Table Of Contents:

1 - The Challenges and Opportunities of Mainstreaming HIV and AIDS Intervention in Ethiopia’s Higher Education System: What Roles for Tertiary Education? Abebe Haile Gabriel

2 - Feasibility of Antiretroviral Drug Therapy in Ethiopia Abdulhamid Bedri Kello

3 - Social Responses to HIV/ AIDS in Addis Ababa, Ethiopia with Reference to Commercial Sex Workers, People Living with HIV/AIDS and Community-Based Funeral Associations in Addis Ababa Alula Pankhurst; Andargatchew Tesfaye; Ayalew Gebre; Bethlehem Tekola; and Habtamu Demille

4 - Gender Relations and Vulnerability Regarding HIV/AIDS in Ethiopia: The Role of Power in Relationships on HIV Risk Awareness and the Ability to Communicate and Negotiate Safer Sex Yared Mekonnen; Gugsa Yimer; Tsehaynesh Messele; Yetnayet Asfaw; and Ambaye Degefa

The Challenges and Opportunities of Mainstreaming HIV and AIDS Intervention in Ethiopia’s Higher Education System: What Roles for Tertiary Education? Abebe Haile Gabriel

Executive Summary

Ethiopia is one of the countries worst affected by HIV and AIDS in many respects. In absence of any other option, education remains the social vaccine that has no substitute. Higher education has a central and strategic role to play towards a sustainable and effective response to the pandemic both in terms of workplace intervention as well as through educational, research and outreach programmes. Higher education is not there just to service the economy and society as it exists, but also to shape it into what it could and should be. The response of higher education to HIV and AIDS needs to be seen in that light.
This study set out to explore the potentials and constraints of mainstreaming HIV and AIDS as a response mechanism in higher education systems in Ethiopia. The study focused on universities and colleges that demonstrate certain unique initiatives (e.g. those employing community based education and research approaches, agricultural extension programmes, teacher education). Both secondary and primary data have been collected and analysed. The major findings of the study are summarized below.
1.    There has been very little attempt by the institutions to develop a policy on HIV and AIDS, with the exception of Jimma University, nor do they have a strategic framework for interventions. Similarly, again with the same notable exception, there was no attempt to generate information on the prevalence of HIV and AIDS among the communities or on its impacts. Therefore, there is no clear picture of the magnitude of HIV and AIDS problem as well as its impacts on the system of higher education. Indirect indicators, however, suggest that both the magnitude and impact of HIV and AIDS may well have been quite serious.
2.    There is inadequate understanding of the role that higher education should be playing as far as responses to the HIV and AIDS pandemic are concerned. HIV and AIDS issues are considered as the prerogatives of HIV and AIDS committees and/or anti-AIDS clubs. The result is that strategic and/or operational plans do not include planning for HIV and AIDS, and therefore, there is no basis for allocating a formal budget line to finance HIV and AIDS activities, or for the monitoring and evaluation of the activities.
3.    In absence of HIV and AIDS units within the formal structure, HIV and AIDS committees and/or student-based anti-AIDS clubs remain the focal points for spearheading piecemeal HIV and AIDS activities that are usually financed by some NGOs. Staff members who sit on the committees consider their assignment and involvement as part-time since they have ‘other’ full time duties. Anti-AIDS clubs rated their influences as unsatisfactory due to various reasons of which lack of management attention to the units, limited leadership capacities due to absence of training, inadequate allocation of financial resources and facilities by the institution are the most frequently reported.
4.    Attracting and retaining quality staff in sufficient numbers were reported as serious challenges in the face of high staff turn-over. A uniform academic staff employment policy issued by the Ministry of Education, which apparently has nothing to say about HIV and AIDS, is exercised across the board. Similarly a nationwide Civil Servants’ Proclamation, which is again silent on HIV and AIDS, is applied to implement human resource management functions for the administrative support staff. Units responsible for human resource management do not generally see clearly how to respond to the challenge since, in their opinion, they have little chance and ability to deal with the problem. By and large, HIV and AIDS are considered a problem of the individual concerned, not that of the institution.
5.    It was found out that institutions have not incorporated HIV and AIDS issues within their educational and/or research and outreach programmes. Only the faculties of health and medicine have some information on HIV and AIDS in their curricula. Respondents ascribe such a state of affairs to the persistence of a centralised system of curriculum design and a slow process of revision of curricula to make them relevant.
6.    Research, consultancy and outreach programmes that involve HIV and AIDS are accidental, isolated and individualised. Lack of institutional mechanisms within the systems to facilitate research and consultancy activities have allegedly undermined individual initiatives and efforts.
7.    Some limited collaborative efforts with other actors (NGOs in particular) exist but such initiatives were found to have originated and induced from outside rather than from within the institutions. Lack of institutional ownership meant susceptibility of programmes to occasional disruptions, changes in personalities, conflict of interests, etc.
8.    Lack of adequate priority given to the problem by leadership, expressed apathy and lack of coordination among staff, misconception as if it were the responsibility of a specialised agency within the institutions (e.g. anti-AIDS clubs) or those outside (e.g. HIV and AIDS secretariat), or those who volunteer to work (e.g. students) have reportedly contributed to the deficiencies.
A number of recommendations are suggested for the way forward.
First, leadership, ownership and commitment are critical to successful HIV and AIDS intervention. It is crucial that these should be demonstrated in deeds. These need to be purposefully nurtured through increased awareness, advocacy, training and coaching, and institutionalising a system of accountability. Clear expectations on an HIV and AIDS response must be set by the Ministry of Education and the Governing Boards of the institutions and subsequently be shared by managers of the institutions.
Second, it will be advisable for the institutions to develop HIV and AIDS policies and strategies that reflect their peculiar situations and thereby meet the challenges posed by the pandemic.
Third, incorporating HIV and AIDS issues into the institutions’ programmes (educational, research, outreach programmes) should be considered seriously. In fact this should be possible with the already available innovative practice of community-based education, developmental research and practical attachment programmes of some of the institutions which could well be adopted by others. However, incorporation of HIV and AIDS issues in the academic programmes might not achieve intended results unless it is addressed in a comprehensive manner so as to design and implement a learner-centred curriculum, learning materials and methodology of training. Staff training on these aspects must be accorded priority.
Fourth, planning and programming for an HIV and AIDS response need to be part and parcel of the overall planning process and should not be left to any specialised agency. Central to the whole process of mainstreaming of intervention is to start planning with available resources however small, which systematically enables institutions to implement effective budgeting, monitoring and evaluation of activities. To this effect, the educational management information system must be re-examined and redesigned to take full account of HIV and AIDS issues on a continuous basis. This helps to identify the magnitude of the problems as well as its impacts, which then becomes the basis for designing intervention strategies.
Fifth, institutional ownership of interventions and the capacity of those units at the forefront could be enhanced through setting up dedicated HIV and AIDS Units that can work. Effectiveness and sustainability of interventions require that they be anchored on an institutional bases that are more stable and enduring, not on piecemeal and ad hoc type arrangements. ‘Workplace’ interventions must be redesigned to involve all members of the community, not just the students. Also the importance of an organized response by the community cannot be overemphasised. For example, staff members could act in an organised manner if they form an association.
Sixth, institutions need to examine and re-engineer their systems so as to encourage and motivate a proactive and purposeful institutional response as opposed to isolated and individualised involvements by some staff members. Installing flexible, efficient and effective systems of financial and human resource management should be possible with the autonomy granted through the Proclamation.
Seventh, higher education institutions must seize the opportunity to live up to the expectations and receptivity by stakeholders (i.e. government, NGOs, donors) to an expanded role for them as partners in the fight against HIV and AIDS in terms of providing education, training, participation in policy formulation, or on field projects.
Eighth, as learning institutions, they must avail themselves to share experiences with promising approaches that work elsewhere. This should be possible with the availability of useful experiences as well as the ease with which to access them. A more active networking and partnership with other universities in Africa or elsewhere provides the framework for collaborative engagement. The availability of online learning resources such as the one initiated by the UNESCO Virtual Institute for Higher Education rapidly and substantially enhances their capacities.
Ninth, there is a need to seize the opportunities that have been provided by conducive local and international environments. The government is undertaking a series of inter-related reforms at the moment which makes it easy to embrace desirable changes. Capacity building is at the centre of it all in which government has positioned the role of higher education as crucial. The national ICT capacity building initiative should serve as a vehicle for reaching out to wider and larger audiences as well as significantly enhancing their capacity to share experiences with the rest of the world.
Finally the importance of a sense of urgency for effective and meaningful response cannot be overemphasised. The sense of urgency naturally emanates from the seriousness of the impact of the HIV and AIDS pandemic as well as from the time wasted by inaction thus far.

Feasibility of Antiretroviral Drug Therapy in Ethiopia Abdulhamid Bedri Kello


HIV/AIDS is a serious problem in Ethiopia, perhaps following only the leading health crisis: the threat of famine. Therefore, it should be a major area of concern to health policy makers and the government in general. The problem mainly affects the young working age groups in a country with a heavy dependency ratio. It has also resulted in higher incidence of killer diseases such as TB. And more importantly, it competes for attention with other important diseases killing thousands each year: malaria, respiratory infections, and intestinal parasites.
Vaccines against HIV are not yet there and we may have to wait for a long time before they become available. There are effective drugs to reduce viral loads and control the effect of HIV/AIDS in the bodies of people living with HIV/AIDS. This has been achieved in the developed countries. However, the drugs are expensive, have side effects, should be taken for a lifetime, and require some level of development of the health infrastructure for the purpose of monitoring and administration. Perhaps more importantly, the competition of these drugs for resources with other health interventions is crucial in the developing countries.
The overall health service coverage in Ethiopia is estimated to be approximately 64 per cent. Coverage estimates for the individual programmes are very low. The proportion of pregnant women immunized for tetanus is estimated at about 29.3 per cent, while about 70 per cent of children have received DPT3 immunizations.
The coverage is not readily translated into services. For instance, drug distribution could seriously limit services. Availability and rational use of drugs are the two most important elements in promoting high quality health care services because drugs account for about 70 per cent of household expenditure on health. Unavailability of drugs is the major factor behind low-level use of drugs at lower-level facilities, and among the poor, drug-vendors/pharmacies are the most frequently visited modern facilities.
This shortage at the national level is reflected by a large number of stock-out essential drugs selected as indicators for availability of drugs. A study showed that stock-out rates in some pharmacies that were set up to alleviate the shortage of essential drugs varied between 25 and 48 per cent, and out-of-stock days varied between 60 and 187 days. Similarly, provision of incomplete services in health facilities due to shortage of laboratory reagents and other medical supplies has been common in both public and private facilities and  with regard to both preventive and curative services.
Curative services take up most of the total health expenditures. There is a similar misallocation of resources across diseases. A good proportion of public expenditure on healthcare is allocated to recurrent expenditure. Recurrent expenditure is financed by the treasury, but capital expenditure comes from loans, foreign assistance, and the treasury's resources.
Since 1992, the share of drugs and non-salary items in recurrent expenditures has increased, and the proportion of salary costs has declined while the share of health centres and health stations has increased.
At the regional level, the allocation for programmes to address malaria and other vector-borne diseases has increased. There is a growing emphasis on primary health care-related services.
The share of health sector expenditure in the total national budget has increased dramatically in recent years. In spite of this, the per capita health expenditure in Ethiopia (US $1.5) is still very low compared to the sub-Saharan African average.
All health status indicators show that the health status of Ethiopians is poor. Though the picture is very similar for most parts of the country, some regions have even worse records. For instance, infant mortality rate for Ethiopia is97 per 1000 live births (the highest being 117 in Benshangul Gumuz Region and the lowest 61 per 1000 live births in the capital city, Addis Ababa). This is partly a result of the high burden of disease the people bear. Another health status indicator, total burden of disease, was 350 Discounted Life Years Lost per 1,000 population. The distribution of the causes of the life years lost reflects the major causes of morbidity and mortality in the country.
There are only rough estimates regarding the magnitude of HIV infection. Adult infection rate is estimated to be 4.6 per cent, and nearly 1.5 million Ethiopian adults and about 100,000 children under the age of five live with HIV/AIDS. The vast majority of those living with HIV/AIDS (90%) are in the age group of 20 to 49 years.
HIV infection in Ethiopia is mainly through heterosexual contacts, and only a small number of people are infected due to contaminated blood transfusion and unsafe injection. Prenatal transmission is also another major transmission mechanism.
The risk factors in multiple partner sexual contacts emanate mainly from the presence of sexually transmitted diseases. About one third of children born or nursed by a mother who is HIV positive may acquire HIV infections. Very few people in Ethiopia would be infected due to blood transfusion as blood is mostly screened before use. Some sharp objects used to cut parts of the body for cultural and medicinal purposes as well as non-sterilized needles used for injection are most likely to contribute to the transmission.
In the Ethiopian case, once a person is infected with HIV, AIDS could develop within 3-to-12 year period and the person most likely dies within less than a year of developing full-blown AIDS. The average incubation period from infection with HIV to development of the disease AIDS is 10.5 years (Mekonen et al. 2005). In contrast, infected children could die within two years (MOH 2000).
The major intervention schemes are: promoting reductions in the number of sexual partners, encouraging delayed onset of sexual activity among adolescents, promoting easy availability and use of condoms, and strengthening the programme aimed at controlling sexually transmitted diseases.
The Ethiopian government has until recently been discussing the possibility of introducing ARV therapy on an out-of-pocket payment basis, based on a financial analysis. Currently, the government has at last introduced a free-of-charge distribution of antiretroviral drugs, alongside those who pay user fees. It is important that an economic analysis be made to give the problem at hand a proper context rather than relying on a financial analysis considering only the cost of drugs and other associated costs. The aim of this research was to conduct an economic analysis of the possible cost of ARV drugs and determine the feasibility of such a therapy in the country. The major hypothesis was that the cost of ARV therapy is prohibitive and too high to be feasible as a public health service.
The rest of the report is divided into eight parts: Part II presents the Ethiopian health care sector. Part III discusses HIV/AIDS epidemiology and distribution, including the Ethiopian HIV/AIDS scene. Part IV discusses antiretroviral drugs and related issues. Part V describes the potential role of foreign assistance in promoting antiretroviral therapies in developing countries. Part VI presents the method used in the economic evaluation of the feasibility of antiretroviral drugs in Ethiopia. Part VII presents results of the study followed by details of cost estimation for treating  opportunistic infections. Finally, the conclusion for the chapter is presented and policy implications are discussed

Social Responses to HIV/ AIDS in Addis Ababa, Ethiopia with Reference to Commercial Sex Workers, People Living with HIV/AIDS and Community-Based Funeral Associations in Addis Ababa Alula Pankhurst; Andargatchew Tesfaye; Ayalew Gebre; Bethlehem Tekola; and Habtamu Demille


HIV/AIDS has become the foremost health problem in Ethiopia; yet the social aspects of this problem have remained comparatively understudied (Mesfin et al. 2005). The importance of the civil society in addressing the challenges has been recognized in other African contexts (Kober & Van Damme 2004); yet the responses of the civil society in Ethiopia are poorly understood, and collaboration with the government, donors, and NGOs that control funding has been limited.
This research addresses a major gap in research on thesocial impacts of the epidemic by considering the responses of three severely affected categories of the civil society in Addis Ababa. The first are Commercial Sex Workers (CSWs), who are commonly blamed for the spread of HIV/AIDS and work in conditions that expose them to risks. The study considers the constraints on their attempt to negotiate safer conditions. The second category are most directly affected: People Living With HIV/AIDS (PLWHA), whose livelihoods are threatened and who face challenges and stigma to cope individually and collectively. The research reviews the methods they use to come to terms with their condition, face discrimination, and the role of joining associations in their ability to cope. The third category are iddir funeral associations, the most widespread forms of community-based institutions which are involved in dealing with death.These institutions have lost members, who have often left behind  AIDS orphans. The research considers the extent of their awareness and assesses their responses in collaboration with other stakeholders.
There has been a tendency to portray these categories as passive victims who have not been responding proactively. This research questions this assumption and documents recent responses and means of coping with the challenges. Although the three topics were researched independently, the study also considered the overlap between them in order to assess the awareness of these highly affected categories of each others’ problems and the extent of their willingness to collaborate. This study was carried out by three staff members of the Department of Sociology and Anthropology of Addis Ababa University. The team members focused on the areas which they had worked on prior to this research with their graduate students who had experience or interest in the subjects.
Objectives and Methods
The overall objective of the research was to develop a better understanding of how the HIV/AIDS epidemic has been faced at a local level in Addis Ababa and the responses of three key categories within the civil society: CSWs, PWHA, and iddirs, with a view to suggesting appropriate strategies and interventions. Specific objectives for the CSWs included assessing their ability to negotiate safe sex, for PLWHA their coping strategies and reactions to stigma, and for iddirs their awareness and involvement in anti-HIV/AIDS activities.
The methods used involved quantitative and qualitative methods, comprising surveys, focus-group discussions (FDGs), and in-depth interviews. 453 questionnaires were filled in three surveys: 303 questionnaires by iddir representatives, 100 by CSWs, and 50 by PLWHA. Ten FDGs were held: five of these with CSWs, two with PLWHA, and three with iddirs. 72 individual in-depth follow-up interviews were carried out: 33 with PLWHA, 22 with iddir leaders, and 17 with CSWs. Special care was taken to develop trust with respondents and to respect ethical issues relating to data gathering and use.
Findings from the CSW Study
    The 100 CSWs covered in this study consisted of 52 women born in Addis Ababa and 48 migrants. Seven types of sex work were identified. The average age of the CSWs in the sample was 23 years; most were single and had little education. Most CSWs tend to maintain contact with and assist family members.
The extent of awareness about HIV/AIDS varies depending on age, education and type of sex work. However, all respondents claimed knowledge about various aspects of HIV/AIDS, which they gained mainly from peers, health personnel, and the mass media. Lack of awareness is, thus, not a major cause of vulnerability; rather, the main constraint is lack of power to insist on safer sex. The CSWs generally became aware of the danger only after joining the profession, but they are not willing to be tested (although many suspect themselves of being carriers) mainly due to fear of stigmatisation and discrimination by parents, relatives and friends, and for fear their survival might be jeopardised if customers suspect their status.
The great majority assert that they try not to have sex without condoms, in spite of customers’ preference. Some reported fears of condom breakage and attempt by clients to remove it. However, despite precautions with ordinary clients, they tend to have sex without condoms with their non-paying lovers and protectors, and some worry as they suspect their partners may be having affairs with other women. The CSWs engage in unprotected sex with these partners as they see this as different from sex for work, because it may be part of the deal or they do not want to disappoint protectors. Such distinctions may become blurred as customers become regular clients, and CSWs feel they have to accept their demands for unprotected sex.
The degree of vulnerability of sex workers to HIV/AIDS varies by type of commercial sex. Almost all CSWs face serious economic difficulties. However, there are some that are particularly deprived, notably share workers, whose capacity to refuse unprotected sexual service is undermined by the pressure of their employers, the “madams”, who share their income and want them to maximize services and the number of clients irrespective of the risks. The street walkers’ vulnerability is related to the power of clients who transport them in their vehicles and confront them with demands in situations where they cannot easily fight back.
Strategies pursued by sex workers to reduce risks of contracting HIV/AIDS include avoiding certain categories of men, staying sober and alert at work, praying and hoping, avoiding certain neighbourhoods considered dangerous, and preparing themselves for self-defence. CSWs also exchange information about dangerous men and try to protect each other against possible danger. Most said they would avoid servicing drunkards and men outside specific areas; they also avoid going out with men to areas they do not know. However, these strategies are not followed by all CSWs and may not be effective, particularly for categories of CSWs that are more vulnerable and in situations where their ability to protect themselves is constrained.
The CSWs generally expressed their dislike of sex work. They joined the profession due to poverty or in search of better pay. Most would give up commercial sex if alternative employment were available. However, many admitted that commercial sex provides a lot of independence and better pay than jobs they had tried earlier. Abandoning sex work is a hard decision, given competition and limited opportunities for alternative employment.
Findings from the PLWHA Study
The majority of the fifty PLWHA had a poor educational background; most were migrants and had no formal occupation. However, there are significant gender differences; males living with HIV/AIDS have relatively better educational, occupational, and other socio-economic backgrounds. HIV/AIDS resulted in many challenges in the livelihoods and expectations of PLWHA. Nearly all took HIV tests because they or their spouses showed symptoms of AIDS or in order to obtain foreign visas. Most of them did so after a long and stressful decision-making process.
On finding out about their status, PLWHA had to cope with anxieties and physical symptoms, as well as the responses of partners, family members, neighbours, friends, workmates, and the community at large. Mainly due to fear of stigma and discrimination, most decided not to talk about their HIV status, even with close relatives or friends. However, those who disclosed their status appreciated positive reactions and the economic support they obtained, and few experienced discrimination from relatives, friends, and community members.
The socio-economic conditions of PLWHA changed since their diagnosis or that of their spouse or the latter’s death. Most women living with HIV/AIDS depended largely on their husbands' income, and widowed PLWHA lost vital sources of income. Moreover, many PLWHA had to care for children on their own as single parents and worried about how to provide for themselves and for their children.
The interviewed PLWHA had joined associations and benefited emotionally, materially, and financially. Such associations provide information, care, counselling, and material support.They also serve as safe spaces where PLWHA can talk, share worries, and help one another. This played a key role in their coping. Social resources, notably, kin and friendship networks, were also found to be crucial in coming to terms with their condition, and those with strong social networks were in a better condition because of the practical and emotional support they received.
Findings from the Iddir Study
The survey of 303 iddirs found six types, the majority of which were sefer or neighbourhood and “male” iddirs, most of which were established in the imperial period. Women’s and youth iddirs are more recent. Average monthly payments were from three to seven birr, and three-quarters of iddirs levy additional payments.
Less than half the iddirs claimed that HIV/AIDS had an impact on their iddir, which included increased death rates, depletion of capital, greater payments to the families of the deceased and increasing numbers of orphans. However, follow-up interviews suggested that iddirs were severely affected, since increased deaths required more pay-outs, and more orphans and PLWHA involved costs, even if only by exempting them from monthly contributions. Several iddir leaders mentioned that recent fee increases were, at least in part, due to the epidemic.
Awareness of AIDS deaths was fairly low at just over a quarter of the sample, though estimates for the past six years increased significantly. However, most iddirs were unable to provide data, since few AIDS deaths are acknowledged publicly although, privately, many respondents were fairly sure about particular cases. Leaders felt that secrecy surrounding HIV/AIDS and limited testing are serious constraints. However, many were convinced that this is changing.
More than half the iddirs have been involved in some sort of activities relating to HIV/AIDS, starting in 1994 and increasing from 2002. The main participants were iddir executives and HIV/AIDS committee members. Involvement has tended to be limited to information and education. Over a quarter have HIV/AIDS committees and one fifth have changed their by-laws to allow for anti-HIV/AIDS activities.
Knowledge about PLWHA within iddirs seems limited. Only 25 iddirs had PLWHA who had gone public; only four asserted having PLWHA in HIV/AIDS committees, and none admitted having PLWHA in their executive committee. This shows there is still a long way to go in terms of involving PLWHA in iddir activities. However, almost a quarter of the iddirs claimed to support PLWHA. Numbers of PLWHA assisted remain limited, but have been increasing. The main form of support was monthly cash payments, followed by counselling; support given in the form of medical and home care, food, and clothing was less common. In practice, though, even exemption from attendance at funerals and fees seems rare, and iddirs mainly act as intermediaries for PLWHA to obtain assistance from NGOs. Only three iddirs levied a smaller additional payment. Deduction of death payments for medical expenses was mentioned in principle, and a few iddirs have assisted NGOs to locate youths to be trained as home-care givers.
AIDS orphans were assisted by 42 iddirs or 14 per cent. Specific assistance, though limited, has been gradually increasing. The main forms of support are educational, notably, uniforms, school fees, and books. Food and medical support are less common, and house rent and cash payments were much rarer. In general, iddirs act as conduits of assistance, as intermediaries between agencies and vulnerable children.But, for ethical and practical reasons, they assist vulnerable children without distinguishing AIDS orphans from others.
Funding for anti-HIV/AIDS work came mainly from monthly contributions or additional payments, but also from NGOs and local government. Collaboration with NGOs was mentioned by a third of the sample, consisting mainly in training and providing funds. Given the more sensitive nature of work with PLWHA, most collaboration focuses on orphans. Collaboration with the local government was mentioned by more than a quarter, mainly in training, networking with other similar organisations, and administrative support. However, development levies have created some resentment, and the formation of iddir councils by the local government is viewed with some wariness by iddir leaders. Several iddirs are part of Tesfa, Social and Development Association, an independent grouping of iddirs, and have obtained support from NGOs and the government for HIV/AID activities through the auspices of Tesfa.
The main problems and constraints mentioned with regard to working in anti-HIV/AIDS activities were inadequate knowledge about HIV/AIDS, followed by stigma and discrimination and lack of amendments of by-laws. Shortage of funds, members’ opposition, and improper management of funds were less mentioned.
In conclusion, the survey suggested that awareness of the impact of the epidemic seemed fairly low. However, the case studies suggest that knowledge about AIDS deaths was hampered by secrecy, stigma, and confidentiality. Interviewed leaders expressed optimism that attitudes are changing as PLWHA realise that testing is essential to become beneficiaries of assistance and as greater numbers receive support. The engagement of iddirs has tended to be limited to collaborating with the government and NGOs in information dissemination at meetings, involvement of the leadership in workshops, and gathering statistics on PLWHA and AIDS orphans. In some cases iddirs act as conduits for assistance in collaboration with NGOs, mainly in the form of handouts for PLWHA and covering educational expenses for orphans. Direct assistance is mainly in the form of exemption from funeral attendance and rarely in delays or exemption from payments. Specific levies for anti-HIV/AIDS activities, providing medical care in lieu of partial death payments, or assistance to orphans instead of funerary expenses were rare.

Interaction between the Three Categories
The degree of interaction between the three categories has an important bearing on the level of civil society awareness of the impact of the epidemic and determination to combat it jointly. The extent of collective action among and between the categories is still fairly limited. CSWs tend to work and live as individuals and do not cooperate much among themselves or form associations. Only the poorest PLWHA join associations, and coordination between these associations is limited. Likewise, iddirs have generally not formed umbrella associations. Furthermore, most CSWs and PLWHA are not members of iddirs, as they do not have permanent residences, cannot afford the fees, or fear stigma. Participation of PLWHA in iddir affairs is limited and CSWs are only involved in iddirs they have formed themselves.
However, there are also encouraging trends. Iddirs are increasingly becoming involved in assisting PLWHA and AIDS orphans. The CSWs who are members of community iddirs have not been facing discrimination, and some categories of CSWs have formed their own iddirs. Males living with HIV/AIDS did not blame CSWs and the latter were often sympathetic to PLWHA, since they are often in intimate contact with them. In addition, many CSWs suspect themselves of being HIV-positive. This study has thus shown that there are beginnings of some sorts of interaction between the three categories, which, individually and jointly, should be among the most significant actors in addressing the challenges of the HIV/AIDS pandemic.

Gender Relations and Vulnerability Regarding HIV/AIDS in Ethiopia: The Role of Power in Relationships on HIV Risk Awareness and the Ability to Communicate and Negotiate Safer Sex Yared Mekonnen; Gugsa Yimer; Tsehaynesh Messele; Yetnayet Asfaw; and Ambaye Degefa

1.1. HIV/AIDS in Ethiopia

The HIV epidemic started in the mid-80s in Ethiopia. The first sera with HIV antibodies date back from 1984, and the first AIDS cases were diagnosed in 1986 in Addis Ababa, the Capital City (Hailu et al. 1989; Lester, Ayhune, and Zewdie 1988). Two years later in 1988, high rates of HIV prevalence were detected among long distance truck drivers (13%) and commercial sex workers (17%) residing along the main trade routes of the country (Mehret, Khodakevich, and Zewdie 1990b; Mehret, Khodakevich, and Zewdie 1990a). Since then the epidemic has expanded at a fast rate throughout the country. According to UNAIDS, at the end of 2002, an estimated total of 2.2 million adults and children were living with HIV/AIDS in Ethiopia (UNAIDS 2003). AIDS is now the leading cause of mortality in the age group 15-49, killing adults in the most productive and reproductive phases of their lives (MOH 2002). Life expectancy in Ethiopia is being reversed as a result of AIDS and expected to drop to 46 years instead of 53 in 2001, and 50 years instead of the expected 59 in 2014 (Mekonnen, Sanders, and Messele 2002; MOH 2002). The primary modes of transmission of HIV in Ethiopia are heterosexual contacts and prenatal transmission (Sentjens et al. 2002; MOH 2002; Fontanet et al. 1998). Like in most sub-Saharan African countries, high-risk sexual behavior and sexually transmitted infections play major roles in the spread of HIV infection in both sexes in Ethiopia (Mekonnen,Sanders, and Aklilu 2003; Fontanet et al. 1998; Fontanet et al. 1999).
1.2 Gender and HIV
In most countries women are at particular risk of HIV infection. Studies elsewhere have shown that where the HIV epidemic has been established longest and spread furthest, women represent an increasing proportion of those infected. Women make up just less than half the global total of adults living with HIV, 55% of the total number in sub-Saharan Africa, and 30% of total adult infections in the rest of the world (UNAIDS 2002).
In Ethiopia, as in most sub-Saharan African countries, women are at higher risk of HIV infection than that of men. A community-based survey on 3853 randomly selected individuals aged 0-49 years in 1994 in Addis Ababa showed that in the age group 15-24 years the prevalence of HIV was 6% in females while it was only 3% among males (Fontanet et al. 1998). Results of the analyses of HIV surveillance data from 12,689 pregnant women in 34 urban and rural sentinel sites throughout the country revealed that the prevalence of HIV was about 12.8% with the peak prevalence documented in the age group 15-24 (MOH 2002). Another study on 677 in and out-of-school adolescents age 15-24 years found a prevalence rate of 11.1% for females while the corresponding figure for males was only 5.6% (Taffa et al. 2002). A study in two factories in Ethiopia also revealed a higher HIV prevalence among females compared to their male counterparts. The prevalence was 12.4% in females while it was 8.5% in males. The same study concluded that high-risk sexual behaviours and sexually transmitted infections play major roles in the spread of HIV infection in both sexes, but that factors such as low economic status and sexual violence make the women more vulnerable than the men (Mekonnen, Sanders, and Messele 2003). Available evidence, though scanty, suggests that the prevalence of HIV peaks in the younger age group especially among females, indicating a continuing high HIV incidence rate among girls in the country. Females tended to become more infected at a younger age than men mainly due to earlier initiation of sexual activity and exposure to older sexual partners that were already infected. In particular, young girls in Ethiopia are more vulnerable to HIV than boys because of early age at sexual debut, early marriage, sexual abuse and violence such as rape and abduction (Betemariam 2002; Mekonnen 2003).
Despite the global recognition of women’s vulnerability to HIV/AIDS and other sexually transmitted infections (STIs) is strongly influenced by gender-based power inequalities, not much has yet been done on the influence of gender relationship power on vulnerability to HIV/AIDS in sub-Saharan Africa, including Ethiopia. This study, therefore, presents the influence of gender relationship power on HIV risk awareness and the ability to communicate and negotiate safer sex in Ethiopia. The study also presents the prevailing gender roles and relations as well as sexual communication.  
The overall objective of this study was to systematically investigate the role of power in sexual relationship on women’s vulnerability to HIV/AIDS. The study, in particular, aimed at generating relevant information that improves our understanding of how the imbalance in power between women and men increases women’s risk and vulnerability to HIV/AIDS and fills critical gaps in the design of prevention programmes that can more effectively address the role of gender relations in the spread of HIV/AIDS in the country.
The specific objectives are to examine:
•    the prevailing gender roles, power in relationship and sexual communication;
•    factors influencing power in gender relations;
•    the influence of gender relationship power on the knowledge, misconception, stigma, risk awareness and risk perception regarding HIV/AIDS;
•    the influence of gender relationship power on partner’s communication regarding HIV/AIDS and negotiation for safer sex; and
•    the influence of gender relationship power on the uptake of VCT.
Since the primary focus of this study is to examine the influence of power in sexual relationship on women’s vulnerability to HIV/AIDS, the literature review is heavily dedicated to reviewing works related to the main focus of the study.
Gender relations, power and sexuality
Gender is defined as the widely shared expectation and norms within a society about appropriate male and female behavior, characteristics and roles, which ascribe to men and women differential access to power, including productive resources and decision-making authority (UNAIDS 1999). The term gender, therefore, emphasizes the social shaping of femininity and masculinity, and challenges the idea that relations between women and men are predestined by nature. The social difference between women and men profoundly affects women’s sexual relations with men, and gender and sexuality intersect with other social divisions such as social class (Holland, Ramazanoglu, and Scott 1992). In most societies, gender inequalities cause women to have less access to and control over economic resources. This in turn leads to dependence for material survival. Women’s socioeconomic position in turn affects their ability to enter into a sexual relationship with men as equal partners and, even where there is a measure of equality, powerful norms about sexuality and sexual behavior construct and constrain women’s behavior (Jackson and Scott 1996). Gender inequalities are reflected in sexual relationships between women and men. Pressure and violence may be the outcomes when male demands for sex are not met (George 1996; du Guerny and Sjoberg 1993).
Findings from the Women and AIDS Research Programme conducted by International Centre for Research on Women (ICRW) from 1990 – 1997 has given important insights into women’s sexual experience. ICRW has labeled the five P’s of sexuality – practices, partners, pleasure, procreation, and power (International Centre for Research on Women 1996). The first two refer to aspects of behavior – how one has sex and with whom; while the next two refer to the underlying motives. The power underlying any sexual interaction determines how all the other P’s of sexuality are expressed and experienced. The unequal power balance in gender relations that favors men, translates into an unequal power balance in heterosexual interactions, in which male pleasure supercedes female pleasure and men have greater control than women over when, where, and how sex takes place. Understanding of individuals’ sexual behavior, male and female, necessitates an understanding of gender and sexuality as constructed by a complex interplay of social, cultural and economic forces that determine the distribution of power.
Gender relationship power and vulnerability to HIV/AIDS
There are different ways in which the imbalance in power between women and men in gender relations curtails women’s sexual autonomy and expands male sexual freedom, thereby increasing women’s risk and vulnerability to HIV. Women’s vulnerability to HIV/AIDS and other sexually transmitted infections (STIs) is strongly influenced by gender-based power inequalities. There are several ways in which this occurs. Because women are often expected to be ignorant about sex and passive in sexual interactions, it is difficult for them to be adequately informed about risk reduction strategies (Blanc 2001; Kristin, Jewkes, and Brown 2004). Even among women who are informed, unequal power within sexual relationships was found to reduce their ability to negotiate for safer sex, to express their concern about sexual fidelity and to say “no” to sex (Pulerwitz, Steven, and Gortmaker 2000; Blanc and Wolff 1998; Gupta and Weiss 1993). For example, Pulerwitz and colleagues (2000) found that women with almost equal relationship power as their partners were more likely to use condoms consistently than those with unequal power in relationship. In Uganda, a scale of women’s sense of empowerment relative to her partner was positively associated with discussion of condom use and with actual use (Blanc and Wolff 1998). Evidence of women’s relative powerlessness to negotiate for safer sex and disease protection also came from studies in Uganda, Rwanda, and Zaire (Becker 1996). Zeireler and Krieger (1989) present the evidence that links the risk of HIV infection among women in the United States to inequalities involving gender, social class and race/ethnicity. They concluded that these inequalities, which are manifested at the national, neighborhood, households and individual levels, can explain the high rate of HIV infection among certain women, especially poor women of color. It was also reported in several studies that power differential is reflected in women’s intimate relationship and sexual behavior. Differences in women and men’s access to power, Dixon-Muller (1993) hypothesizes, influence decisions about intercourse, including the type and frequency of sexual practices. Similarly, Miller, Burns, and Rothspan (1995) propose that power inequalities not only may result in different sexual behaviors for men versus women, such as men maintaining more sexual partners than women, but may also lead to male control over the process of safer sex negotiation. According to Amaro (1995), women may, therefore, be less able to avoid the sexual behaviors that place them at risk of HIV infection.
It is, therefore, evident from the available literature that relationship power is an important component in the safer sex negotiation process and thus a key factor in women’s HIV/STI risk.

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