Background
Landlocked in the Horn of Africa, Ethiopia is the continent’s oldest independent country. Apart from a five-year invasion by Italy, from 1936 to 1941, it has never been colonized. Its ancient monarchy was toppled in 1974 by a Marxist junta that established a socialist state in 1975. Drought, famine, political instability and bloody coups dominated the 1970s and ’80s; the Derg regime was overthrown in 1991 by a coalition of rebel forces, the Ethiopian People’s Revolutionary Democratic Front. In some rural areas of Ethiopia, obsolete Soviet tanks still lie at the side of the roads and are silent reminders of the confrontations that tore the country apart for two decades.
Ethiopia gave itself a constitution in 1994, and the next year it held the first multiparty elections. Eritrea to the north gained independence from Ethiopia through a referendum in 1993, but border disputes escalated into a full-blown war in 1998 and caused the loss of tens of thousands of lives. A fragile truce was reached in 2000, but final border demarcation is still on hold because Ethiopia objected to the findings of an international commission in 2002.
Ethiopia is one of the poorest countries in Africa and in the world, with an adult literacy rate of about 43 percent. Only 28 percent of pregnant women receive prenatal care, according to the 2005 Ethiopia Demographic and Health Survey, and more than 15 percent of children are expected to die before the age of 5.
The country’s economy is based on agriculture and is often stricken by drought and floods. More than 85 percent of the population lives in the countryside, usually in precarious huts made of mud and straw, and many receive food aid from foreign governments and international relief organizations. Coffee, believed to have originated in Ethiopia, is one of the country’s leading crops, but low prices in the international market are driving farmers to supplement it with khat, a leafy stimulant that Ethiopia supplies to countries around the world.
Both Islam and Ethiopian Orthodox Christianity, the country’s major faiths, play crucial roles in Ethiopians’ lives – religion is a source of hope amid the harshness of life. Religious leaders are revered and obeyed. Belief in the existence of spirits, both malevolent and benevolent, is widespread, as a component of faith.
The face of HIV
The HIV epidemic started in Ethiopia in the mid-1980s, and today the country has one of the largest number of people living with the virus globally. Of the estimated 1.3 million HIV-infected people, 817,000 are women and 96,000 are children under 15. Prevalence is higher among women (4 percent) than among men (3 percent).
Initially, the epidemic was concentrated in major urban areas and trade routes and among high-risk groups, such as commercial sex workers. But in the 1990s, the epidemic spread into the general population. Today, heterosexual transmission accounts for 87 percent of the infections; an additional 10 percent of infections is passed from pregnant women to their babies. High-risk groups include youths, mobile workers, military and security forces, commercial sex workers and refugees.
AIDS is the cause of about a third of all young adult deaths in Ethiopia, and there are an estimated 744,100 AIDS orphans. When parents die, grandparents and other relatives struggle to feed and care for the children left behind in a country where at any point in time 6 million to 13 million people go hungry.
In recent years the epidemic seems to have stabilized in the urban areas; in the countryside, where most people live, the HIV prevalence rate had been on the rise, but recent reports suggest that it might have begun to level off. In rural areas knowledge of HIV is considerably lower. A 2002 survey, for example, found that only 8.8 percent of male farmers and less than 1 percent of female farmers had a comprehensive understanding of HIV/AIDS. One of the most common misconceptions found among farmers was that HIV can be contracted by eating an uncooked egg from a chicken that had swallowed a condom.
Challenges to fighting the HIV epidemic
Poverty, discrimination against those affected by HIV, gender disparity and widespread commercial and survival sex are all drivers of the epidemic in Ethiopia.
In a May meeting in Addis Ababa, members of a women’s association talked about their economic struggles and the tough choices they sometimes have to make. “Because of extreme poverty, women are vulnerable to prostitution,” said one of the women. “They go for sugar daddies who give them money for sex. They go to them to get money, to get bread.”
At times, even university students have to resort to “survival sex.” “Girls don’t have money, and there aren’t jobs,” said Nolawit Girma, an Addis Ababa University student who was participating in May in a HIV prevention training offered by a local nongovernmental organization. There are other troubling trends among Girma’s peers: Condoms are rarely used; sexuality is not discussed at home; and students lack basic information about HIV.
In recent years, religious leaders, especially the Orthodox patriarch, have used their influence to raise awareness about HIV and motivate their followers to fight discrimination and stigma. But those doing prevention work in Ethiopia say a lot remains to be done, especially in the rural areas where traditional practices, such as early marriage and female circumcision, add yet another level of HIV risk.
International organizations trying to slow the spread of the epidemic in Ethiopia say they need better behavioral and biological data to support their work, and donors are sometimes reluctant to invest money in research studies. Beverly Stauffer, an HIV consultant in Ethiopia, said these studies can help them better understand populations: “their knowledge; beliefs; attitudes; practices; culture; religious, structural and social factors that may present barriers to change as well as indicate strengths to build on.”
Ethiopian government response
The Ethiopian government has been credited by the World Health Organization with demonstrating a “very high level” of political commitment to combat the epidemic since its beginnings. A national task force on HIV was created in 1985, but a new national HIV policy and a comprehensive strategic plan of action were not developed until more than a decade later.
Since 2000, the HIV/AIDS Prevention and Control Office has facilitated the implementation of programs funded by the World Bank and the Global Fund for AIDS, Tuberculosis and Malaria and is now working closely with the President’s Emergency Plan for AIDS Relief (PEPFAR).
In a recent report, the Ethiopian government said its response to the epidemic has prioritized access to counseling and testing, prevention of HIV transmission from pregnant women to their babies and condom promotion, among other strategies. These efforts, the government said, have resulted in increased HIV awareness and condom use. It then added: “However, compared with the magnitude of the problem the results achieved so far are extremely modest and the national response and intervention are still far from adequate.”
U.S. government response
Since its arrival in 2004, PEPFAR has started the first-ever free antiretroviral therapy in the country. It has also partnered with the Ethiopian Orthodox Church and the Muslim Development Agency on large abstinence and fidelity programs and supported caring and income-generation activities for people infected with HIV. The money the U.S. government has invested in Ethiopia through PEPFAR has tripled since 2004, reaching $115 million in 2006.
In fiscal 2005, the country received $18.8 million for prevention activities, or 25.9 percent of the country’s total PEFPAR funding for prevention, care and treatment. Another $14.8 million — or 20.3 percent — went to care, while treatment activities were allocated $39 million — or 53.8 percent.
The treatment program consumes the most funds. By the end of 2006, PEPFAR’s goal is to support antiretroviral therapy to 60,000 patients in 89 hospitals and 267 health centers in cooperation with the Global Fund. So far, 47,000 people are receiving treatment, according to Management Sciences for Health, a U.S. nonprofit group funded by PEPFAR to ensure that antiretroviral drugs are delivered and managed properly.
Prevention efforts include mother-to-child-transmission programs as well as blood and injection safety programs. Abstinence from sexual relationships is the main PEPFAR message for Ethiopian youth, but U.S. government officials say they complement that training with condom information when youth are sexually active. In 2006, PEPFAR planned to reach 3.7 million youth with abstinence-only education and 13 million people with abstinence and fidelity programs.
The main group doing social marketing of condoms in Ethiopia, DKT International, said condom supply by the U.S. government has not decreased in the past few years; in 2005, it shipped about 60 million condoms.
PEPFAR, however, has placed restrictions around the promotion of condoms. For example, funds cannot be used for media campaigns that target young people and encourage condom use as the primary way to prevent HIV. Andrew Piller, DKT Ethiopia director, said the British, Irish and Dutch governments have stepped up to provide social marketing support. The European donors “made it clear that they were ready to fill the gap if necessary,” Piller said.