normal lives for many years. Even with the onset of AIDS, symptoms can be greatly
diminished by treatment. Treatment options include: treatments for infections, treatments for cancers, and
treatments for symptoms.

I.8.1. Basic Care and Support for PLHIV

In Ethiopia, more than 700,000 people are HIV positive and some of them have developed full-blown AIDS.
Treatment and care for people who are HIV positive and for their families are important. Many countries in
Africa including Ethiopia have developed community-based programs to deliver better care and support for
people with HIV and AIDS. There are a number of key things that can be done: Some of the care and support
programs include:

 Organizing counseling and emotional support for people with HIV and AIDS and their families.
 Setting up organizations and associations that bring together PLWHIV and AIDS to deal with HIV and
AIDS issues effectively.
 Setting up medical treatment to help people keep their immune systems strong and fight opportunistic
infections.
 Getting all on antiretroviral treatment.
 Organizing grants, food parcels and poverty alleviation projects to help families survive.
 Providing home-based care for people who are ill.

It is very important to incorporate nutrition, psychosocial support, and medical treatment. Counseling without
treatment and nutrition will not keep someone alive. Clinic treatment without home-based care will not
provide for people once they are bed-ridden. Hence, all are necessary.

 Psycho-Social Support
The stigma surrounding HIV and AIDS makes life more difficult for people living with HIV and AIDS and
their families. Loneliness, anxiety, stress, confusion, bitterness and depression can make people more
vulnerable to illness if they do not get any kind of support. Self and social stigma isolates PLHIV from their
community, which exacerbate their health conditions. Hence, they need a lot of emotional, spiritual,
psychological, social, physical and clinical support.

Psychological care could be providing mental health counseling, participating in family care and support
groups, create memory books, participate in cultural and age-specific psychological care, identification and
treatment of HIV-related psychiatric illnesses, and bereavement preparedness.

Forming support group or association is one of the effective ways to provide psycho-social care. Different
people and different institutions can provide some support, but it is important for people living with HIV and
AIDS to come together and support one another. People living with HIV and AIDS would know better what
their hopes, joys, anxieties, fears and needs are and they are the ones who should define how best they want to
be understood and treated. Hence, psycho-social support is one way to increase their quality of life.

 Poverty Alleviation and Food Programs

Keeping employment, generating income, or linking with those who provide food for those who cannot earn
their living is important intervention. Poverty exasperates the scourge of HIV. Social support includes
linkages to food support and income-generating programs, and other activities to strengthen the health and
well-being of affected households and communities.

 Home-Based Care

Some community-based programs provide home-based care and support services by community-based health
workers to vulnerable households for seriously ill family members or caring for orphans and vulnerable
children. This includes direct physical and emotional care and support services to PLWHA and orphan and
vulnerable children with the support of trained primary caregivers. Fortunately, HIV treatment has changed
the course of history lowering the death rate and increasing parents’ survival.

I.8.2. ARV Treatment

Antiretroviral drugs slow the progress of HIV because fewer HIV cells are formed. Antiretroviral treatment
(ART) is delivered as part of a comprehensive care, which includes VCT, the diagnosis and treatment of
STDs, tuberculosis (TB), opportunistic infections, and the PMTCT as well as the treatment of pregnant
women. ART changes a uniformly fatal disease to a manageable chronic illness.
Successful use of ART suppresses HIV viral replication, consequently slowing down disease progression,
improving immunity, and delaying mortality. ART does not cure the person with AIDS but prolongs and
enhances the quality of life of PLHIV. Once ART is started, it has to be taken for life time duration.

Adherence to taking the medication every day is a challenge for those who are vertically infected as well as
those who are psychologically unadjusted. However, taking HIV medications every day provides many
benefits. Among them, it:

 Allows HIV medications to reduce the amount of HIV in the body. Keeping the amount of virus in the
blood as low as possible is the best way to protect the health of PLWHIV.
 Helps keep the immune system stronger and enable to fight infections better.
 Reduces the risk of passing HIV to others for staying on treatment plan and keeping the amount of
HIV in the body as low as possible means that it is less likely that one can pass the virus to others.
 Helps prevent drug resistance, which the virus changes its form and no longer responds to certain HIV
medications. This is a problem because that drug no longer works on the person with HIV. Skipping
medications, even now and then, give HIV the chance to multiply rapidly by making it easier for drug
resistance to develop. HIV can also become resistant to the medications one is taking or to similar
drugs that the person has not yet taken. This limits the options for successful HIV treatment. Drug-
resistant strains of HIV can be transmitted to others, too.

 ART reduces viral load, ideally to an undetectable level. If one’s viral load goes down after starting
ART, then the treatment is working, and one should always take his/her medicine as prescribed by

Activity 10 it is better to call Mr.X or Y instead of naming

Read the following case study and answer the questions that follow individually first and then discuss your
answers with one or two of your classmates.

Yohannes is a second year student at Arba Minch University. When he went to a hosptial to get medical
treatment for his recurring cough, Yohannes was privately informed that he was HIV positive and needed to
take great precaution. However, he decided not to expose his status to anyone and not to change his behavior.
Even he was not interested to inform Meron, who was his only girlfriend for some time during his first year of
the university stay. He intended to have unprotected sex with other females.

Meron is a beautiful second year student from a poor family of Dire DawaCity Administration. After she
completed her preparatory school, she was involved in some construction activities going in the city
administration. She had different sexual partners at that time and often practiced unsafe sex. Currently, she is
dating another student, who knows neither his nor Meron’s HIV status.

1. What is the possible cause of Yohannes’ HIV infection?

2. What were the ethical and behavioral mistakes of Yohannes and Meron?
3. What are the possible reasons that Yohannes does not want to disclose his HIV status to others?
4. What were the risk and vulnerable factors of Yohannes and Meron behaviors?
 health care providers. Even when the viral load is undetectable, HIV can still exist in semen, vaginal
and rectal fluids, breast milk, and other parts of the body, so it is essential to continue taking steps to
prevent HIVtransmission.

I.9. HIV and AIDS and People with Disability special need

Activity 11
I.9.1.
De
1. How do you define disability?
2. How would HIV and AIDS affect people with disabilities?

finition

The WHO defines disabilities as an umbrella term, covering impairments, activity limitations, and
participation restrictions. Impairment is a problem in body function or structure; an activity limitation is a
difficulty encountered by an individual in executing a task or action; while a participation restriction is a
problem experienced by an individual in involvement in life situations. Disability is thus not just a health
problem. It is a complex phenomenon, reflecting the interaction between features of a person’s body and
features of the society in which he or she lives.

I.9.2. HIV and AIDS and People with Disability

It needs more elaboration

Some impairment may increase the vulnerability of people with disabilities. They can be double stigmatized if
they are HIV positive in addition to their disabilities. Awareness raising and preventive care as well as
disease management keeps people with disability healthy.

I.10. Major Impacts of HIV and AIDS

Activity 12

Divide the class into four groups. Let students discuss the following and present in class.

1. What is the impact of HIV and AIDS at the individual level on the HIV positive person?
2. What is the impact of HIV and AIDS at the family level?
3. What is the impact of HIV and AIDS at the community level?
4. What is the impact of HIV and AIDS at the national level?

HIV and AIDS is one of the most destructive diseases humankind has ever faced. It brings profound social,
economic and public health consequences. It is one of the world’s most serious health and development
challenges.

 As to its impact on an individual, HIV-infected persons are often discriminated by society. Proper
concern and care are seldom given by relatives and friends. In addition, finding out about their HIV
status can cause great stress and can let the individuals feel like being given a death sentence. They
tend to limit their interaction with others.
 It changes family composition and the way communities operate, affecting food security and
destabilizing traditional support systems.
 By eroding the knowledge-base of society and weakening production sectors, it destroys social capital.
 By inhibiting public and private sector development and cutting across all sectors of society, it
weakens national institutions.
 By affecting the military, it weakens the security of countries.
 By eventually impairing economic growth, the epidemic has an impact on investment, trade and
national security, leading to still more widespread and extreme poverty. The most devastating
consequences of HIV infection arise not simply because many people will die but because the deaths
will occur mainly among adults between the ages of 25 and 45 years, the very people who work to
support families and productive economically.

Therefore HIV/AIDS is changing the contours and dynamics of poverty through its demographic and
socio-economic impacts.

I.11. HIV and AIDS Intervention

Activity 13

Divide the class into three groups to discuss about the kind of interventions needed at different
levels to deal with HIV and AIDS.

1. Interventions by the government?

2. Interventions at the community level?
I.11.1. Responses to HIV and AIDS at a National Level

- Formulating HIV and AIDS policy

- Conducting HIV and AIDS surveillance activities
- Establishing a system and structure
- Formulating ARV Drugs Supply and Use Policy
- Developing Strategic Plan
- Availing ARV drugs
- Having updated data
- Non-discriminatory laws
- Monitoring and evaluating the progress on prevention as well as treatment.
I.11.2. Responses to HIV and AIDS at Community Level

- Establishing voluntary services

- Forming associations of HIV and AIDS
- Establishing different support groups
- Availing legal services
- Providing home-based care
- Availing treatment services
- Availing counseling services
- Availing spiritual services
- Developing awareness creation programs
- Providing linkage services to income generation activities

References
CHAPTER-II
II. Sexual and Reproductive Health (16 hours)
Activity 14

Let students define the following concepts related to the chapter.

1. What is sexuality?
2. What is sex and its different phases?
3. What is sexual health?
4. What is reproductive health?

Sexual and reproductive health is an important part of human life. All human beings have the basic human
right to enjoy good physical and mental health. Good health is not only the absence of disease but involves
physical, social, and emotional well-being. Many students who join university are in their last stage of
adolescence period; when life circumstances are changed, new behaviors are easily learned, and peer
influences is high forexploration and experimentation.

Adolescents have been exposed to various sexual and reproductive health (SRH) problems because of their
risky sexual behaviors and lack of necessary precautions. Since young people are suffering from the tragedy
of HIV and AIDS, there is a growing need to address sexual and reproductive health problems among HEI
students to safeguard against STIs, unintended pregnancy, HIV and AIDS and the like.

Therefore, the second part of the course presents about human sexuality, SRH and problems related toSRH.At
the end of this chapter, students will be able to:
 Describe sexuality, sexual and reproductive health
 Identify common SRH problems and their manifestations
 Enumerate various contraceptive options in family planning
 Elucidate sexual and reproductive rights
 Understand the skills to prevent sexual and reproductive health problems

II.1. Basic Concepts and Definitions

Sex refers to one's biological characteristics- anatomical (breasts, vagina, penis, etc.) that define one as a male
or female. A person’s sex is determined by their chromosomes, hormones and genitals. A person’s sex is
usually assigned at birth based on their genitals.
According to WHO’s definition, sexuality is a central aspect of being human throughout life and encompasses
sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction.Sexuality is
an expression of who we are as human beings. Sexuality is broader than sex. It includes the sense of how we
see ourselves, how the world sees us—male or female and our gender identity. We are all sexual beings, from
birth to death. Sexuality is about people and their intimate physical, emotional, sexual relationships, not just
body parts.Sexuality includes all the feelings, thoughts, and behaviors of being male or female, being
attractive, and being loved, as well as being in relationships that include intimacy and physical activity.

Sexuality is a fundamental aspect of human life: it has physical, psychological, spiritual, social, economic,
political and cultural dimensions. Sexuality cannot be understood without reference to gender. Diversity is a
fundamental characteristic of sexuality. The rules that govern sexual behavior differ widely across and within
cultures. Certain behaviors are seen as acceptable and desirable while others are considered unacceptable.
This does not mean that these behaviors do not occur, or that they should be excluded from discussion within
the context of sexuality education.

II.1.1. Human Sexual Intercourse Cycle

Sex may be used for sexual intercourse, which includes penile-vaginal, oral or anal sex. Sex is much more
than intercourse. Most people think “sexual intercourse” when they hear the word “sex,” but sex is about
intimacy and emotional closeness.Human sexual intercourse takes place in a stage whereby men and women
respond differently.

Phase I -DESIRE: A person’s body begins to respond sexually with sexual stimulation and desire. Men’s
first signs that their body is responding sexually is with erections. Women’s body reaction shows that the
vagina becomes wet or lubricates.Women’s sexual response is slower than men’s.

Phase II -EXCITEMENT: This is a stage where the sexual stimulation continues and excitement builds.The
body starts to become sexually excited. Physiologically, the basic process is the accumulation of blood in
parts of the body, especially the genitals, resulting in an erection of the penis or clitoris. Excitement is quicker
in men than in women. In many men, a few drops of fluid appear at the tip of the penis. The fluid may
contain some sperm and can contain HIV. This fluid reduces the acidity of the urethra. The body’s response
can be affected by age, alcohol, drugs and fatigue.

Phase III-ORGASM: This is the result of built up excitement and a stage where the climax is reached, a
sudden peak of pleasure. Both men and women experience sharp increases in pulse rate, blood pressure and
breathing rate during orgasm. Muscles contract throughout the body, including those in the hands and feet.
The process is similar in both sexes. In men, orgasm and ejaculation usually go together. In men, ejaculation
occurs in two phases. First, glands containing fluids (the seminal vesicles and prostate) contract and deposit
their fluids into a bulb at the base of the urethra; men feel these contractions as a sensation that ejaculation is
about to happen and cannot be stopped. In fact, it cannot be stopped. This is called the point of ejaculatory
inevitability. The second phase occurs when the urethral bulb and the penis contract rhythmically, forcing the
semen through the urethra and out the penis. Orgasm in women usually takes longer to achieve than in men.
Unlike men, women can have multiple orgasms or move from one orgasm to another within a short time.
Some women may ejaculate during orgasm. In female ejaculation, fluid (not urine) spurts out of the urethral
opening.

Phase IV -RESOLUTION: This is a stage whereby theerection goes down, body returns to normal state over
some time.Orgasm results in a massive release of muscular tension and blood from the engorged blood
vessels. The processes described above are reversed and the body returns to its usual state. Resolution
generally takes 15-30 minutes, though it may take longer if the person has not had an orgasm. For most men,
a period of rest, called the refractory period, is necessary before they are able to get another erection and have
another ejaculation. The length of this period varies (from a few minutes to 24 hours) according to the man’s
age, how exciting the stimulation is, and the amount of time since his last ejaculation. Young men have short
refractory periods and can often get erect again very quickly.

Human Sexual Response Cycle

EXCITEMENT:

 Penis becomes erect

Activity 15

Discuss the following

Questions.
 What do you  Clitoris becomes erect
notice about the  Nipples become erect
variations of men  Vagina gets wet
and women?  Inner lips of the vulva swell
Answer: Not all  Skin of the scrotum swells
parts of the cycle  Scrotum pulls up closer to the body
occur every time a  Heart rate increases
person gets  Blood pressure increases
sexually excited.  Pre-ejaculate appears at the tip of the penis
 Who gets sexually  Breath rate increases
excited more  Muscles become more and more tense
quickly, men or
women?
Answer: men
ORGASM
 Who achieves
orgasm more  Pulse rate increases even more
quickly, men or  Blood pressure increases even more
women?  Breathing rate increases even more
Answer: men
 Rhythmic contractions in the genitals
 After orgasm,
 Ejaculation
who takes longer
 Muscles contract throughout the body
time to return to a
 Feelings of intense pleasure
normal state, men
or women?
Answer: Women
 In these variations RESOULTION
(point to dotted
lines on the  Muscles relax
diagrams that  Breathing slows
show the  Heart rate slows
response without  Blood pressure goes down
orgasms), the  Penis becomes soft
person did not  Clitoris becomes soft
have an orgasm.
Do you think that
sex can be All sexual behaviors are somewhere on an intimacy continuum. At one end of
satisfying at times
a continuum of physical closeness is touching parts of the body that are public,
without orgasm?
Why or why not? such as face and hands; at the other end, touching private parts of the body,
Probing question:
such as breasts or genitals. There is a parallel continuum of emotional
Why do people
have sex? closeness. That is, there is information that one shares readily with others,
Answer: Sex can such as name or favorite hobbies. As one reveals oneself and trust develops,
be satisfying at
times without more can be safely shared. We should make decisions by asking: “How close
orgasm. do I want this person to be with me?” and not “How far do I want to go?”
Sometimes the
person
appreciates the
intimacy or the act
or it feels good
even though they
Humansexualityis an expression of who we are as human being, how people experience the erotic and express
themselves as sexual beings; the awareness of themselves as males or females; the capacity they have for
erotic experiences and responses. It can be described as the way someone is attracted to another person of the
opposite sex (heterosexuality), to the same sex (homosexuality), to both sexes (bisexuality), or attracted to no
sexes (asexuality). Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes,
values, behavior, practices, roles, and relationships. It is a function of one’s whole personality that is life long,
beginning from birth.

‘Being sexual’ is an important part of many people’s lives: it can be a source of pleasure and comfort and a
way of expressing affection and love or starting a family. It can also involve negative health and social
outcomes. Whether or not young people choose to be sexually active, sexuality education prioritizes the
acquisition and/or reinforcement of values such as reciprocity, equality, responsibility and respect, which are
prerequisites for healthy and safer sexual and social relationships.
Sexual practices require consent and being of age to make the right decisions.

Note:
Getting Consent

It is important to get consent in sexual situations because it prevents misunderstandings and rape as well as
sexual and emotional problems.
Consent means that both people agree on what they want to do and when and how they want to do.
Knowledge about sex is important to make decision on what you want to do sexually, and not to act confused
about it.
If one is not sure, then postponing the activity until certain is essential.
It is important to say clearly what you do and do not want to do – do not leave it up to the other person to
guess or ‘read your mind’.
If you get conflicting or confusing messages, ask direct questions. Donot assume you know what the other
person means.
Poor communication or lack of communication causes misunderstandings that can break friendships or
relationships.
Not all rapes or sexual assaults can be prevented but the more we know about sex and learn how to
communicate interest, the better

II.1.2. Factors Influencing Human Sexuality

Sexuality goes beyond sex (sexual intercourse) to include feelings about one’s own body (sensuality), the
ability and need to be close to someone else (intimacy), feelings of sexual attraction, and the capacity to
reproduce. Accordingly, it is possible to see these interaction with the following elements of “the five circles
of sexuality” developed for Youth-Friendly Service: Service Providers Guide Training Manual. Note the
interaction of all first four elements with each other, which are of course the healthy circles in human
sexuality, and the fifth unhealthy circle used to control others.
The Five Circles of Sexuality

 Sensuality

Sensuality is how our bodies derive pleasure. It is part of our body that deals with the five senses: sight, touch,
hearing, smell, and taste. Any of these senses when enjoyed can be sensual. The sensual- response cycle is
also part of our sensuality because it is the mechanism that enables us to enjoy and respond to sexual pleasure.
The sexual response cycle explains the sequence of physical and emotional changes that occur as a person
becomes sexually aroused and participates in sexually stimulating activities, including intercourse and
masturbation. Knowing how the human body derives pleasure and responds during each phase of the cycle
can enhance the relationship and help one pinpoint the cause of sexual dysfunction. Both men and women
experience these phases, although the timing usually is different.

Sensuality also involves our need to be touched and held by others in loving and caring ways. This is called
“skin hunger”. Adolescents typically receive less touch from family members than young children do.
Therefore, many teenagers satisfy their skin hunger through close physical contact with peers. Sexual
intercourse may result from adolescent’s need to be held, rather than from sexual desire.

Fantasy is another part of our sensuality. Our brain gives us the capacity to fantasize about sexual behaviors
and experiences without having to act on them.

 Intimacy and Relationships

Our ability to love, trust, and care for others is based on our level of intimacy. We learn about intimacy from
the relationships around us, particularly those in our families. Emotional risk taking is part of intimacy. In
order to have true intimacy with others, an individual must open up and share feelings and personal
information. We take a risk when we do this, but intimacy is not possible otherwise.

 Sexual Identity

Every individual has his or her own personal sexual identity. Four components make up an individual’s sexual
identity includes the following:
a) Biological Sex: based on physical and hormonal influence being male or female.
b) Gender Identity: this is based on natural sex but involves the feeling we have being male or female. This
process starts to from around age two, when a little boy or girl realizes that he or she is different from the
other sex. If a person feels like he or she identifies with the opposite biological sex, he or she often
considers him or herself –transgender. In the most extreme cases, a transgendered person will have an
operation to change his or her biological sex so that it can correspond to his/her gender identity.
c) Gender Roles: society’s expectation of oneself based on biological sex.
d) Sexual Orientation: is the fourth part of sexual identity. According to American Psychological
Association, sexual orientation refers to an enduring pattern of emotional, romantic, and/or sexual
attractions to men, women, or both sexes. Sexual orientation also refers to a person’s sense of identity
based on those attractions, related behaviors, and membership in a community of others who share those
attractions. Research over several decades has demonstrated that sexual orientation ranges along a
continuum, from exclusive attraction to the other sex to exclusive attraction to the same sex. However,
sexual orientation is usually discussed in terms of three categories: heterosexual (having emotional,
romantic, or sexual attractions to members of the other sex), gay/lesbian (having emotional, romantic, or
sexual attractions to members of one’s own sex), and bisexual (having emotional, romantic, or sexual
attractions to both men and women). This range of behaviors and attractions has been described in various
 cultures and nations throughout the world. Many cultures use identity labels to describe people who
express these attractions.

 Sexual Health

WHO defined sexual health as a state of physical, mental and social well-being in relation to sexualit. It
requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of
having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. It is something
that enhances personality, communication, and love; including the right to sexual information and the right to
pleasure. Sexual health involves our behavior related to produce children, enjoying sexual behaviors, and
maintaining our sexual and reproductive organs. Issues like sexual intercourse, pregnancy, and sexually
transmitted infections are part of our sexual health.

Sexual health and reproductive health are overlapping and intertwined concepts. Thus, the combined term
"sexual and reproductive health" has emerged to include all aspects of sexuality, reproduction and health.
State of health and well-being:

 Physical, mental, and social well-being related to sexuality and reproduction

 Freedom to enjoy sexual relations without fear of pregnancy, disease, abuse of power, sexual
coercion, and violence
 Equal balance of power in sexual relations
 Respect for bodily integrity and the right to control one’s own body

Sexual reproductive health has the following components:

1. Prevention of unplanned pregnancy and family planning
2. Improvement and provision of maternal and child health, including infant feeding choices
3. Promotion of gender equity and equality
4. Prevention and management of sterility
5. Prevention and management of sexually transmitted infections and reproductive tract infections
including HIV/AIDS
6. Early diagnosis and treatment of breast cancer and reproductive tract cancers.
7. Adolescent reproductive health
8. Prevention of unsafe abortion and post abortion care
9. Reduction of harmful practices
 Sexuality to Control Others

This element of sexuality is not healthy. Unfortunately, many people use sexuality to violate someone else or
get something from another person. Rape is a clear example of using sex to control somebody else. Sexual
abuse and sex work are others. Even advertising often sends messages of sex in order to get people to buy
products. This also can be said as sexualizationwhich is defined as using sex or sexuality to influence,
manipulate or control other people's behaviors including seduction, and withholding sex from a partner to
'punish' the partner or to get something, offering money for sex, selling products with sexual messages, sexual
harassment, sexual abuse and rape.

II.1.3. Sexual Dysfunctions

Sexual difficulties may begin early in a person's life, or they may develop after an individual has previously
experienced enjoyable and satisfying sex. It may develop gradually over time, or may occur suddenly as a
total or partial inability to participate in one or more stages of the sexual act. The causes can be physical,
psychological, or both.

 Organic Factors
 Vascular, endocrine, neurological
 Illnesses anddisabilities (diabetes, arthritis, cancer, multiple sclerosis, stroke)
 Spinal cord injuries, cerebral palsy

Coping mechanism: help the clients accept limitations and explore options.

 Cultural Influences
 Negative childhood learning about sexuality
 Narrowly defined sexuality
 Rigid goals often leading to performance anxiety

 Individual Factors
 Lack of sexual knowledge andwrong attitudes
 Low self-concept and body image;
 Emotional problems
  Sexual abuse and assault

 Relationship Factors
 Unresolved problems – dislike, resentment, anger, lack of trust, respect, and power.
 Ineffective communication– Inaccurate assumptions, reliance on gender stereotypes and lack of
listening and negotiations.
 Fears about pregnancy or STI/Ds
 Concealment of true sexual orientation

 Difficulties Expressed on Sexual Response Cycle

Sexual Difficulty can be in understood by segregating the difficulties in to sexual response cycle Phases

II.1.3..1. Desire Phase Difficulties

• Hypoactive sexual desire/inhibited sexual desire: it is low or absent sexual desire which is usually
temporary; often due to relationship problems, past abuse, internalized – attitudes.
• Dissatisfaction with frequency of sexual activity: inability to compromise! The reason is differing
levels of desire, polarization: one feels deprived, other feels pressured.
• Sexual Aversion Disorder: extreme, irrational fear of sexual activities or ideas; consistent phobic
response, often due to sexual abuse or assault.

II.1.3..2. Excitement Phase Difficulties

• Female Sexual Arousal Disorder: inhibited lubrication; often due to apathy, anger, fear, decreased
estrogen levels.
The suggestion can be non-coital activities may increase lubrication; use of water-soluble jelly also
helps.
• Male Erectile Disorder: persistent lack of erection rigid enough for penetration; brief episodes
common in all men (especially tired, stressed, and using drugs or alcohol).
• Long-term difficulty often organic factors

II.1.3..3. Orgasm Phase Difficulties

 • Female Orgasmic Disorder/Anorgasmia: absence of orgasm might be situational or cultural factors.
• Male Orgasmic Disorder:inability to ejaculate during sex.
• Premature Ejaculation:it varies with couples; and the definition is based on subjective satisfaction.
Many men (about 25%) often experience this; and physiological predisposition and anxiety are the
commonest reasons.
• Faking Orgasm: this is pretending as they reached to orgasm but not in reality due to performance
pressure, caretaking of partner, lack of hope/ability to achieve orgasm. The negative consequences are:
emotional disturbance, guilt, resentment and anger. This can be stopped with effort (learning about
what works better, communicating desires and needs therapist’s interventions).
II.1.3..4. Dyspareunia - Pain during sexual intercourse

• Painful intercourse in men:The cause may include phimosis (tight foreskin); infected/irritated
foreskin.
• Painful intercourse in women:decreased lubrication because of many reasons, like infections,
negative attitude towards sexual intercourse, fear, or the intercourse started without
• Vaginismus:strong, involuntary contractions of outer 1/3 of vagina; due to fear, hostility, chronic
pain, strong sexual taboos.

II.1.4. Reproductive Health

The WHO broadly definedreproductive healthas“a state of complete physical, mental, and social well-being
and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its
functions and processes.”The definition suggests that reproductive health encompasses the:
 ability to reproduce
 freedom to control reproduction
 ability to go through pregnancy and childbirth safely, with successful maternal and infant survival
and outcomes.
 ability to obtain information about and access to safe, effective and affordable methods of family
planning
 ability to have a satisfying, safe sex life, free from fear of pregnancy and disease
 ability to minimize gynecologic disease and risk throughout all stages of life
Reproductive health, then, is concerned with people’s ability to have a responsible, satisfying and safe sex
life, their capability to reproduce, and their having the freedom to decide if, when and how often to do so.
Embedded in this set of concerns are certain implicit rights of both men and women to:
 be informed of safe, effective, affordable and acceptable methods of fertility regulation;
 have access to safe, effective, affordable and acceptable methods of fertility of their choice;
 have access to appropriate health care services that will enable women to go through pregnancy
and childbirth safely, and provide couples with the best chance of having a healthy infant.
II.2. Basic Anatomy and Physiology of Reproductive Organs
Activity 16

Activities: Dear learners: Be in a group of male and female separately. Draw a picture
of a woman’s body and a man’s body.
II.2.1. 1. Begin with the body of your own sex, and draw the sexual and reproductive organs on the
picture and decide what names to call them.
2. Draw the sexual and reproductive organs on the body map of the opposite sex and decide
on names.
Male Reproductive Organ

Male reproductive organs look similar. If circumcised, his foreskin will be removed. Penises may vary
slightly in shape and size. Many boys have concerns about the shape or size of their penis. However, all
penises function the same way regardless of their shape or size. Boys should wash their genital area daily.
They should clean the area behind the foreskin if they have not been circumcised. This helps prevent
infection.

 Urinary Bladder: It serves as a reservoir for urine and is connected to the urethra.
 Urethra: Tube through which urine and semen (including sperm) pass out of the body.
 Epididymis: Area where sperm is stored in the testicles.
 Vas Deferens: Tubes that carry sperm from the epididymis.
  Seminal Vesicle: small sac at the back of the prostate gland where the thick milky fluid in semen is
produced.
 Prostate Gland: The prostate gland is a walnut-sized structure that is located below the urinary
bladder in front of the rectum. The prostate gland contributes additional fluid to the seminal fluid.
 Testicles: Glands (which fell like two small balls) which produce sperm and the male sex hormone.
(Where, Temp, sign of normality etc…)
 Scrotum: Sac that holds the two testicles.
 Pubic hair: Grows around the penis after puberty.
 Penis: ade up of spongy tissue. Normally soft, but fills up with blood and becomes stiff (erect) when a
boy is sexually aroused. The penis has three parts:
o The Root – Which attaches to the wall of the abdomen;
o The Body (shaft) , and;
o The Glans (head) - head of the penis, sensitive to touch. The glans is covered with a loose layer of
skin called Foreskin (It is removed when a boy is circumcised).
 Urethral Opening: Through which urine and semen pass. Unlike girls, boys have the same opening
for urine and sexual fluids. It is not possible for urine to pass through the urethra at the same time as
semen is being ejaculated.

II.2.2. Female Reproductive Organ

Every girl’s body looks similar. Girls should wash the outside of the genital area daily. The vagina has a
natural cleansing mechanism and should not frequently be washed inside. Frequent washing of the inside
(douching) can increase risk of infection, especially if done before sexual intercourse.

 External Female Reproductive Organ

  Pubic Hair: Is hair that grows around the vulva after puberty.
 Monsvenris:Is a pad of fat that lie in front of the symphysis pubis and is covered with hair at puberty
 OuterLabia/Majora:two folds, or lips, of skin which protect the vulva.
 InnerLabia/Minora:two smaller folds, or lips, of skin which lie between the outer labia.
 Clitoris:Small bump at the top of the inner labia, filled with nerve endings. It is very sensitive to
touch. Stimulation of the clitoris can be pleasurable and lead to orgasm.
 Vulva:The different parts of the vulva make up the woman's outside reproductive organs.
 UrethralOpening:small opening below the clitoris through which urine passes out of the body.
 VaginalOpening:Opening below the urethral opening and above the anus. It leads to the vagina,
cervix, and uterus. It is through the vaginal opening that menstrual blood passes out of the body, the
penis may enter during sex, and babies are born.
 Hymen:Is the membrane that covers the opening of the vagina. Hymen is also a sign of virginity.

 Internal Female Reproductive Organ

 Ovaries: Two glands, one at the end of each uterine tube, which produce eggs and female sex
hormones.
 Uterine (Fallopian) Tubes: Two tubes that connect the uterus to the ovaries. An egg is released from
one of the ovaries each month, and passes along a uterine tube into the uterus.
 Uterus or Womb: Hollow sac of muscle, shaped like an upside down pear. This is where an embryo
develops into a baby during pregnancy.
 Cervix: Mouth of the uterus, connecting it to the vagina. It has a very small opening and is kept moist
by mucus. The cervix feels round, hard and smooth, with a small bump in the middle.
 Vagina:A moist tube of muscles, normally about 8cm long, which connects the vulva to the inner
reproductive organs. It is very flexible. It secretes slippery mucus during sexual arousal.
 The vagina and cervix are lower reproductive tract. The uterus, uterine tubes, and ovaries are upper
reproductive tract.

 Reproductive System

II.2.2..1. Female Reproductive System

The Menstrual Cycle

 An egg starts to develop in the ovary.
While the egg is developing, the lining of the uterus is getting thick and soft.
 The egg is released by the ovary.
 The egg travels to the uterus.
 If the egg doesn’t meet a sperm, it dissolves.
About two weeks later, since the lining of the uterus is not needed for a pregnancy, it comes out
through the vagina.
II.2.2..2. Male Reproductive System

The male reproductive system consists of the penis, two testicles, two epididymides, two vas deferentia, two
seminal vesicles, and the prostate gland. The production of sperm is a complex process and requires normal
functioning of the testicles (testes) as well as the hypothalamus and pituitary glands — organs in your brain
that produce hormones that trigger sperm production. Once sperm are produced in the testicles, delicate tubes
transport them until they mix with semen and are ejaculated out of the penis. Problems with any of these
systems can affect sperm production.

 Similarities between Male and Female Reproductive Systems

The reproductive systems of the male and female have some basic similarities and some specialized
differences. They are the same in that most of the reproductive organs of both sexes develop from similar
embryonic tissue, meaning they are homologous. Both systems have gonads that produce (sperm and egg or
ovum) and sex organs. And both systems experience maturation of their reproductive organs, which become
functional during puberty as a result of the gonads secreting sex hormones.

In short, this is a known list of sex organs that evolve from the same tissue in a human life.

Activity 17

Read the following reproductive system story and try to guess for which part of the reproductive 
system the story is specifically presented. D
 I am produced in the testicles.
 When the penis becomes erect, I leave the body through the urethra in a white, milky fluid in a
process called ejaculation.
 I go through a woman’s vagina in search of an egg cell.
 If I can find the egg before the other sperm do, I will be the winner: part of a fertilized egg!
 Without me, an egg cell couldn’t begin the process of reproduction.

ifferences between Male and Female Reproductive Systems

The differences between the female and male reproductive systems are based on the functions of each
individual's role in the reproduction cycle. A male, who is healthy, and sexually mature, continuously
produces sperm. The development of women’s “eggs” is arrested during fetal development.

II.2.2..1. Menstruation

Menstruation is the normal, predictable physiologic process whereby the inner lining of the uterus
(endometrium) is expelled by the body. Typically, this occurs monthly. Menstruation has many effects on
girls and women, including emotional and self-image issues. In the United States, the average age at menarche
(the start of menstruation in females) is 12.8 years, with a range between 8 and 18. Genetics is the most
important factor in determining the age at which menarche starts, but geographic location, nutrition, weight,
general health, nutrition, and psychological factors are also important. Most women will experience 300 to
400 menstrual cycles within their lifetime. Normal, regular menstrual cycles vary in frequency from 21 to 36
days (with the average cycle lasting 28 days), bleeding lasts 3 to 7 days, and blood loss averages 20 to 80 mL .
Irregular menses can be associated with irregular ovulation, stress, disease, and hormonal imbalances.

II.2.2..2. Reproductive Cycle

The reproductive cycle, also referred to as the menstrual cycle, results from a functional hypothalamic–
pituitary– ovarian axis and a precise sequencing of hormones that lead to ovulation.
If conception doesnot occur, menses ensues. The ranges of normal menstrual cycles are as follows:
• Cycle length: 21 to 36 days,
• Duration of flow: 3 to 7 days
• Amount of flow: 20 to 80 ml.

The female reproductive cycle involves two cycles that occur simultaneously: the ovarian cycle, during which
ovulation occurs, and the endometrial cycle, during which menstruation occurs. Ovulation divides these two
cycles at mid-cycle. Ovulation occurs when the ovum is released from its follicle; after leaving the ovary, the
ovum enters the fallopian tube and journeys toward the uterus. If sperm fertilizes the ovum during its journey,
pregnancy occurs.

II.2.3. Puberty
Puberty is a time of physical and emotional change that happens as children grow and mature. Puberty signals
changes in a person’s reproductive capability. Young people experience a range of social, emotional, and
physical changes during puberty. As the body matures, it is important to maintain good hygiene (e.g. washing
the genitals, menstrual hygiene, etc.). During puberty, young women need access to and knowledge about the
proper use of sanitary pads and other menstrual aids. Male hormonal changes regulate the beginning of sperm
production. Young men may experience wet dreams during puberty and later in life.

Puberty is a time of sexual maturation which leads to major physical and emotional changes and can be
stressful. Puberty occurs at different times for different people, and has different effects on boys and girls.
Adolescence is the time between the beginning of sexual maturation (puberty) and adulthood.Male and female
hormones differ and have a major influence on the emotional and physical changes that occur over one’s
lifetime. Hormones can affect body shape and size, body hair growth, and other changes.

Puberty is the period of growing and changing from a child to an adult.The pituitary gland sends out hormone
messages to certain parts of the body to tell them to change.

Girls: anytime between the ages of 9 and 16.

Boys: anytime between the ages of 10 and 16. Everyone changes at his/her own rate.

Activity 18

Use a tick mark in the appropriate box.

Ser. Changes Could happen Could happen Could happen

No. only to girls only to boys only to both

1. Can get pimples

2. Period begins

3. Can have mood swings

4. Shoulders get wider

5. Hips get wider

6. Pubic and underarm hair grows

7. Can have crushes on someone

8. Breasts get bigger

9. Increased sweating

10. Testicles increase in size

11. Sperm are made

II.3. Sexual and Reproductive Health Rights
Sexual rights embrace human rights that are already recognized in national laws, international human rights
documents and other consensus statements. The Ethiopian Constitution imposes a responsibility and duty to
the respect and enforcement of fundamental rights and freedoms. International instruments are made an
integral part of the Constitution upon ratification. Since human rights treaties are also part of a special kind of
international agreements, they should be understood to be subordinate to the Constitution. Hence, the
following articles from the constitution and the international laws are important to protect sexuality rights.

Article 10(1): Human rights and freedoms, emanating from the nature of mankind, are inviolable and
inalienable.
Article 14: Rights to life, the Security of Person and Liberty
Article 16: Everyone has the right to protection against bodily harm.

Based on such Constitution rights, all persons have the right to life, liberty and to be free from cruel, inhuman
and degrading treatment in all cases, and particularly on account of sex, age, gender, gender identity, sexual
orientation, marital status and sexual history or behavior and shall have the right to exercise their sexuality
free of violence or coercion.

Simply defined, sexual, and reproductive health rights are the right for all people, regardless of age, gender
and other characteristics, to make choices regarding their own sexuality and reproduction, provided that they
respect the rights of others. It includes the right to access to information and services to support these choices
and promote sexual and reproductive health.

Sexual rights embrace human rights that are already recognized in national laws, international human rights
document, and other consensus statements. They include the right of all persons, free of coercion,
discrimination, and violence, to:
 The highest attainable standard of sexual health, including access to sexual and reproductive health
care services;
 Seek, receive and impart information related to sexuality;
 Sexuality education;
 Respect for bodily integrity
 Choose their partner;
 Decide to be sexually active or not;
 Consensual sexual relations;
  Consensual marriage;
 Decide whether or not, and when, to have children; and
 Pursue a satisfying, safe, and pleasurable sexual life.

Human rights relating to gender-based violence (GBV) against women are set out in basic human rights
treaties and include the human right to:
 Full respect for human dignity.
 Be free from inhuman or degrading treatment or punishment.
 The highest attainable standard of physical and mental health.
 Freedom from discrimination and violence, public or private, due to any status, including gender,
race, ethnicity or age.
 Full equality between women and men in decision-making.
 Freedom from sexual abuse, physical abuse, and psychological violence.
 A workplace free from violence and abuse.
 Freedom from marital rape.
 Freedom from female genital mutilation and other traditional harmful practices.
 Freedom from trafficking and forced prostitution.
 Freedom from violence associated with armed conflict, including murder, systematic rape, sexual
slavery, and forced pregnancy.
 Freedom from forced sterilization and forced abortion.
 Freedom from coercive use of contraceptives.
 Freedom from female infanticide.
 Equal access to justice, equal protection of the law, and effective remedies for victims of violence.
 Access to services, including physical and mental health services.

The responsible exercise of human rights requires that all persons respect the rights of others”. Although
cheap, effective interventions are available for many SRH problems, according to WHO unsafe sex is the
second most important risk factor leading to disability, disease or death in developing countries and the ninth
most important in developed countries.

II.4. Common Adolescent Sexual and Reproductive HealthProblems

Activity 19

List down the problems related to sexual and reproductive health?

Sexual reproductive health related problems of adolescents include:

 Lack of accurate scientific information;
 Having trouble negotiating condom use for girls;
 Having low self-esteem;
 Lacking autonomy in sexual and reproductive decision making;
 Being stereotyped as “sexually immoral” or “promiscuous”;
 Being assumed to be sex workers;
 Facing challenges around HIV disclosure (to partner, to family, to parents, to children, etc.);
 Contracting STIs/reproductive tract infections;
 Having unintended pregnancies;
 Lacking access to HIV/AIDSs care, treatment, and support services;
 Not knowing they are HIV-positive;
 Being coerced into having abortions;
 Not knowing that they can have safe and healthy pregnancies;
 Early sexual debut may expose to multiple sexual partners;
 Unprotected sex which may result in STI.
 Unintended pregnancy may lead to dropping out of school;
 Single motherhood at younger age.

II.5. Sexually Transmitted Infections

Activity 20

Divide the class into five smaller working groups. Choose a recorder and a reporter to your
group. And discuss the following questions and present it to the class.
1. What are the names of some sexually transmitted infections?
2. How are STIs transmitted?
3. How do you know if you have an STI?
4. Can all STIs be treated? Where can you go for help?
5. How can you protect yourself?
II.5.1. Definition and Magnitude

Sexually transmitted infections are infections caused by organisms that are passed through sexual activity
with an infected partner.STI is a term used in place of STDs. One does not necessarily have to have sex to get
STIs, but sexual activity is the most common way for them to be spread.

STIs are spread mostly through unprotected vaginal or anal sex. Some can be spread through oral sex, like
herpes, genital warts and gonorrhoea. Some STIs, like herpes and genital warts (HPV), can be spread through
skin-to-skin contact of the genitals. Some STIs, like gonorrhoea, chlamydia, syphilis, herpes, HIV, and
hepatitis B and C, can be passed to a baby during pregnancy or birth. STIs are passed more easily from men to
women than the reverse (because of female anatomy). Generally, STIs are infections that are spread primarily
through person-to-person through sexual contact.

WHO estimates half of PLHIV are <25yrs andhalf of new the HIV infection occurs among 15-24 years of age.
In Ethiopia, STI prevalence among 15-24 years is 0.35% and 0.4% in 15:54 female and male respectively.

HIV prevalence in adolescent and youth is about 4.1%. Since there is strong inter-relation between STI and
HIV, providers should successfully prevent new cases and manage existing cases of STIs and HIV in
adolescents and youths.

II.5.2. Types and Common Symptoms of Sexually Transmitted Infections

 Types of STIs

There are more than 30 different STIs. STIs are caused by bacteria, viruses, and parasites. The most common
STIs caused by bacteria are: gonorrhoea, chlamydia, chancroid and syphilis. They can be cured. The most
common STIs caused by viruses are: human papillomavirus (HPV) or genital warts, herpes, hepatitis B and C,
and HIV. They cannot be cured, but most can be treated. The most common STIs caused by parasites are:
trichomoniasis, scabies and pubic lice. They can be cured.

But there are other common names like STD which shows the status manifested with sign and symptom after
infection has occurred and reproductive tract infection(RTI) which indicates the site where the infection has
taken place. RTIs are infections of the genital tract of women and men. There are three types of RTIs:

II.5.2..1. Common Bacterial Sexually Transmitted Infections

• Gonorrhoea
• Chlamydia
• Syphilis
• Chancroid
• Granuloma inguinale or donovanosis.

II.5.2..2. Common Viral Sexually Transmitted Infections

• Human immunodeficiency virus (causes AIDS)

• Herpes simplex virus type 2 (causes genital herpes)
• Human papilloma virus (causes genital warts and certain subtypes lead to cervical cancer in women)
• Hepatitis B virus (causes hepatitis and chronic cases may lead to cancer of the liver)
• Hepetitis C
• Cytomegalovirus (causes inflammation in a number of organs including the brain, the eye, and the
bowel).

II.5.2..3. Parasitic Organisms

• Vaginal trichomoniasis
• Candida albicans (causes vulvovaginitis in women; inflammation of the glans penis and fore-skin
[balano-posthitis] in men).
• Scabies and public lies
 Signs and Symptoms of STIs

In more than half of all cases, STIs do not have any noticeable signs or symptoms. The most common signs
and symptoms of STIs on or around the genitals are: soreness, unusual sores or lumps, itching, pain, pain
when urinating, bad smells, and/or an unusual discharge. Women have fewer noticeable signs and symptoms
than men. Because STIs often donot have signs and symptoms, many people are not aware that they have
one. So if you have had unprotected sex, you could have an STI and not know it.

II.5.3. Mode of Transmission

STIs are transmitted:

a) Through unprotected penetrative sexual intercourse (vaginal or anal)

b) From mother to child:
– During pregnancy (HIV, Syphillis)
– At delivery (Ghonoira , chalamidia, HIV)
– After delivery through breast milk
c) Through the use of unsterile needles or injections or other contact with blood or blood products (e.g.
syphilis, HIV and hepatitis).

II.5.4. Prevention

In order to prevent getting STIs, one should:

 Avoid having unprotected sex. Always use either a male or female condom and learn how to use them
correctly to best protect against STIs.
 Avoid using shared, non-sterile needles for drugs, body piercing, or tattoos.
 Visit doctor regularly to check for STIs and speak to your doctor about your exposures.
 Learn more about STIs. The more you know about STIs, the better you can protect yourself against
them.
 Look for resources in your community.

The global strategy for the prevention and control of STIs

• Prevention by promoting safer sexual behaviors;
 • General access to quality condoms at affordable prices;
• Promotion of early recourse to health services by people suffering from STIs and by their partners;
• Inclusion of STI treatment in basic health services;
• Specific services for populations with frequent or unplanned high-risk sexual behaviors such as sex
workers, adolescents, long-distance truck-drivers, military personnel, substance users and prisoners;
• Proper treatment of STIs, i.e. use of correct and effective medicines, treatment of sexual partners,
education and advice;
• Screening of clinically asymptomatic patients, where feasible; (e.g. syphilis, Chlamydia);
• Provision for counseling and voluntary testing for HIV infection.
•
II.5.5. Importance of Early Diagnosis, Treatment and Partner Notification

• If you have some of the symptoms mentioned above, or think you may have a sexually transmitted
infection, you'll need a medical exam to diagnose and determine the best treatment for the specific
STI.
• Your doctor will ask you questions about your symptoms and perform a physical exam. To help
diagnose STI, your doctor may order blood tests, urine tests, or may take a swab from the genital area,
which will be sent to a laboratory for evaluation.
• Sexually active individuals, particularly those with multiple partners, are recommended to have
regular checkups. In some cases, there are no obvioussymptoms and the infections that cause STIs can
only be identified through regular STI screening tests.
• 70–80% of infected women may be asymptomatic and so will not seek treatment hence partners need
to notify them.

II.5.6. Treatment

• Antibiotics can be used to treat bacterial infections, like the ones that cause gonorrhea, syphilis, or
chancroid.Gonorrhea often occurs at the same time as chlamydia, so doctors usually prescribe
antibiotics to treat both gonorrhea and chlamydia.
• People with acute hepatitis B are usually treated only for symptoms. Most adults clear the virus on
their own. However, for the few people that do not, treatment exists to reduce the risk of long-term
liver damage.
 • There is no cure for HIV.Doctors prescribe different combinations of antiviral medications to slow
down the progress of the disease. Treatments can vary from one person to the next to determine what
combination works best for you. Doctors also treat secondary infections that result from a weakened
immune system.
• Donot be shy about asking new sexual partners if they have STIs, or letting them know if you have
one. To avoid spreading STIs, people who are sexually active and have multiple partners can be
routinely screened - and rapidly treated - by a doctor.

II.5.7. Consequences of STIs

Activity 21

Dear learners, be in a group of four to six and discuss the major consequences of STIs and present
your responses to the class.

 Long-Term Health Consequences of STIs

The long term health consequences are more serious among women. In women and girls many STIs go
undiagnosed until a serious problem develops. It may result in permanent infertility, chronic pain from pelvic
inflammatory disease, and cervical cancer. Heart and brain damage may also occur. STIs are also a risk factor
for HIV, low birth weight, prematurity, and risk of other disease, infection, and blindness from ophthalmic
neonatorum.

 Long-Term Social Consequences of STIs

STIs also results in long term social consequences, which includes: infertility and loss of community
credibility, possible judgment, rejection by service providers,and the difficulty of notifying sexual partners
may have health and relational costs.

II.5.8. Complications of Untreated STIs

 Symptoms of Untreated STIs

As stated above, many people with STIs might have no obvious symptoms at all.As a result, the person may
not seek treatment for a long time. This delay could result in higher risks of STI-related health problems or
complications, as well as the possibility of spreading the STI to partners. A number of symptoms can indicate
the existence of an STI, although specific symptoms are unique for different infections:
 heavier than normal vaginal discharge
 discharge from the penis or rectum
 itching in genital or anal areas
 sores or rashes in genital or anal areas, sometimes also in the mouth
 pain during intercourse
 painful or more frequent urination
 swollen glands in the groin
 fever, headache, general feeling of illness
 pelvic pain that is not related to monthly period

 With syphilis, sores called chancres often appear about 3 weeks after exposure. There are usually one
or more sores at the place of initial infection. If left untreated, this first phase of syphilis lasts 3 to 6
weeks. A rash over larger areas of the body can follow 3 to 6 weeks after the sores appear. This is the
beginning of the second stage of syphilis. People with syphilis may also get aching muscles and
swollen lymph glands as well as flat warts during this stage. Syphilis can also lead to eye
inflammation, causing blurred vision. In the second stage, symptoms may come and go over the next 1
to 2 years, then disappear. About one-third of people in the second stage of syphilis will go on to the
third stage, where the infection damages the brain, heart, nervous system, bones, joints, eyes, and other
body areas.
 Hepatitis B can cause many symptoms including a decrease in appetite (associated with nausea and
vomiting), jaundice, dark yellowing of urine, and aching in the muscles and joints. These symptoms
are signs of liver inflammation or damage.
 Genital herpes produces a tingling sensation in the genitals. Sores develop in and around the male and
female genitals, anus, thighs, buttocks, and mouth.
 Chancroidis caused by a bacterial infection in the genital area. 4 to 7 days after exposure to the
bacteria, sores form, often with a red border around them. Although this infection is more common in
tropical areas, it is possible to get it elsewhere. Antibiotics treat this infection normally within 2
weeks.
 It's possible to transmit pubic lice from one person to another without sexual contact (for example, by
sharing bedding, towels, or clothing). However, sexual contact may transfer the eggs or lice from one
person to another. Symptoms may include itching of the genital area. You may also be able to see the
 lice (small, brown, pinhead-sized insects) or their eggs (oval and whitish in color) in your pubic hair.
Wash clothes and bedding in hot water if you discover pubic lice and speak to your doctor or
pharmacist for ways to treat the problem. Medicated shampoos or rinses are available over-the-counter
to treat pubic lice.

 Complications Associated with Many of the STIs

 Infertility, pregnancy complications, or higher risks of cervical cancer can occur in women.
 Gonorrhea, if not treated, can spread via the blood stream to joints and heart valves.
 Both gonorrhea and chlamydia can cause eye infections in newborns that came in contact with the
bacteria during delivery.
 If syphilis is not treated, it may eventually cause serious damage to the bones, heart, eyes, brain, and
nervous system.
 Hepatitis B can lead to long-term liver damage and higher risks of developing liver cancer.
 HIV weakens a person's immune system, putting them at risk for many different infections.
 Chancroid makes a person more susceptible to HIV infection when they are exposed to the virus.
 An active herpes infection at the end of a pregnancy will require delivery by a caesarean section to
avoid spreading the infection to the baby.
II.6. Unintended Pregnancy

Activity 22

Brainstorming Questions
What do you think are the consequences of unsafe sex?

Please list the dangers of abortion from the following scenario

There is a young 18-year old college student. She has friends from different backgrounds. She feels
attracted to a boy in her class and develops a friendship with him. She really begins to like him and
spends time with him. Eventually he asks her to have sex with him. She was not in a position to
resist his pressure and they made unsafe sex. After 3 month she found herself pregnant.

II.6.1. Definition

An unintended pregnancy is a pregnancy that is reported to have been either unwanted (that is, the pregnancy
occurred when no children, or no more children, were desired) or mistimed (that is, the pregnancy occurred
earlier than desired), which mainly results from not using contraception, or inconsistent or incorrect use of
effective contraceptive methods.
II.6.2. Teenage Pregnancy

It is defined as a teenage girl, usually within the ages of 13-19, becoming pregnant. Which refers to girls who
have not reached legal adulthood, which varies across the world, who become pregnant each year, an
estimated 14 million adolescents between the ages of 15 and 19 give birth globally, and more than 90% of
these live births occur in developing countries.

Teenagers suffer from a disproportionate share of:

 early marriage, unwanted pregnancies,
 unsafe abortions, STIs including HIV,
 female genital mutilation,
 malnutrition and anemia,
 infertility, sexual and GBV,
 other serious reproductive health problems

Teenage pregnancy is a major health concern because of its association with higher morbidity and mortality
for both mother and child. Childbearing during the teenage years frequently has adverse social consequences
as well, particularly on educational attainment, because women who become mothers in their teens are more
likely to curtail their education.

According to the 2011 EDHS, teenagers in rural areas are much more likely to have started childbearing than
their urban counterparts (15% and 4%, respectively), mainly due to the high prevalence of early marriage in
rural Ethiopia. Among regions the percentage of women age 15-19 who have begun childbearing ranges from
3% in Addis Ababa to 21% in Gambela. Teenagers with less education are much more likely to have started
childbearing than those who are better educated. 33% of teenagers with no education have begun
childbearing, but no teenagers with more than a secondary education in sample have begun childbearing.
Teenagers in the lowest wealth quintile are almost four times as likely to start childbearing early as women in
the highest wealth quintile (21% and 6%, respectively).

An estimated 70,000 teenage girls die each year during pregnancy and childbirth and more than one million
infants born to adolescent girls die before their first birthday. Due to such a grave health consequences
teenage pregnancies are termed a death sentence in poorest countries. About two million or more suffer from
chronic illness, disabilities, shame and abandonment.

Some factors associated with teenage pregnancy in Ethiopia areage, educational status, place of residence,
employment, contraceptive use, and so forth.

II.6.3. Causes
 substance abuse,
 early sexual debut,
 rape,
 harmful traditional practices.

II.6.4. Magnitude

Unintended pregnancy is when a pregnant woman decides on her own freewill that the pregnancy is
undesired; hence intends to terminate her pregnancy. Each year in the world there are about 75 million
unintended pregnancies that result in abortions of which the majority are known to be unsafe.

II.6.5. Prevention

Concerted efforts are needed to empower teenagers to:

– Educate community about its adverse effects
– fight early marriage
– promote education and
– encourage the utilization of family planning targeting the rural teenage

II.6.6. Consequences

 Global level- population growth

 Societal level- a negative impact on their position and potential contribution to society
  Individual level - Adverse maternal and child health outcomes including obstructed labor, low birth
weight, fetal growth retardation, and high infant and maternal mortality rate, etc.

II.7. Abortion

II.7.1. Definition

Abortion is the termination or initiation of termination of pregnancy before reaching viability (before 20weeks
or <500grams according to WHO or before 28 weeks of gestation or less than 1kg fetal weight in Ethiopia and
UK). It can be spontaneous where termination is not provoked deliberately (this is called miscarriage) or
induced when there is a deliberate interference with the pregnancy for the sake of terminating it.

Clinical stages of spontaneous abortion are: threatened, inevitable, incomplete, complete, or missed abortion.
If any of the stages mentioned get infected it is called septic abortion. About Fifteen percent of all clinically
recognizable pregnancies end in spontaneous abortions.

It is estimated that 30 to 50 million induced abortions are performed annually in the world and about half of
these are performed illegally. In Ethiopia, it is estimated that there are 3.27 million pregnancies every year of
which approximately 500,000 end in either spontaneous or unsafely induced abortion.

WHO characterizes unsafe abortion done by the lack of skilled providers, safe techniques, and/or sanitary
facilities.Unsafe abortion is the commonest cause of maternal mortality accounting for up to 32% of all
maternal deaths in Ethiopia. Abortion is more than a medical issue, or an ethical issue, or a legal issue. It is
above all a human issue, involving women and men as individuals, as couples and as a member of the society.

II.7.2. Complications of Abortion

 Acute Complications

• Incomplete abortion
• Sepsis
• Hemorrhage
 • Uterine perforation
• Bowel injury

 Long-term Complications

• Chronic pelvic pain

• Pelvic inflammatory disease
• Tubal blockage and secondary infertility
• Ectopic pregnancy
• Increased risk of spontaneous abortion or premature delivery in subsequent pregnancies.
• These complications can limit women’s productivity inside and outside the home, constrain their
ability to care for children and adversely affect sexual life.

II.7.3. Types of Abortion

• Safe
• Unsafe abortion

II.7.4. Magnitude

Accurate estimates are difficult to get, but it is clear that unsafe abortion is widespread and generally
performed by untrained persons. It is the leading cause of maternal mortality. In a community-based study,
abortion accounted for 54.2% of the direct causes of maternal deaths. It is one of the top ten causes of
admissions among women. Unsafe abortion accounts for nearly 60% of all gynecologic admissions and
almost 30% of all obstetric and gynecologic admissions. In a study done in Addis Ababa; abortion hospital
occupancy rate among mothers was 32.2%.

Why Do Women Find Themselves with Unwanted Pregnancy, on-use of contraception?

The majority of unwanted pregnancies occur in non-users of contraceptive methods. Despite the fact that
family planning services are more effective and available than ever before, estimates suggest that ,worldwide:
 • 350 million couples lack access to information about contraceptives and a full range of modern family
planning methods;
• 105 million married women have unmet need for family planning;
• 12 to 15 million women may also lack access to services that will enable them to achieve their
reproductive intentions.
• Even after treatment for complications of unsafe abortion, many women leave hospitals without any
counseling on how to prevent future pregnancies, and without a contraceptive method.

II.7.5. Causes of Unsafe Abortion

 Contraceptive failure

Contraceptive failure results in 8-30 million pregnancies each year either from inconsistent or incorrect use of
family planning methods or method-related failure.

 Sexual Coercion or Rape

Twenty to fifty percent of women and girls report sexual abuse, rape or sexual coercion which carries about
5% risk of pregnancy in those in reproductive age unless emergency contraceptives given.

 Other factors

• Lack of control over contraception;

• Young age or single marital status;
• Abandonment or unstable relationship;
• Mental or physical health problems;
• Severe malformation of the fetus; and
• Financial constraints.

II.7.6. Prevention

 Why Does Induced Abortion Occur?

Each year women around the world experience 80 million unwanted pregnancies. Out of these mothers, nearly
42 million decide to have an abortion and about 20 million of them undergo unsafe abortion. A woman's
decision to get an abortion is not made in a vacuum, but is bound up in society's feelings about abortion as
well as her feelings about the pregnancy.

II.7.6..1. Social Factors

Social or cultural attitudes influence the emotional decision of obtaining abortion: shame of having a baby
before getting married,adequate family size,the child becoming economic burden, and unable to raise the child
could be sources of external pressure.

II.7.6..2. Religious Attitudes

In spite of unwanted pregnancy, some may keep the unborn child due to religious reasons for fear of
punishment by their God or considering it as sin to kill a baby.

II.7.6..3. Personal and Interpersonal Reasons

Continuing pregnancy can be a great source of conflict. Often, pregnancy is the unwanted by- product of
wanted sexual relations, while a pregnancy that is desired to prove her ability as a woman may have little
relationship to desire for the actual child.

II.7.6..4. Age and Marital Status

These are important factors in the decision along with number of other children already born. In some
instances abortion is the first responsible decision the woman has made, and often the effect is beneficial to
other children in a large family or to the woman planning an unwise marriage. Counseling helps the outcome.
A large benefit of legalized abortion is the opportunity to talk with a trained counselor.

II.7.6..5. Poor Access to Family Planning Information and Services

Unsafe abortion is a public health problem, particularly among young women since they are less likely than
older women to have the social contacts and financial means to obtain. When there is no adequate
information and service provision, young women may resort to unsafe abortion risking their life.

 When Abortion is Illegal

• It is most difficult for a woman to obtain it.

• The psychological trauma is generally great because society is generally against abortion
• Evidence shows that restrictive legislation is associated with higher rates of unsafe abortion and
correspondingly high mortality.
• Once abortion is legalized, a supportive relationship can be established and the decrease in external
stress will be accompanied by a similar decrease in negative feelings.
• Up to 23 unsafe abortion/1000 women restrictive laws compared to 2/1000 in permissive laws.
• Mortality 34/1000 live births in restrictive countries compared to 1 or less per 1000 live.

 Inadequate Services

In many developing countries, safe abortion services are not available to the full extent permitted by law.
Many health workers lack vital information about the legal status of abortion, and do not know how to
perform abortions. When women experience complications due to unsafe abortion, appropriate medical care is
often unavailable or inaccessible.

Lack of protocols for post-abortion care, misdiagnosis, negative attitudes on the part of health care providers
and case overload result in life-threatening. These factors are also costly, delay services for women seeking
treatment from the health system.

 What Can Be Done about Unwanted Pregnancy?

• Ensure universal access to family planning

• Increase the availability of safe abortion services to the extent allowed by law
• Improve the quality and accessibility of post-abortion care
• Educate communities about reproductive health and unsafe abortion; and
 • Work for changes in policies to safeguard women’s reproductive health.

II.8. Components of SRH Services

II.8.1. Family Planning

 Demographic Rationale

Reducing high fertility and slowing population growth provided the dominant rationale for family planning
programs in the 1960s and 1970s. The rationale was based on concerns over the potentially negative effects of
rapid population growth and high fertility on living standards and human welfare, economic productivity,
natural resources, and the environment in the developing world, but still surveys showed substantial unmet
need for family planning.

 Health Rationale

During the 1980s, the public health consequences of high fertility for mothers and children raised concerns for
international community especially for developing countries. High rates of infant, child, and maternal
mortality as well as abortion and its health consequences, were pressing health problems in many developing
nations and had also become of greater concern for international development agencies.

II.8.1..1. Benefits to Women’s Health

Simply by providing contraceptives to women who desire to use it, we can reduce maternal deaths by as much
as one-third because:
• Avoiding pregnancy at the extremes of maternal age;
• Decreasing risks by decreasing parity: If all women had five births or fewer, the number of maternal
deaths could drop by 26% worldwide;
• Preventing high-risk pregnancies decrease maternal deaths by quarter;
• Preventing unwanted pregnancy reduces unnecessary risks of pregnancy, childbirth and risks of
induced abortion;
 • Improving health through non-contraceptive benefits including prevention of STIs.

II.8.1..2. Family Planning Benefits Children’s Health

Family planning indirectly contributes to children’s health, development, and survival by reducing the risk of
maternal mortality and morbidity. Spacing births at least two years apart has to do with their survival. On
average, babies born less than two years after the previous birth in the family are about twice as likely to die
in the first year as babies born after at least a 2-year interval. Even older children who are spaced too closely
face an increased risk of death during the toddler and childhood years. Planning births during the mother’s
optimal age-not too old or too young: women who are very young or very old are more likely to have an
infant or child death. Family planning prevents further pregnancies in a mother who has had numerous
pregnancies already and avoids close birth spacing and sharing limited resources such as food.

II.8.1..3. Family Planning Benefits of Women and Their Societies

Family planning reduces the health risks of women and gives them more control over their reproductive lives.
With better health and greater control over their lives, women can take advantage of education, employment,
and civic opportunities. If couples have fewer children in the future, the rate of population growth would
decrease. As a result, future demands on natural resources such as water and fertile soil will be less. Everyone
will have a better opportunity for a better quality of life.

 Human Rights Rationale

This rationale became preeminent in the 1990s, in part because of the excesses reactions to the demographic
rationale. It rests on the belief that individuals and couples have a fundamental right to control reproductive
decisions, including family size and the timing of births.

II.8.2. Methods

The commonly used family planning methods are:

 Natural Method
 – Breast feeding
– Abstinence
– Withdrawal (Coitus interrupts)
– Calendar methods
– Cervical mucus (Billing’s Method)
– Sympathothermal

 Artificial Methods

These are barrier methods

– Diaphragm
– Condom
– Intra-uterine device (IUD)

 Hormonal Methods

– Pills
– Implants
– Injectable

 Surgical Methods (Permanent)

– Tubal ligation (ligating the oviduct).

– Vasectomy (legating the sperm duct).

 Emergency Contraception

– IUD
– Levonorgestrel-only or combined estrogen-progesterone
– RU486
Even though various methods are available and accessible, clients do not get the opportunity to discuss with
health care providers how/when to use and where to go. Therefore, it is important to ensure provision of
information and counseling in family planning services.
II.9. Youth Friendly Services

Youth is a period between childhood and adulthood; which involves distinct physiological, psychological,
cognitive, social, and economic changes. According to WHO definitions:
• Adolescent: the age between 10-19 years.
• Youth: 15-24 years of age
• Young: 15- 29 years of age

WHO defined Youth Friendly Health Services as “Services that are: accessible, safe, effective, acceptable,
and appropriate for adolescents in meeting their need, in the right place, at the right price (free where
necessary)”.

II.9.1. Why Focus on Adolescent and Young People?

Activity 23

Discuss the need to focus on adolescents and young people to have youth-friendly services.

 Number or Proportion

The youth below 25 years of ageaccount to 60% of the population in Ethiopia.

 Nature of Adolescents and Young on Sexuality

• Major physical, cognitive, emotional, sexual, and social changes occur during adolescence and affects
young people’s sexual behavior.
• Many young people engaged in risky behaviors due to curiosity, peer pressure, sexual maturation, a
feeling of vulnerability, a sense of omnipotence and so on.
• The increasing gap between puberty and marriage leads to unmarried youth require reproductive
health care for a longer period.
 Health and Health Related Issues

• This is related to the higher proportion of HIV and STI among adolescents and young.
• STIs and HIV: STIs that cause sores (like chancroid, syphilis and herpes) or inflamed or irritated skin
make it easier for HIV to be transmitted. When a person has HIV and an STI, they are more likely to
pass the virus to their sexual partners.
• There is higher risk of maternal death among 15-19 year of age as compared to 25-29 years of age
(4X). Many young women are sexually active and do not use contraceptive methods.

II.9.2. Abortion and Youth in Ethiopia

• Many young people are sexually active (sexual debut started as early as 13 years of age).
Contraception use among youth is very low.
• The MOH report of 2007 shows that 54% of pregnancies of girls under age 15, and 37% of ages 20-24
are unwanted.
• Research conducted in 2008 shows that 101 unintended pregnancies occurred per 1,000 women aged
15–44, and 42% of all pregnancies were unintended.
•
II.9.3. Reasons Youth Fail to Receive RH Care Service

• Poor treatment,
• Fear of being judged by service provider,
• Lack of privacy,
• Feeling that services are intended for married people, and
• Unaware of service locations or services offered.

II.9.4. Approaches for Working with Youth Directly

• Stimulating behavior changes in individuals by marketing a product, service, or action;

• Health education in reproductive health issues;
• Providing counseling services on RH issues
• Providing RH services such as: STI screening and treatment, family planning, pregnancy care, and so
forth.