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METTU UNIVERSITY
2011E.C

RESEARCH PROPOSAL

TITLE-STRATEGIC PLAN
FOR INTENSIFYING MULTI-SECTORAL
HIV/AIDS

METTU UNIVERSITY/ETHIOPIA
2011 E.C

By: Health Informatics Students

Students Information

FACULTYOF:-PUBLIC HEALTH AND MEDICAL SCIENCE

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DEPARTMENT:-HEALTH INFORMATICS
COURSE TITLE:HEALTH EDUCATION AND
COMMUNICATION
COURSECODE:-HeED103
Name ID NO.
1.ABERA BEKANA RU1566/11
2.ABRAHAM GETA RU1484/11
3.AMANUEL ADISU RU1534/11
4.AMRIYA JUHAR RU1469/11
5.ARIF ABRAHIM RU1533/11
6.ASKALE MOSISA Ru1456/11
7.BADANE TARFASA RU1451/11
8.CHALI JIREGNA RU1543/11
9.NAHILI TILAHUN RU1457/11
10.SARA KIFLU RU1468/11
11.SUDI TESFAYE RU1431/11
12.TOLASA FAYISA RU1540/11
13.TSIYON DEREJE RU1446 /11
14.TULAMTU TOLINA RU1440/11

Complied by: HI 1st Year G1

Table of Content

UNITS PAGES

Abstract................................................................... ........................ I
Acknowledgement................................................................... ..............II
Background................................................................... .............. III

1. Basic Facts About HIV\AIDS

1.1. Definitions of HIV and AIDS....................................................................1
1.2. Modes of HIV transmission...................................................................2
1.3. Factors contributing to the progression of HIV infection in Ethiopia .3

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1.4. Impacts of AIDS......................... .. ... .......................................... ......4

1.5. Prevention of HIV/AIDS...................................................................5

2. Vision, Mission, Goal, Strategic Results,

and Guiding Principles
2.1. Vision................................................................... ....... ......... ........ 9
2.2. Mission.........................................................................................9
2.3. Goal. .................................................................. . ... ... ....... ..... ....9
2.4. Strategic Results................................................................... ...... ..9
2.5. Guiding Principles.................................................................... 9
2.6. Strategies of HIV/AIDS...................................................................10

3.Thematic Areas
3.1. Capacity Building..................................................................................
3.2. Community mobilization and empowerment..........................................
3.3. Leadership and Governance...................................................................
3.4. Mainstreaming..................................................................... ..............
3.5. Coordination and Partnership ...................................................................

4. Monitoring and Evaluation...................................................................

5. Models of Behavioral Change
5.1. Health Belief Model....................................................................................
Acronyms
Appendix
Reference ........

Abstract
Problem Statement: The rapidly growing literature on HIV/AIDS in Ethiopia has failed to examine the
epidemic, its impacts, and the national prevention and control program in their socio economic, cultural,
and political contexts.

Objectives:This paper reviews the epidemiology, driving forces, and impacts of the epidemic at the
societal level and evaluatesprospects for prevention and control.

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Methods: The literature was reviewed through online searches of PubMed/National Institute of Health,
Medscape, and PAHA (Partners Against HIV/AIDS in Ethiopia) databases; unpublished sources were
obtained from the Ministry of Health and other Ethiopian institutions, United Nations organizations, as
well as the Centers for Disease Control and Prevention (CDC) and nongovernment organizations.

Results: Since the rapid spread of HIV infection in the 1980s and 1990s—primarily by commercial sex
workers, truck drivers, and soldiers along major transportation routes—children, adolescents, and the
general population have increasingly become infected. While the epidemic has spread rapidly in
thetowns and more slowly in rural areas, surveillance activities remain underdeveloped.
Thus, the fragmentary data on the occurrence and impact of HIV/AIDS are speculative, and planning and
implementation ofprevention and control programs have been hindered.

Available data show that knowledge levels about HIV/AIDS and use of condoms have increased in towns,
and a few populations with declining risk behavior have been identified in Addis Ababa, although a high
degree of denial, discrimination, and high-risk behavior persist. Little is known about the situation in
rural Ethiopia. Poverty, war, gender inequities,traditional practices, and political problems have all
inhibited the effectiveness of prevention and patient care/support programs. The socioecnomic impacts
of HIV/AIDS are severe and increasing, and a sharp decline in population growth is anticipated.

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Acknowledgements
Firstly,We would like to express our sincere gratitude to our GOD.Without his support nothing can be
accomplished even work done is impossible. Next to that We wish to express our gratitude and
appreciation to Instructor Mr. Abdi Geda for the continuous support of our research proposal, for his
patience, motivation, and immense knowledge. His guidance helped us in all the time..
We also thank the dedicated idea of Mr. Abdi Geda, the Foundation for this Research, for providing the
technical assistance required to undertake this analysis; special thanks is required from us.

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Background

Ethiopia follows a Federal government system and consists of nine National Regional States and two City
Administrations with 840 districts. The population size of the country is estimated to be over 100 million
of which 83% live in rural areas. Since the first AIDS cases identified in 1986 the country had started to
respond to the epidemic in different approaches. The early response was a health sector response, but
after the endorsement of the HIV/AIDS policy in 1998 the country followed a multi sectoral approach to
fight the epidemic. To implement the HIV policy aligning with the dynamics of the epidemic, recent
evidences of effective interventions and technologies three consecutive five year strategic frame works
or plans to intensify the multi-sectoral response to HIV/AIDS in the country were developed. The first
one was “Strategic

Framework for the National response to HIV/AIDS in Ethiopia (2001-2005)”. The second and third are
Strategic Plan for intensifying multi-sectoral in Ethiopia (SPM-I: 2004-2008) and SPM-II (2010-2014)
respectively. Over these years the response was guided by these and health sector development plan (I-
IV) which reversed the epidemic in the country. In order to identify the priority areas and design
effective programs with high impact interventions for the post 2015 and invest the resources
accordingly, it is important to understand the epidemiology and state of the current response. The Need
for targeted approaches to high impact interventions, improving efficiency and increasing domestic
resources to the national responses have become critical elements to achieve high infection aversion
and lives saved. This is why this HIV Investment case is developed to guide the 2015-2020 national
response and paving the path to ending the AIDS epidemic in the country by 2030.

UNIT UNE

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1.Basic Facts about HIV and AIDS

Introduction
HIV/AIDS has been a major health issue in sub-Saharan Africa for more than two decades. Ethiopia has
one of the lowest HIV prevalence rates in East Africa, but there are still more than one million people
estimated to be living with HIV in Ethiopia. Continued education, prevention, and treatment are
necessary to prevent the spread of future infections and to care for those already infected.The last
decade has seen tremendous growth in HIV-related programmes, including education and stigma-
reduction programs, behaviour change initiatives, expansion of HIV testing, and programmes aimed at
youth. The 2005 and 2011 Ethiopia Demographic and Health Surveys, as well as most MEASURE DHS
surveys in East Africa, measured HIV prevention knowledge, HIV-related attitudes, high risk sexual
behaviours, HIV testing, and HIV prevalence. A detailed look at these data suggest that many
programmes have been effective. Overall awareness of HIV/AIDS has increased, and HIV testing has
become much more common. But EDHS data also point to areas where improvement is still needed, and
where focused activities could help to address inequities.

1.1. Definitions of HIV and AIDS

HIV – is the Human Immunodeficiency Virus. HIV is responsible for causing the immune system
— body's defence against infection and disease —to gradually deteriorate, resulting in AIDS.
☞HIV breaks down the immune system — by infecting specific white blood cells.
☞As time passes, the immune system is unable to fight the HIV infection and the person may develop
serious and deadly diseases, including other infections and some types of cancer. Cancers most often
associated with HIV and AIDS include lymphoma, Kaposi’ s sarcoma, cervical and anal cancer.
Other cancers that may develop in people with HIV infection include Hodgkin’ s disease, oral cancer,
testicular cancer and certain skin cancers.

AIDS is an acronym for acquired immunodeficiency syndrome and refers to the most advanced and
severe stage of HIV infection.
A: Acquired — not inherited, differentiate from a genetic or inherited condition that causes
immune dysfunction
I: Immune — affecting the immune system
D: Deficiency — inability to protect against illness
S: Syndrome —a group of symptoms or illnesses that occur as a result of an infection
An AIDS diagnosis can be made on the basis of clinical symptoms and/or blood tests.

Differences between HIV, HIV infection and AIDS

☞HIV is the virus that causes HIV infection, including AIDS.

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Without treatment, HIV infection progresses from seroconversion to asymptomatic HIV infection,
symptomatic HIV infection and, in the final stages, to AIDS.
☞AIDS is the most severe manifestation of infection with HIV.
HIV infection describes the person who is HIV-infected. This person may be at any stage of
infection: seroconversion, asymptomatic or symptomatic HIV infection, or AIDS.
Almost all people with HIV infection will ultimately develop HIV-related disease and AIDS.

Types of HIV
There are two types of HIV: HIV-1 and HIV-2. Both types are transmitted the same way, and both are
associated with similar HIV-related opportunistic infections. HIV-1 is more common in Ethiopia. HIV-2
is found predominantly in West Africa, Angola and Mozambique.

Differences between HIV-1 and HIV-2

HIV-2 appears to develop more slowly and to be milder than HIV-1. People infected with HIV-2 are less
infectious in the early stages of infection. Different prophylaxis and treatment regimens may also be
required for people infected with HIV-2.
Natural course of HIV infection
The immune system protects the body by recognizing and attempting to destroy:
☞Infectious agents such as bacteria, viruses and parasites
☞Abnormal cells
☞Foreign objects — anything from splinters to transplanted organs

1.2. Modes of HIV transmission

HIV can be transmitted through sexual contact, blood, injection drug use and from mother-to-child (also
known as perinatal or vertical transmission).

Sexual contact
Unprotected sexual intercourse (vaginal, oral, or anal) with an HIV-infected partner; pregnant women
are particularly vulnerable to HIV infection due to physiological changes occurring during pregnancy.
Contact with HIV-infected body fluids: blood, semen, vaginal fluids and breastmilk.

Mother-to-child transmission (MTCT)

From mothers who are HIV-infected to their infants during pregnancy, labour and delivery and
breastfeeding.

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 HIV cannot be transmitted by :
June 17, 2019 [HEALTH EDUCATION] Coughing or sneezing
I n s e c t b i t e s
Blood-to-blood transmission Touching or hugging
☞ Transfusion with HIV-infected blood K i s s i n g
☞ Direct contact with HIV-infected blood Public baths/pool s
☞ Sharing of sharp skin piercing instruments such as knives, scalpels, P u b l i c t o i l e t s
needles or any other sharp object that had been used previously on a S h a k i n g h a n d s
person with HIV. This includes medical, recreational, ceremonial,
Working or going to school with a person who is HIV-infected
religious or beautifying procedures in the community, healthcare
facility, or any other setting. T e l e p h o n e s

Occupational exposure W a t e r o r f o o d
Sharing cups, glasses, plates, or other utensils
Persons vulnerable to HIV infection
☞Individuals with multiple sex partners
☞Babies born to HIV-infected mothers
☞People with other sexually transmitted infections (STIs)
☞Men who have sex with men
☞Injection drug users
☞Recipients of unsafe blood and blood products

1.3. Factors contributing to the progression of HIV infection in Ethiopia.

There are different factors which directly or indirectly affect the risk and magnitude of the HIV/AIDS
problem in a given society. Studies have outlined broad ranges of biological, behavioural and societal
factors that play an important role in the dissemination of HIV infection . 1.lndividual,
2. Environmental
3. Economical and
4. Socio-cultural factors prevail which may contribute positively to the transmission of HIV / AIDS in
Ethiopia.
1. Individual
B i o l o g i c a l B e h a v i o : r a l
•Historyand/orpresenceofSTDs; •Frequentchangeofsexpartners;
•Lackofmalecircumcision ; • M u l t i p l e s e x p a r t n e r s ;
• A n a l i n t e r c o u r s e ; •Unprotectedsexualintercourse;
• S e x d u r i n g m e n s e s ; •Sexwithacommercialsexworker;
• T r a u m a t i c s e x ; •Sexwithaninfectedpartner;
• C e r v i c a l e c t o p y •LackofknowledgeofSTDs/HIV;
•Prevention/treatmentofSTDs; • L o w r i s k p e r c e p t i o n
•Avoidanceofsexduringmenses; • A b s t i n e n c e ;
•Preventionoftraumaticsex • M u t u a l f i d e l i t y ;

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• C o n s i s t e n t c o n d o m u s e

S o c i e t a l n o r m s D e v e l o p m e n t a l i s s u e s

•High rates of prostitution; • U n d e r d e v e l o p m e n t ;

•Multiple partners by men; • P o v e r t y ;
•Gender discrimination ; • R u r a l / u r b a n m i g r a t i o n ;
• Poo r at titud es to ward co ndom u se ; • C i v i l u n r e s t ;
•Lowliteracyratesforwomen;
•Socials tatus of women;
•Laws/policies,includinglackofhumanrights;
•Extended postpartum abstinence
• U n e m p l o y m e n t
•Improvement instatus of women ; •Generaleconomicdevelopmentprograms;
•Job opportunities for women; •Enactmentofappropriatelaws/policies ;
•Promotion of mutual fidelity; •Income-generatingopportunities;
•Changes in societal attitudes to ward condomuse •Improvementineducationofwomen

1.4. THE IMPACT OF AIDS

No systematic national studies have been carried out to document the socio-economic impacts of
HIV/AIDS in Ethiopia. However, isolated reports and anecdotal evidence suggest a heavy burden on
caregivers especially women and on society in general. A 2003 study by the Ministry of Education
reported a 5 percent increase in death among teachers, some of which might be due to AIDS.
Absenteeism attributable HIV/AIDS was estimated at about a week per semester among a third of the
teachers due to illness or due to illness of a family member. School dropout rates also climbed, due most
likely, to death of parents with orphaned children repeating grades at higher rates than non-orphaned
children. Overall education costs are on the rise due to the replacement of teachers “…and premature
payment for terminal benefits”. Other data sources include a 2003 study by the Ministry of Labor and
Social Affairs which showed that “… AIDS orphans unable to sustain their own livelihood are expelled
from their parental residences following the deaths of their parents”.

A.Co-infection
The impacts of HIV/AIDS include co-infection with another disease, TB in particular, through the gradual
weakening of the body’s immune defenses by the virus. “A report issued in 2003 by the TB & Leprosy
Prevention and Control Team of the MOH listed the following major problems attributable to co-
infection:
• “Increase in the number of TB patients
• Low cure rate of TB patients,
• High mortality during treatment,
• High rate of adverse drug reactions leading to a high number of defaulters,

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• High rate of TB recurrence, and

• Increase of TB drug resistance.”

B.Socio-economic impacts
More study results have also been published in the wake the research done the Employers Federation of
Ethiopia in 2002. These showed the impact of HIV/AIDS to be most pronounced in the wholesale and
retail trade sectors followed by the manufacturing, agriculture and public service sectors.
“Reduced productivity, shortages of skilled manpower, increased mortality in the work force, increased
absenteeism and rising medical costs were found to be the major effects in the industrial sector.”
In view of the large number of people requiring treatment, care and support both for the infected as
well as the affected, the epidemic poses a great threat to the overall development efforts of the
country. Moreover the degree of impact could be much higher in Ethiopia than other Sub-Saharan
African countries due to the large population size and the level of poverty of the population.

C. Demographic Impacts
Projected Impacts on Population Size
“The cumulative number of AIDS deaths was 1,267,000 by 2005 and is projected to reach 1.9 million by
2010 if present trends continue.” it would have had a substantial impact on the future growth of the
population in the 15-49 age group thereby affecting the growth rate of the next generation of Ethiopians
had it not been for the peaking of the infection rate in 2005 and a sustained decline since. The trend of a
rapid rise in rates between 1990 and 2005 symbolized a prospect of significant HIV/AIDS impacts on a
generation of young adults and the probable end results that are likely to occur in the absence of
effective societal response led by well planned and effective acts of intervention and resource
mobilization by the government.

D. Impacts on Life Expectancy

HIV/AIDS as having reduced life expectancy in Ethiopia by as much as 5 years (2004 – 06). The rate of
reduction in life expectancy increased from 4.2 years of life lost in 2000 to 5 years of life lost in 2004,
20005, and 2006, but the loss was projected to decline to 2.8 years in 2010. The gradual increase in
overall life expectancy since presupposes the continued ebbing of infection rates and a gradual decrease
in HIV/AIDS mortality due, in part, to anti retroviral therapies.

1.5. Prevention of HIV/AIDS

A combination preventions programs targeting general communities, in school youth, female sex
workers, vulnerable women, truck drivers, daily laborers in development sectors and uniformed forces
have been implemented with different scales.

A. Behavior change communication (BCC)

ØBCC: General population
During SPM II Behavior change communication program targeting communities particularly in Tigray,
Amhara, Oromia, SNNP, Harari, Addis Ababa and Dire Dawa have been implemented largely through the

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Health Extension program and Health Development army. In addition to these, HIV related Information,
Education and Communication particularly prevention of Mother to child transmission, promotion of
condom use and adherence education have been disseminated through print and electronic media. The
key achievements are:
☞About 75-80% of Kebeles have been implementing the Health Development Army initiatives.
☞ High level of HIV/AIDS awareness among the population with 97% of women and 99% of men having
heard of HIV/AIDS (EDHS, 2011).
☞Increased demand for and utilization of services (HTC, ART, PMTCT, institutional delivery)

The gaps in this area include

☞The Health development army largely focuses on maternal health and overlooks the HIV prevention
component; field observation in different districts and kebeles indicate that there is a tendency of
community complacency to HIV prevention.
☞Lack of use of available evidences in the wereda and nearby health facilities to implement BCC tailored
to the locality.
☞ Low comprehensive knowledge about HIV/AIDS among the general population.
 BCC: School
HIV/AIDS is incorporated in to the Curriculum of primary and secondary level education. In
addition to this co curricular activities such as mini media, anti AIDS clubs, Girls club etc do
exist in schools which help students to have capacity of self expression, debate, negotiation
and promote peer education. The positive achievements include:
☞ Many of the schools have teachers who received training on Life Skill Education. For
instance, with HIV Rolling continuation Channel grant only, over 20,000 teachers were trained
on life skilled education in late 2013 and first half of 2014.
☞Majority of the Universities have been implementing HIV prevention programs
☞ High testing uptake and high rate of preventive behavior in University students such as
condom use
☞ Low HIV prevalence in students and young people. For instance the study conducted among
students in Amhara in 2012 showed the HIV prevalence to be 0.07% (CDC,2012) while a study
conducted among University students in Dire Dawa in 2013 found the HIV prevalence to be
0.4% (NASTAD/CDC, 2013).

The main programmatic constraints and gaps in Education sector HIV program are:
☞ School HIV program is neither comprehensively guided nor performance is adequately tracked.
Though the Education sector has HIV specific strategic plan, it did not expansively guide the
implementation of School HIV program and the Management information system of the Education
sector does not track any HIV related performance.
☞ Percentage of university students who had sex with female sex workers or non regular partners is
high.

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 BCC: MARPs and other vulnerable populations

With the implementation of the Prevention package for Most at risk population groups a better
focus to targeted prevention was given during the SPM II period. Among these:
☞ With the support of PEPFAR and involvement of Civil society organizations, prevention program
targeting female sex workers, waitresses , daily labors and truck drivers was scaled up to 169 towns and
transport corridors.
☞ Improved mainstreaming of HIV/AIDS into large scale development schemes, road
constructionprojects and sugar factories. With difference in intensity and scale, Peer education and
work place interventions have been implemented in the mega projects, public and private factories and
flower plantation in the country.

The critical gaps in the BCC program include

☞In adequate coverage of BCC program for Most at risk population such as female sex workers, daily
laborers etc. The size estimation of the different MARPs is not fully known.
☞ The coverage of the BCC program in the development schemes is limited and not extended to the
pool of female sex workers influx to the locality and surrounding communities of the project site.
☞ Poor coordination and weak capacity of implementers: HIV prevention units at large scale
development schemes and public health facility or Health office in surrounding towns do not exert their
efforts in coordinated manner. As most of the large scale development schemes are newly established
they do not have adequate program capacity.

 B. Structural Prevention Interventions

Gender mainstreaming in to HIV services, enhanced community mobilization against harmful
traditional practices such as early marriage, Female genital mutilation and HIV vulnerability
reduction among women through strengthening economic interventions were implemented in
the SPM II period. The major achievements include:
☞ Increased HIV service utilization among women. Women accounted for 53% of last year’s HIV
tests
☞ Reduction in practices of early marriage, Genital mutilation and widow inheritance.
☞ Income generating schemes targeting vulnerable women have been expanded and many have been
benefited from the program.

Challenges/gaps
☞ Deep rooted social customs: though encouraging progress registered in changing social customs such
as early marriage, widow inheritance and FGM, still such practices exist in some areas.
☞Lack of adequate evidences on the impact of IGA on reducing HIV infection.

 C. Distribution and use of condom

A great proportion of condom was distributed through social marketing using different outlets
such as pharmacies, drug stores, hotels, bars, kiosk, etc. Free condom has also been distributed
through health facilities, mega projects and NGOs/community based organizations and

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accounted for one fourth of the whole annually distributed condom. The main targets for the
free condom were STI cases, work forces in the development schemes, truckers and female sex
workers. During the SPM-II period there was an improvement in distributing condom to the risky
population; for example, of the 126.8 Million condom distributed from July 2013 to March 2014
in the country, 30% was distributed to Most at risk population. The overall annual distribution
ranged from 147 to 174 million which was over 50 % less of the target. None of the annual
targets were met in the last four years. This could be due to over ambitious target.

The gaps in the condom programming are:

☞ Lack of unified coordination and integration of efforts of actors involved in condom distribution.
☞ Low condom coverage
☞ Knowledge gaps for quantification of universal condom needs.
☞ Consistent condom use among sex workers and other who are most at risk is not universal.
☞ Incomplete understanding of condom preference by target group
☞ Lack of clarity on what should be the condom outlet in different sectors-fixed outlets and scheduled
outlets

 D. Prevention of Mother-to-Child Transmission (PMTCT)

Over the last four years of the SPM-II period, Efforts were made to prevent and control STI
through promotion of healthy sexual behaviors, improving availability and use of condom and
provision of integrated care in Public and private health facilities. The focus of the next five
years is to reduce the incidence of the common sexually transmitted infections among the
population, with a special emphasis to most at risk and vulnerable population groups and
intensify appropriate diagnosis and treatment of STI through overhauling Syndromic case
management at all service delivery points. The key interventions include
☞ Improving program management through having required structures and appropriate
staffing at national, regional and wereda as part of the overall HIV program coordination.
Promote healthy sexual behavior, use of condom and treatment seeking behavior through the
targeted BCC program
☞ Evaluate the existing Syndromic case management algorithm and revise the guidelines
accordingly.
☞ Strengthen the capacity of health care providers to appropriately diagnose, treat, provide
counseling and report STI cases.
☞ Expand user friendly STIs and reproductive health services to MARPs & other vulnerable population
☞ Ensure availability of drugs for STI through proper quantification, timely procurement and distribution
to health facilities
☞ Strengthen congenital syphilis prevention through improving routine RPR test in all ANC clinics and
appropriate treatment.

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☞ Strengthen follow up of Syndromic STI case management on a regular basis and program monitoring
and evaluation.
☞ Strengthen STI surveillance

E.Blood Safety
As blood safety is an integral component of the national HIV response, due focus will also be given
during the investment period to support the implementation of the national strategies for blood safety
and availability. The support will focus on
☞ Raising public awareness on the need for voluntary blood donation
☞ Promoting 100% voluntary non remunerated blood donation from low risk population and counseling.
☞ Ensuring quality- assured testing of all donated blood for HIV.
☞ Complementing the supplies for universal precaution

UNIT TWO

2. Vision, Mission, Goal, Strategic Results,

and Guiding Principles
Vision:
To see Ethiopia free of HIV/AIDS
Mission:
To prevent and control HIV/AIDS epidemic and mitigate its impacts by creating universal access to HIV
prevention, treatment, care and support services through intensified community mobilization and
empowerment, by building capacity and ensuring the active involvement and ownership across sectors,
enhancing partnership under the principle of the “three ones”, and mobilizing and ensuring appropriate
use of resources.

Goal:
To reduce new HIV infections, AIDS related morbidity and mortality and mitigate its impacts.

Strategic Results:
• Comprehensive knowledge and behavioural change created on individual and mass bases,
• Reduced new HIV infection, and
• Improved quality of lives of infected and affected people.

Guiding Principles
1.Multisectoralism: The HIV/AIDS epidemic is posing a formidable challenge to the development of all
sectors as illnesses and deaths from AIDS reduce productivity of their labour force. Responding
effectively to the behavioural, social, cultural, and economic factors that make individuals and

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communities vulnerable to HIV infection and mitigating the associated crises of AIDS requires organized
and concerted efforts from all actors in the public and private sector, NGOs, FBOs, PLHIV and
communities at large. All sectors should mainstream HIV/AIDS prevention and control into their core
mandates, plans and programmes. Hence, multi-sectoralism remains to be the core guiding principle of
comprehensive and expanded response against HIV/AIDS.

2.Empowerment: Families and communities should be empowered and own the HIV programs so as to
halt and reverse the epidemic.

3.Shared sense of urgency: HIV/AIDS needs to be combated with a shared sense of urgency by all actors
to reverse and stop further spread of the epidemic, mitigate its impacts and succeed in our fight against
poverty.

4.Partnership: All sectors of the society have to be involved in order to effectively respond to the
epidemic by minimizing duplication of efforts, pooling resources together, creating synergy and
maximizing impact. Effective scale up of the HIV services requires a coalition approach, which
accommodates all partners working within the national HIV strategic plan framework.

5.Gender sensitivity: The fight against HIV/AIDS cannot be successful unless it effectively addresses the
social, cultural, and economic causes of gender inequality in our society. Women should be actively
involved in the fight against HIV/AIDS and gender sensitive HIV/AIDS prevention and control programs
should be ensured by all actors.

6.Together with PLHIV: Greater involvement of people living with HIV (GIPA) should be ensured in all
programs of HIV/AIDS prevention and control at all levels.

7.Result Oriented: The investment on HIV/AIDS prevention and control programs should yield the
expected results in averting new infections and improving quality of life of the infected and affected
population. The response should be led by evidence based/informed planning and programming.

7.Best use of resources: Resources mobilized from external development partners, the government and
communities should be utilized in an effective and efficient manner with accountability.

2.2. STRATEGIES OF HIV/AIDS

HIV-prevention strategies can be classified according to the foundation on which they are based: (1)
Formal institution-based programs (e.g., at the workplace, school, or clinic);
(2) Community-based programs (e.g., among informal youth groups or informal women's groups); and
(3) Population-based programs (e.g., national media campaigns or policy development).

1. Institution-based Programs

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Both institution-based and community-based programs are designed to reach individuals and small
groups, with the aim of teaching and reinforcing protective behaviors. They are intended to give
individuals the opportunity to acquire information, assess their own risk of HIV, interact with a provider,
and obtain relevant behavioral and communication skills that can help in reducing high-risk behavior;
they also generate notions of peer norms that are conducive to risk reduction.
Institution-based programs include interventions in the workplace (factories, prisons, commercial farms,
mining communities, military bases); in schools; and in health facilities, such as STD and family planning
clinics, hospitals, and HIV counseling and testing clinics. Targeted groups within these institutions may
not be homogeneous in terms of individual behavior or social norms, and may or may not exhibit more
high-risk sexual behavior than the general population. The relative ease of access to these institutional
populations renders such programs attractive and potentially cost-effective.

2. Community-based Programs
Community-based programs use group interventions to reach communities. These interventions include
the use of peer educators to reach sex workers or school-aged youth, use of traditional health providers
to reach rural communities, or programs targeted to other community groups
Community participation can sometimes be a critical factor for program success and
sustainability.According to the guiding principles described earlier, HIV/AIDS-prevention programs
should be designed at the outset with attention to their acceptability within the community and target
groups, the external or institutional support required to develop and sustain the skills and talent needed
to make them work, and the infrastructure support and the individual and collective commitments
needed to maintain them over time (Lamptey and Coates, 1994). Community involvement is often only
an empty slogan in programs without any real involvement of the community in decision making.

3. Population-based Programs
Population-based programs, using mass media, aim to change societal norms, and provide information
as well as individual behavior-change messages to large segments of the population. They may also
encourage the enactment of policies to support HIV/AIDS-prevention efforts. Examples include media
education programs, condom social marketing programs, and policy changes such as a regulation
requiring condom use in brothels.
Population-based programs may be targeted to such large segments of the population as adolescents,
sexually active males, men and women with multiple partners, or all sexually active men and women.
Undoubtedly the best known and most widely cited example of a population-based intervention is
condom social marketing.

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UNIT THREE

3. Thematic Areas
General Objective: To create an enabling environment for scaled up and comprehensive HIV/AIDS multi-
sectoral response.
This thematic area has five sub-thematic areas:
(1) capacity building
(2) community mobilization and empowerment
(3) leadership and governance
(4) mainstreaming and
(5) coordination and partnership.

3.1. Capacity Building

Specific Objectives:
• To ensure the capacity of the health sector to achieve Millennium Development Goals 6 (MDG 6) by
2015.
• To build the capacity of key and strategic sectors, civil society organizations (CSOs) and private sectors
to contribute to the achievement of MDG 6 by 2015
Strategies:
• Strengthen the capacity of the health sector.
• Build the capacity of key sectors, CSOs and the private sector
Strengthening the health sector is indispensable to ensure effective HIV/AIDS multi-sectoral response.
The expansion and equipping of health facilities together with availing adequate skilled human resource
in the health facilities as well as at different levels of management of the health system is an important
component of building the capacity of the health sector.
Building the capacity of key sectors and communities is also of utmost importance to intensify the fight
against HIV/AIDS. In order to move towards the achievements of MDG 6 by 2015 (“to halt and reverse
the spread of HIV”), there is a real and pressing need for creating adequate capacity at community and
institution levels.
Capacities of key sectors that can have significant effect on the fight against HIV/AIDS such as,

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Education, Health, Mining, Defence, Industry, Communication , Culture and Tourism, Transport, Women,
Children and Youth , Labour and Social, Water and Energy, Trade, Agriculture, Civil service, Urban
Development and Construction, Federal affairs and Ministry of Finance and Economic Development,
need to be strengthened. In addition, the building of leadership across sectors and communities and
strengthening the capacity among stakeholders such as Most At Risk Populations (MARPs), Network of
Networks of HIV Positive in Ethiopia (NEP+), Ethiopian Inter-faith Forum for Development, Dialogue and
Action
(EIFDDA) and other Civil Society Organizations (CSOs) is crucial to synchronize and harmonize efforts
towards a common goal.
Interventions:
• Support the expansion of health centres.
• Support universities and colleges to provide pre-service training for health science students.
• Train health workers on HIV/AIDS.
• Staff key sectors with experts on prevention and impact mitigation.
• Provide support to federal sectors to build the capacity of regional sectors on HIV.
• Prepare health facilities for people with disability.
• Build the capacity of networks of associations of PLHIV, OVC, elderly people, people with disability,
CSOs and FBOs.
• Provide support to associations of PLHIV, OVC, the elderly, people with disability, CSOs and FBOs.

3.2. Community mobilization and empowerment

Specific objective:
• To sustain community movement and attain social change by 2015.
Strategies:
• Ensure community ownership and leadership of HIV/AIDS.
• Augment community mobilization with behavioural change interventions.
• Strengthen institutional support to community anti-AIDS movement.
Community mobilization and empowerment is crucial to attain success in the fight against HIV/AIDS. The
anti-HIV/AIDS community movement should be anchored with the development and implementation of
a concrete action plan. The community must own the movement and integrate an HIV/AIDS response
into the existing socio-cultural and economic activities. Anti-AIDS community movement was intensified
and over 80% of Kebeles across the nation covered with community However, social transformation,
which can bring the required level of changes in behaviour and social norms, has not been fully realized
in the community at large. Hence, there is a need to consolidate and intensify the anti-HIV/AIDS
community movement to bring social transformation.
The movement should engage key players in the community including the youth, women, farmers
through their associations, kebele administrations, health extension workers (HEWs), teachers and
agricultural development agents, Iddirs, faith-based organizations, NGOs and PLHIV. The overall
movement should be led by the Kebele administration with technical leadership provided by the HEWs.
Interventions:
• Train community leaders.

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• Conduct community conversation.

• Enforce relevant community by-laws.
• Train Health Extension Workers (HEW) on Behavioural Change Communication (BCC).
• Train community anti-AIDS promoters from model households.
• Train health development armies (DA) on BCC.
• Strengthen Kebeles to provide support to community anti-AIDS movement.

3.3. Leadership and Governance

Specific objective:
• To ensure responsiveness and accountability in the leadership and governance of the
Multisectoral HIV/AIDS response.
Strategies:
• Build the capacity of leadership and governing bodies at various levels.
• Avail regular updates on the HIV/AIDS epidemic situation and response to leadership and governance.
• Ensure inclusion of HIV plans in the overall sector plan and oversight sector performance.
Strengthening leadership and governance is essential to create transparency, responsiveness and
accountability in the multi-sectoral response against HIV/AIDS. Setting the response to HIV/AIDS as a
national priority and strategic development issue by different sectors and enforcing its implementation
requires a sustained leadership commitment from the executives and governing bodies at various levels.
Interventions:
• Provide training on strategic leadership on the fight against HIV/AIDS to leadership and governing
bodies.
• Select and document best practices.
• Arrange experience sharing visits for leadership and governing bodies from the regions.
• Disseminate annual performance reports and analytical reports on the epidemic and response.
• Establish AIDS Resource Centres (ARC) in the federal and regional parliament.
• Provide oversight in the inclusion of HIV/AIDS plans in the overall sectors’ plans.
• Conduct periodic review by the parliament and other governing bodies.

3.4. Mainstreaming
Specific objective:
• To enhance the HIV/AIDS response across sectors.
Strategies:
• Strengthen ownership of HIV/AIDS programs across sectors.
• Ensure the inclusion of HIV M and E into sectors’ management information system (MIS).
Mainstreaming HIV/AIDS prevention and control into core mandates and activities of various sectors
(public, private and CSOs) is crucial to prevent further spread of the epidemic and mitigate its impacts.
As HIV/AIDS is a development problem affecting all sectors, mainstreaming HIV/AIDS should be taken as
a strategic issue to attain the development goals at all levels.
Interventions:
• Conduct assessment on vulnerability and impact of HIV/AIDS and the capacity of the existing

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response.
• Develop sector specific policies, strategies and plans on HIV/AIDS.
• Establish a unit for mainstreaming HIV/AIDS in both public and non-public sectors.
• Ensure allocation of resources by all sectors for HIV/AIDS mainstreaming.
• Incorporate monitoring and evaluation of HIV/AIDS into sectors’ MIS.

3.5. Coordination and Partnership

Specific objective:
• To ensure synergy of multi-sectoral HIV/AIDS response at all levels.
Strategies:
• Build the capacity of HIV/AIDS response coordination of HAPCOs/ Health Bureau (HBs) at all levels.
• Strengthen partnerships at all levels.
• Strengthen networking among service providers.
Strong leadership and broader coordination is required to translate the strategic plan into a viable
annual plan of action. Adherence of a wide range of actors to the ‘Three Ones’ principles will anchor the
production of a synchronized and harmonized annual plan and report. HAPCO will ensure coherence and
close collaboration among development partners, CSOs, FBOs and the private sector with the aim of
further aligning and harmonizing HIV activities in the country. Strengthening partnership forums and
sub-forums is essential for effective coordination of the Multisectoral response.
Interventions:
☞Provide training on coordination.
☞Develop a joint annual plan guided by SPM II.
☞Institute one national multi-sectoral monitoring and evaluation system.
☞Develop partnership guidelines.
☞Establish/ strengthen partnership forums at national, regional and woreda levels.
☞Strengthen partnerships for cross-boarder interventions.
☞Map HIV/AIDS service providers and stakeholders at all levels.
☞Establish/ strengthen linkages and networking of HIV/AIDS services.

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UNIT FOUR

4. Monitoring and Evaluation

Monitoring and Evaluation of HIV/AIDS multi-sectoral response will focus on tracking the progress on
attaining results. A multi-sectoral HIV/AIDS monitoring and evaluation system will be strengthened to
improve program performance. During SPM II, a community information system will be established and
strengthened to track the progress of the non-health response. Outcomes and impacts of the multi-
sectoral response will be monitored and evaluated by conducting surveillances, surveys, and studies.
Emphasis will be given to monitor the epidemic trends and driving behavioral, socio-cultural and socio-
economic factors to match the response to the epidemic. Moreover, appropriate indicators will be
selected with clear targets for each thematic area for whole period of SPM II and annually.

A multi-sectoral response monitoring and evaluation plan will be developed and implemented through
joint efforts in a coordinated manner, in line with the principle of “three ones”. Federal HAPCO, in
collaboration with federal level stakeholders, is responsible for the coordination of the multi-sectoral
monitoring and evaluation, and will convene semi-annual and annual joint review meetings and conduct
semi-annual and annual joint support supervision at national level. Similarly, regional and sub-regional
HAPCOs will coordinate the multi-sectoral M and E in their respective administrative levels. They will
conduct quarterly support supervision, semi-annual and annual joint review meetings. A mid-term
review and final evaluation of SPM II will also be conducted.Data collection and reporting formats will be
harmonized to facilitate data summarization and analysis.
A multi%sectoral response database will be established at the federal and regional levels to enhance
data storage and retrieval. Information dissemination will be strengthened through web postings, report
publications and review meetings.

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UNIT FIVE

5. MODELS OF BEHAVIOURAL CHANGE

Health Belief Model

Rationale For Choosing This Model

As HIV transmission is propelled by behavioural factors, theories about how individuals change their
behaviour have provided the foundation for most HIV prevention efforts worldwide. These theories
have been generally created using cognitive-attitudinal and affective-motivational constructs. Nearly all
the psychosocial theories originated in the West but have been used for AIDS internationally with mixed
results. Only one of the psychosocial models discussed below, the AIDS risk reduction model, was
developed specifically for AIDS.

Psychosocial models of behavioural risk can be categorized into 3 major groups: those predicting risk
behaviour, those predicting behavioural change and those predicting maintenance of safe behaviour.

Models of individual behavioural change generally focus on stages that individuals pass through while
trying to change behaviour. These theoriesand models generally do not consider the interaction of
social, cultural and environmental issues as independent of individual factors. Although each theory is
built on different assumptions they all state that behavioural changes occur by altering potential risk-
producing situations and social relationships, risk perceptions, attitudes, self-efficacy beliefs, intentions
and out come expectations.

HIV prevention interventions based on psychological-behavioural theory is the practice of targeted risk-
reduction skills. These skills are generally passed on to individuals in a process consisting of instruction,
modeling ,practice and feedback.

Health belief model

The Health belief model, developed in the1950s, holds that health behaviour is a function of individual’s
socio-demographic characteristics, knowledge and attitudes. According to this model, a person must

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hold the following beliefs in order to be able to change behaviour:

1. Perceived Susceptibility: One's subjective perception of the risk of contracting a health condition,
E.g"am I at risk for HIV?”

2. Perceived Severity: Feelings concerning the seriousness of contracting an illness or of leaving it

untreated (including evaluations of both medical and clinical consequences and possible social
consequences).
E.g “how serious is AIDS; how hard would my life be if I got it?”

3. Perceived Benefits: The believed effectiveness of strategies designed to reduce the threat of illness.
E.g (“if I start using condoms, I can avoid HIV infection”)

4 Perceived Barriers: The potential negative consequences that may result from taking particular health
actions, including physical, psychological, and financial demands.

5.Cues to Action: Events, either bodily (e.g., physical symptoms of a health condition) or environmental
(e.g., media publicity) that motivate people to take action. Cues to actions is an aspect of the HBM that
has not been systematically studied.

In this model, promoting action to change behaviour includes changing individual personal beliefs.
Individuals weigh the benefits against the perceived costs and barriers to change. For change to occur,
benefits must outweigh costs. With respect to HIV, interventions often target perception of risk, beliefs
in severity of AIDS (“there is no cure”), beliefs ineffectiveness of condom use and benefits of condom
use or delaying onset of sexual relations.

Conclusion: The HIV/AIDS epidemic has become a major threat to Ethiopian society. Limited
administrative capacity and persisting economic, behavioral, and attitudinal problems at all levels of
society need to be improved rapidly, and the Ministry of Health's Multisectoral
HIV/AIDS Strategic Plan should be implemented on schedule to reverse the epidemic. Emerging
behavioral changes associated with declining HIV rates in selected urban populations similar to those
developing countries with successful prevention programs give rise to guarded optimism, assuming that
these changes can be achieved in the broader population.

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Acronyms
AIDS: Acquired Immune Deficiency Syndrome
ANC: Antenatal Care
ARC: AIDS Resource Centre
BCC: Behavioural Change Communication
BSS: Behavioural Surveillance Survey
CBO: Community-Based Organization
CSO: Civil Society Organizations
DHS: Demographic and Health Survey
EIFDDA: Ethiopian Inter-faith Forum for Development, Dialogue and Action
EHNR: Ethiopian Health and Nutrition Research Institute
EMSAP: Ethiopian Multi‐Sectoral HIV/AIDS Program
FBO: Faith-Based Organization
FMOH: Federal Ministry of Health
HAPCO: HIV/AIDS Prevention and Control Office
HCT: HIV Counselling and Testing
HEWs: Health Extension Workers
HIV: Human Immunodeficiency Virus
HMIS: Health Management Information System
HR Human Resource
IP:Infection Prevention
MAC-E: Millennium AIDS Campaign-Ethiopia
MARPs: Most At Risk Populations
MOH:Ministry Of Health
MOLSA: Ministry of Labour and Social Affairs
MTCT: Mother-To-Child Transmission of HIV
MWCYA: Ministry of Women,Children and Youth Affairs
NAC: National AIDS Council
NEP+: Network of Networks of HIV Positive in Ethiopia
NGO: Nongovernmental Organization
OVC: Orphans and Vulnerable Children
PIHCT: Provider-Initiated HIV Counselling and Testing
PLHIV: People Living With HIV/AIDS
PMTCT: Prevention of Mother-To-Child Transmission of HIV
RAC: Regional AIDS Council
REB: Regional Education Bureau
RHAPCO: Regional HIV/AIDS Prevention and Control Office
RHB: Regional Health Bureau
SPM:Strategic Plan Management
STI: Sexually Transmitted Infection
TB: Tuberculosis

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Appendix

Total Funding Level

Table Resource Allocation by PEPFAR Budget Code (new funds only)

PEPFAR Budget Code Budget Code Description Amount Allocated

MTCT Mother to Child Transmission $3,554,493
HVAB Abstinence/Be Faithful Prevention $6,952
HVOP Other Sexual Prevention $15,487,575
IDUP Injecting and Non-Injecting Drug Use $0
HMBL Blood Safety $697,693
HMIN Injection Safety $33,450
CIRC Male Circumcision $954,737
HVCT Counseling and Testing $13,269,550
HBHC Adult Care and Support $16,980,726
PDCS Pediatric Care and Support $3,830,973
HKID Orphans and Vulnerable Children $13,229,711
HTXS Adult Treatment $49,749,684
HTXD ARV Drugs $32,109
PDTX Pediatric Treatment $4,151,810
HVTB TB/HIV Care $4,181,052
HLAB Lab $3,351,955
HVSI Strategic Information $3,234,432
OHSS Health Systems Strengthening $3,088,220
HVMS Management and Operations $8,764,038
TOTAL $144,599,165

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3.AIDS in Ethiopia. Sixth Report. Federal Ministry of Health/National HIV/AIDS Prevention and
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5. AIDS Epidemic Update. UNAIDS. World Health Organization. Joint United Nations Programme
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8. Ministry of Health. National AIDS Program Review Report. 1994; Dec. 5-16.

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