Preventing and Coping with HIV/AIDS in Post-Conflict Societies:
Gender-Based Lessons from Sub-Saharan Africa

Experiences from Addis Ababa, Ethiopia
Yene H. K. Assegid - March 2001


TABLE OF CONTENTS:

BACKGROUND: HIV/AIDS IN ETHIOPIA
EXPERIENCES ON PEER EDUCATION AMONG SEX WORKERS
MAINSTREAMING HIV PREVENTION, AIDS CARE AND SUPPORT AT THE WORKPLACE
NEED FOR TECHNICAL SUPPORT AND TRAINING ON HIV/AIDS ISSUES
RECOMMENDATIONS 
REFERENCES

Background: HIV/AIDS in Ethiopia

Ethiopia is one of the countries most affected by HIV/AIDS in the world. In fact, it is estimated that about 9 to 10%of the world HIV/AIDS infected populations live in Ethiopia. Studies conducted for the 'African Development Forum (ADF) 2000' reported that in Addis Ababa, HIV prevalence among antenatal clinic attendees tested, were from 5 to 20% between 1983 and 1993. In 1997, 18% women attending antenatal clinics tested HIV positive. In terms of the military, 3 % of the military recruits were tested positive 1991. In terms of sex workers, figures of HIV prevalence were as follows: less than 1% tested positive in 1985 compared to figures as high as 54% in 1990 increasing all the way to 75% in 1998. 

Today, it is estimated that the HIV prevalence for Addis Ababa, the major urban area, ranges between 17 to 20 % of the general population. Further figures from the ADF 2000 state that the economic impact of HIV/AIDS on education will result in around 4.3 million students loosing about 51,000 teachers due to AIDS in 1999 (UNICEF, 1999). The economic impact of HIV/AIDS on the health sector will increase hospital bed occupancy to 28% nationwide by the year 2005 (Kello, 1999). The bed occupancy by AIDS patients is much higher in urban areas as compared to rural hospitals. In terms of the impact on agriculture, a survey carried out in 1994 reported that the mean number of hours per week in agriculture per household was 33.6 hours in non-AIDS affected household compared to 11.6 to 16.4 hours in those affected by AIDS (Baryoh, 2000). A survey conducted to estimate the economic impact of HIV/AIDS on firms and business states that AIDS accounted for 53% of all illness incidences over a 5 year period (Bersufekad, 1994).

In response to the crisis of the AIDS epidemic the government of Ethiopia has draft and is in the process of implementing its National HIV/AIDS policy since 1998. A National AIDS Council has been in operation for the past couple of years. The Office of the President has declared a State of Emergency allowing all groups, individuals and institutions to scale up action in combating HIV/AIDS.

Experiences on Peer Education Among Sex Workers

Under to auspices of Medecins Sans Frontieres Belgium (MSF-B), Addis Ababa, I was involved in the project of HIV/AIDS and STD Prevention among Commercial Sex Workers in Addis Ababa.

My responsibilities focused on launching a sound IEC programme as well as in assuring that as many commercial sex workers as possible accessed the programme. Commercial sex work exists in various forms in Addis; mainly varying based on earning and places of work. Call girls, street girls, bar ladies make up the women earning the most money compared to our target group which was comprised of very poor women working out of their homes or out of rented rooms. Most of the women within our target group we rarely high school graduates and mostly drop out or with very little to no education. These women were particularly vulnerable because, poverty, was their main and sole reason for earning their livelihood through prostitution. The age ranged from as young as early teens to late fifties, the average being within the mid twenties to mid thirties. These women and adolescent girls were either displaced persons from rural to urban migration, children of sex workers, or just others coming from broken or abusive homes, widows, divorcees, etc.

During our discussions with them we found out that it was not uncommon that they were either formerly married to soldiers, mothers of soldiers or even sometimes daughters of soldiers. One lady, who had ceased working as a sex worker, once found herself stunned when her eldest son joined the army in the war between Ethiopia and Eritrea. He enlisted to save her the burden of having to support him by selling her body. He enlisted and left to the front without telling her or saying goodbye in an effort to save her the pain of seeing him go away. This lady, this mother who was actually very close to the project staff and a leader within her community, did not know how to react to her son's departure. She had no news from him for months, until one day when he returned home due to injury. This mother, who herself was involved in sex work for years, was terrified of the thought that her son might get infected with HIV at the front as many young sex workers had migrated there in the hopes of getting more business.

Many young men aged 18 and over went to war from this small neighborhood which we worked in. A lot of them left because they had nothing else to do, because of peer pressure as well as to earn whatever they could. A lot of them left but did not return. During the war between Ethiopia and Eritrea our project witnessed many of the sex workers' lives being broken. Many mothers loosing their sons. Many households being just disrupted. Hopelessness was rampant with the war situation, combined with the HIV/AIDS epidemic ravaging communities and the absence of alternatives to better life. Today the situation is not very different.

The project was co-financed from European Union (EU) and the MSF Head Office. Its primary goal was to provide an IEC programme to sex workers as well as to complement health centers with a STD Syndromic Case Management programme. Overtime, although the medical aspect remained unchanged, the IEC programme developed into an independent project to offer the women not only IEC, but a more comprehensive programme including counseling, access to legal advice as well as to encompass an income generating programme. Well over a thousand women were served among this programme each year. The main strategy to reach all of these women was to establish and maintain a peer education network. Training of trainers (TOT) was provided to women with leadership qualities and they in turn shared their acquired knowledge to their peers through weekly meetings in Drop-In Centers established by the project. Through this strategy of peer networking, we reached approximately 1,500 women each year. Each peer educator had a group of peers ranging from 8 to 15 in numbers. The project had at any one time between 100 and 150 Peer educators, who were paid a small monthly fee of about USD 10.00 for their work in organizing and leading the peer meetings.

The impact of the project was difficult to see on a first look, yet deeper research through interviews and focus group discussions revealed that the women were actually slowly adopting a health conscious behavior, trying to use protection with their clients whenever possible. Of course, violent clients made it difficult to maintain the behavior but overall, the women started giving more value to their lives. The counseling and income generating aspect of the programme actually empowered the women to get their human rights respected. The income-generating programme in particular allowed to the women more strength in negotiating the use of condoms.

In terms of obstacles, the main issue was gaining and maintaining the confidence of the women to join into the project. It was hard for them to believe that all we promised was true. Many of the women had been deceived in the past by fly by night projects that never materialized. Although gaining their confidence was difficult. Once we had it, it was even more difficult to maintain as outsiders often tried to come into the project for this or that study. It took the team great determination to secure the women's confidentiality and screen who from the visiting organizations would respect the women and who would treat them or view them as ordinary prostitutes without a right to dignity. For the project staff, working long hours along side with these women had brought us very close and it just made it easier and hard at the same time to protect these women and to not allow anyone to exploit our closeness to them. Of course, the project also suffered from misunderstanding of the situation with our regional partners, this misunderstanding escalated to the point that the regional government ordered to closing of the project in 1998. Later that same year, the project re-opened with the Ministry of Women's Affair as a national partner. Today, the ministry is still our partner and the project is growing.

It is hard to list factors that have contributed to the success of the project. Personally, I believe the main reason for success was the team we had managed to build within the project. The staff was young, motivated and most of all modest and one that truly felt for the women. Second, the staff was one team, but we managed to build a greater team with the women. The women were not seen as beneficiaries but rather as part of the project. We stood to serve them and to listen to their needs. The project team respected the women and was available to them at all times. We were with them regularly within their living areas and they visited us regularly in the office.

Although monitoring and evaluation were not so regular in the first year of the project, we installed mechanism to monitor our work and evaluated our work through interviews with the women. We communicated our goals and foreseen activities to the women ahead of time. We held discussions with the women to evaluate whether or not the project goals were in line with their needs. Finally, we held regular meeting with the women to evaluate whether our work reflected our initial discussions and in line with the goals and objectives we set together. 

Regarding health programmes and peace-building, such a relationship was not highlighted by our project. However, we tried to support as much as possible women who had sons that had gone to the war front.

One of the main factor contributing to the project success was not just the qualification of each team member but the human character of each team member. A college degree was not enough per se. The most important was rather what each team member had to contribute as an individual to the project. How did they feel about prostitution, about HIV? What solutions could they bring in with them?

Second, we took the project as a business. We, the team are there to serve not to dictate or to judge or to change the lives of our target group. We were there to assess the needs and to do all that we could to meet the needs of these women, which is how the project grew and expanded. It was our duty to convince donors, headquarters, etc. to allow us the funds or the logistics to fulfill what we perceived as necessary activities from a grass root perspective; regardless of what theoreticians preached.

Third, closeness to the target group contributed to our success. Understanding, truly knowing and feeling the target group is the key in understanding the needs and planning adapted project action plans without deviating too much from the initial project main goals. Paper goals are different from "goals" emerging from discussions with the target groups. One example for this is the fact that although an STD treatment program was in place, women were not accessing the medications. After discussions we found out that many of the women could not access because one had to have a legal ID card to get service at public Health Centers. The problem was that in order to get an ID card, one had to be a home-owner and if a tenant then one had to get the landlord to go and notify the local government to give an ID in their name. But since most rental arrangements were not official or since the landlords were also making money of the sex work, they were always some unwillingness to assist the women in getting ID cards. Our response to that was to negotiate and convince government officials to allow us to distribute project ID cards to the network women, which would be recognized and used to access the health centers. This initiative opened access to health care to 70% of our target group. This translated in affording the women STD treatment for less than USD 1.00 as well as affording them free primary health care.

Mainstreaming HIV Prevention, AIDS Care and Support at the Workplace 

The workplace approach has become a key issue in the prevention of HIV/AIDS. It is within the PRHE-Project (Promotion of Reproductive Health in Ethiopia) of the German Technical Cooperation (GTZ) that I was given the opportunity to establish a workplace programme for all GTZ projects in Ethiopia as well as their national counterpart organizations.

The project established the GTZ Project Support Unit (PSU) on HIV/AIDS, started in March 1999 after a brief study conducted by a consultant from GTZ headquarters in Germany. The consultant visited about 10 out of the total of more than 30 GTZ projects, which existed in Ethiopia. The visit consisted in running half day to one day workshops in order to establish the knowledge and attitude of the staff as well as to assess what the staff deemed necessary to undertake in fighting HIV from the workplace. Based on the results of the study, we then launched the PSU, aiming to establish some what of a peer education based on Focal Person in each project. The role of the PSU would then be to train these Focal persons, to provide them with needed material as well as to act as clearing house in dispatching updated information on HIV/AIDS.

The first workshop we organized with the aim of introducing the PSU to the projects and to the Focal persons was only attended by 3 projects out of 9 invited to attend, although all nine projects had accepted to attend the workshop. We perceived their absence as a lack of commitment to fighting HIV/AIDS and of non-consideration of HIV as a priority or a threat to the livelihood of their staff.

At that time our funding was quite limited and not proportional to the work professionally. It took a lot of pro-active lobbying the project's team leaders and to convince them to give the PSU due attention and time. It also took a lot of convincing to ask each project to contribute some funds (2,000 DM per year per project) for the activities. But convincing the team leaders was not enough. A lot of the staff were hard to reach. I felt as though they coined HIV/AIDS as some one else's problem and that they knew it all. Yet, loosing staff to AIDS was not uncommon. Although it was often rarely disclosed a cause of death, the symptoms and the signs all led to believing that the persons died of AIDS.

The most difficult aspect of the workplace approach is in having the institution to draft an internal policy for health and benefits focusing especially on HIV and AIDS. Initiating the staff to ask for life insurance policies and better health benefits was also a difficult task or discussion to lead. The difficulties lay in our inability to answer the staff's questions related to cost of policies or monetary benefits to be gained from such insurance policies as mentioned above. This difficulty in turn came up due to the fact that the existing local insurance companies had not yet developed policies suited or accommodating HIV or AIDS, thus, it was hard to find ready made programs to buy into. It was also difficult to work with the insurance companies to draft or create sample insurance programs to present to our staff and to the institution's management. Another difficulty encountered during the workshops was the religious inclinations of the participants. Indeed, we had some participants who absolutely refused not only the access to condoms within the workplace, but refused to even talk about condoms as a protection method. This type of conviction made it hard to maintain group discussions effective as the group usually just got stuck on this one issue. It took skillful moderation to come out of such discussions without offending our participants.

Success with the PSU came quite late. It took us almost a year to overcome the initial set-backs. A year might be considered a short time to see a project in operation, but when it comes to HIV and AIDS, I feel it is too long. Who knows how many persons might have gotten infected during that time, and how many infections could have been avoided had we been in operation sooner. What did we call success? Well, within a year we had established at least one if not two focal persons within each GTZ project as well as one focal person within each project's national counter-parts office. Several training of trainers were delivered to train these focal persons in their role of peer educator and communicators. A number of IEC material was created and produced. The material was mainly either re-adapted from what others had done in other African countries or was a shared productions with local NGO's. However, the PSU produced manuals for training on different topics ranging from living with HIV to parenting in times of HIV to communication on HIV and AIDS etc. These manuals have been tested, edited and are now ready to be used and shared with other organizations.

In terms of the PSU, I think the main factor contributing to our success was our perseverance to achieve what we set out to do as well as our unwavering positive attitude in approaching the other GTZ projects, regardless of the initial rejections we faced.

Need for Technical Support and Training on HIV/AIDS issues

In all these years working on HIV/AIDS in Ethiopia, I have realized time and time again that although there are more and more persons willing to work on HIV/AIDS issues, many do not have the training they should have to be most successful in their work. Yes, some training opportunities do come by, they remain in the hands of very few in management positions who often do not share the acquired knowledge or material they brought back. Most individuals working at grass roots do not have access to training. The reasons are often because these individuals are either un-informed about the existence of the training, and even if they know about it, lack of funds, sponsors and difficulty in obtaining visas preventing them from ever getting there. 

In an effort to make more training readily available to persons and groups working HIV/AIDS issues, I have launched and established a local organization called "everyONE: Advanced Health Communication Training and Technical Support". EveryONE aims at bringing training and technical support into the country for the benefit of persons working at the grass root as well as at management levels. The fact that the training is within the country and free or at minimal cost will afford many to build their capacity in health communication. The training and technical support focus not only on communication skills but includes nutrition skills for persons living with HIV (PLWHA), income generating/marketing training for PLWHA and their families as well as Project Management, Human Resources Management, Fundraising for organizations working on HIV/AIDS. As an organization, everyONE relies on partnership within the country as well as internationally to achieve its goals as efficiently as possible.

Recommendations

With all modesty I wish to recommend to policy makers and African Governments to lay the administrative grounds to facilitate community based and grass roots work on HIV/AIDS. It is important that communities feel empowered and supported to initiate action against HIV/AIDS. Often times, I have seen many persons abandoning their dreams to work within their community due to the complicated administrative procedures to launch their work. Furthermore, I would recommend to establish infrastructures to facilitate the exchange of experience and knowledge within our borders and beyond. Government and policy makers can play a key role in assisting groups and institutions working on HIV in accessing others in similar work. Exchange visits, training, better internet access, airfare discounts, etc…could be part of the initiative to facilitate exchange.

As far as the international community (meaning especially the donor community), my recommendation is that the funds disbursed be accompanied by support in managing the funds, in monitoring and evaluating the activities. It is not enough to just give funds, it would be more effective to give organizations the option of also getting some fund management, M & E and planning support.

References