Research Overview of HIV/AIDS KABP

Research Overview of HIV/AIDS KABP Among Young People in Ethiopia

Johns Hopkins’ Center for Communication Programs AIDS Resource Center

July 2008 ACRONYMS

BBC British Broadcasting Corporation

BSS Behavior Surveillance Survey

CCP/ARC Johns Hopkins’ Center for Communication Programs/AIDS Resource Center

CSW Commercial Sex Workers

DHS Demographic Health Survey

EDHS Ethiopia Demographic Health Survey

ETV Ethiopian Television

FGDs Focus Group Discussions

HAPCO HIV/AIDS Prevention Control Office

ISY In School Youth

MOH Ministry of Health

OSY Out of School Youth

PLHA People Living with HIV and AIDS

STIs Sexually Transmitted Infections

UNAIDS The Joint United Nations Programme on HIV/AIDS

VCT Voluntary Counseling and Testing

Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs – AIDS Resource Center 2 HIV/AIDS and Sexual Reproductive Health of Young People in Ethiopia An Overview of the Latest Research

July 2008

Epidemiological Data

Estimates for Ethiopia’s adult HIV prevalence rate range from 1.4% (DHS, 2005) to 4.4% (UNAIDS, 2004). The latest estimate – 2.1% - is provisional and is intended for adoption for planning programs in Ethiopia (MOH-HAPCO 2007).

The highest HIV prevalence rate is currently seen in the age group 15-24. Scholl estimated this to be 12.1% for 2002, but currently the prevalence is estimated at 5.6% (MOH, 2006).

Within the 15-19 age group, HIV prevalence is much higher among females than males. This difference is attributable to early sexual activity among young women with older male partners (Scholl, 2004). The MOH estimates that 76.9% of infected people in the 15 – 19 age group are female and 23.1% are male. (MOH, 2006).

There is a significant urban-rural differential in HIV prevalence in Ethiopia: as of 2007, the MOH estimates that the urban prevalence rate is 7.8% and the rural prevalence rate is 1% (MOH-HAPCO, 2007).

Socio-cultural Data

Educational attainment among Ethiopian youth is relatively low, and women are significantly less educated than men. The 2005 DHS shows that 40.1% and 21.2% of women and men respectively in the 15 – 19 age group have had no formal education. In the 20 – 24 age group, 60.2% and 32.7% of women and men respectively have had no formal education (DHS, 2005).

The 2005 BSS interviewed 16,253 in-school youth (ISY) aged 15 – 19. The survey found that 8th grade was the highest level of education achieved by 48.2% of ISY and 9th – 10th grade by 42.2% of ISY. Approximately 8% of them had reached grade 11 or 12 (BSS, 2005).

One of the factors that appears to contribute to the low levels of educational attainment among youth is employment. One-half of urban youth and two-thirds of rural youth interviewed for the 2000 DHS survey worked in the twelve months before the survey (Govindasamy, 2002).

Literacy rates are also very low: in the 15 – 19 age group, 47.5% of women and 25.4% of young men can not read at all. In the 20 – 24 age group, 66.1% of women and 35.3% of men can not read at all (DHS, 2005).

The 2005 BSS reported that of the 13.7% of ISY who were involved in income-generating employment, 77.2% of them retained it for personal use and didn’t provide economic support to other persons (BSS, 2005).

Ethiopian women marry young: the median age at marriage is 16. Men tend to be slightly older (about 23) when they marry. Thirty percent of young women 15-19 surveyed for the 2000 DHS were married or in union (DHS, 2000).

HIV Knowledge

The 2005 Ethiopia DHS shows that general awareness of HIV/AIDS is high; approximately 89% of young women and 94% of young men have heard of HIV/AIDS. Awareness increases with age, and is highest among the educated and urban residents (HCP, 2004). These trends are supported by the 2005 BSS which found that 99.8% of all ISY interviewed had heard about HIV or AIDS and 88.6% knew somebody who was infected with the virus or who had died of AIDS (BSS, 2005).

A survey of ISY and OSY in Oromia found that although 81% of young people know that HIV could be transmitted through sexual contact, other modes of transmission were not as well known (HCP, 2004). Only 17.2% of OSY have comprehensive knowledge about HIV/AIDS. Among OSY, males are 3.5 times as likely

Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs – AIDS Resource Center 3 to have comprehensive knowledge than females (BSS, 2005).

Despite an increase in knowledge about HIV and AIDS, misconceptions still flourish among certain target populations. Qualitative research shows that these misconceptions concern condom effectiveness and use, externalization of the virus to other groups, symptoms and modes of transmission, denial of the existence of the virus, explanation of the virus as divine punishment, and mistrust of NGOs and interventions (BSS, 2005).

Transmission

Young people do have basic knowledge about HIV transmission. Fifty-five percent of ISY from the 2005 BSS knew all three programmatically important HIV prevention methods. Lower proportions were reported in SNNPR and Amhara regions (BSS, 2005). Similarly, 68% of respondents from a quantitative study held in Addis Ababa were able to mention the three major ways of limiting the risk of HIV infection – abstinence, faithfulness and condom use (BBC, 2007).

Although knowledge of HIV is high, in-depth knowledge about the three preventive methods and absence of misconceptions about HIV/AIDS transmission is low. The 2005 BSS found that only 22.6% of ISY had comprehensive knowledge about HIV/AIDS and modes of transmission (BSS, 2005).

Among high school students (sexually and non-sexually active), there is a gap in knowledge about the sexual means of HIV transmission. 94.8%, 87.2% and 4.5% agreed that HIV could be transmitted through vaginal, oral and anal sex respectively. The trend is the same among data for sexually active students only (G/Mariam, 2007).

In regards to transmission of the virus from mother to child, the BSS found that 80.1% of ISY knew that HIV could be transmitted from an HIV+ mother to her unborn child and 86.1% knew that HIV could be transmitted through breast milk (BSS, 2005).

Treatment

A majority (although small) of young people in Ethiopia are aware of the existence of antiretroviral treatment. Sixty point five percent of ISY and 52.9% of OSY knew of ART and of these 97 percent of both ISY and OSY believed that ART was not a cure for AIDS (BSS, 2005).

Misconceptions about HIV’s treatability and curability are still prevalent among young people. About 15% of youth respondents in a baseline study believed that HIV and AIDS are curable. This percentage increases among urban youth. In Addis, the percentage reached 28% (BBC, 2007).

In a qualitative study, the majority of participants in the study sites (Awassa, Addis and Dire Dawa) believed that HIV can be cured through holy water (Orthodox) and prayers (protestants). Participants in Addis Ababa who affirmed that AIDS is incurable, hesitated to debate the issue with participants who believed it could be cured with holy water and prayer for fear of blaspheming (Ali, 2006).

Counseling and Testing

Although young people believe that knowing one’s HIV status is important, a majority of them have not tested for HIV. A study found that although 90% of respondents believe that men and women who intend to have sex, pregnant women, and engaged couples should test for HIV, only 21% of respondents aged 15 – 19 and 43% of respondents aged 20 – 24 had tested for HIV (BBC, 2007).

Qualitative data supports the disparity between knowledge and behavior. Almost all participants in a qualitative study considered VCT as an important way of preventing the spread of HIV. However the majority of males aged 20-24 (especially in Addis, Dire Dawa and Awassa) said they wouldn’t test for HIV unless it was mandatory because of stigma and discrimination, fear of descending into despair and hopelessness, worrying about eventual death, etc. (Ali, 2006) Other reasons for young people not wanting to test for HIV include not being sick, not wanting to think about self-exposure to HIV and not wanting to know one’s status (BBC, 2007).

Stigma and Discrimination

Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs – AIDS Resource Center 4 Many young people still hold discriminating attitudes against people living with HIV or AIDS. At the national level, the BSS found that 52.5% of ISY and 58.4% of OSY had at least one stigmatizing attitude towards people living with HIV or AIDS. The highest level of stigma was found among ISY (31%) and OSY (41.5%) when asked if they would willingly purchase food sold by an HIV infected shopkeeper/food seller (BSS, 2005).

However, stigma and discrimination is relatively lower in urban centers than in rural areas. Results from a quantitative study showed that rural respondents were more likely than urban respondents to object to conducting certain activities with PLHAs or object to PLHAs holding service positions (BBC, 2007).

Participants in a rural site in Amhara stated that if a family member had HIV or AIDS, they would be kept separate from the family and their status would be kept hidden from the community (Ali, 2006).

Sexuality

Sexual Health Knowledge

Young people in Ethiopia are more often exposed to negative aspects of their own sexual health and sexuality. Perceptions held by youth about sexual health are incomplete and tend to be associated with negative aspects of sexual health, i.e. HIV/AIDS, STIs, female circumcision, risks of premarital and marital sex, unwanted pregnancy, sexual harassment, health complications caused by rape, precautions people take before having sex, etc (Ali, 2006).

In FGDs conducted in 2007, young men and girls aged 15-19 who practiced abstinence associated various feelings, beliefs and actions with the act of sex. For example, respondents reported that sex was a means to express love, happiness, excitement, and a means to satisfaction and relief from sexual feelings. Respondents also felt that sex occurs as a natural phenomenon; can occur during a loss of self control; can be done at the right or wrong time; can happen with or without partner consent and can expose a person to disease and unwanted pregnancy. Young girls also assigned value to sex when practiced among married couples and assigned danger to sex when practiced “accidentally and without planning” (CCP/ARC, 2007).

In the same study, randomly picked older young people aged 18 -21 held similar to attitudes to their younger counterparts. They also touched on the importance of sex for procreation (men) and the need to be physically fit for sexual activity (women). Young men also alluded to sex being an activity possible between same sexes and between men and animals (CCP/ARC, 2007).

Youth in the study regions (and particularly those in urban settings) seemed to have a lot of knowledge about sex and sexual development processes. The source of information is from school, media and reading material on romance and love. Rural youth seemed less informed. Nevertheless, youth expressed that they want more information about sexual development (biological/behavioral) (Ali, 2006).

Awareness among young people about STIs and their symptoms is low. A study analyzing DHS data also found that young women were more aware than young men of both women’s and men’s symptoms, but young men knew more about men’s symptoms (Maria, 2007).

Risk Perception

In Ethiopia, young people are seen by others as the population group at highest risk for HIV due to their multiple developmental stages and experimentation with new and risky activities such as early sexual initiation and drug abuse. However, many young people consider themselves to not be at risk for HIV because they reported that they didn’t engage in risky behavior or took the “necessary precautions” (BSS, 2005). Nevertheless, the association of risk with different types of risky behaviors among young people and the consistency at which they utilize the “necessary precautions” is debatable.

For example, many young people do not view certain risky sexual practices as risky. A BBC study found that significantly less respondents believed that sex at an early age (below 18) and anal sex were highly risky to one’s health. The proportions of males, youth aged 20 -24, rural respondents and married respondents who believed these sexual practices were highly risky were lower than their counterparts (females, 15 – 19, urban,

Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs – AIDS Resource Center 5 and single respondents) (BBC, 2007).

Yong people are aware of the risks associated with having sex. A quantitative baseline study found that between 80 and 90% of respondents believed that certain sexual practices were highly risky to one’s health. These practices were sex with someone with an STI, casual sex, sex without knowing partner’s status, sex after alcohol and drug use, sex without a condom, continuing sex after a condom breaks, or having multiple sexual partners (BBC, 2007).

The majority of youth in both urban and rural settings understood the importance of safe sex and linked safe sex with avoiding sex without a condom, avoiding casual sex and being faithful to one HIV negative partner. Nevertheless, youth also mentioned a disconnect between knowledge and practice (Ali, 2006).

A recent study also found that high school students have low HIV risk perception in the short term. Twenty- nine point one percent of high school students reported that their chances of catching the virus were low and 28.2% felt that there was no chance of infection. However, 81.9% of sexually active respondents reported that there was a chance of being infected if they continued with their current and 87.1% reported that there was a very high likelihood of contracting HIV in their lifetime (G/Mariam, 2007).

Sexual debut

The mean age of sexual debut in Ethiopia for men is 21.1 and for women is 16.4 (BSS, 2005). In a study conducted among government and non government high schools, 70% of sexually active respondents began having sex between the ages of 15 – 19 and 28.6% started having sex before the age of 15. The average age of sexual debut among respondents was 15.3 years (G/Mariam, 2007).

Social attitudes about the suitable age for sexual debut are different than the actual age. Findings from a qualitative study revealed that although young people believed that the right age for engaging in sexual relationships was 18 – 20 for both sexes, actual practice deviated from these beliefs. For example, the majority reported that young people begin to have sex at 14. In other regions, participants reported the norm being 15 and 16 for girls and boys respectively (Ali, 2006).

Young people gave the following reasons for early sexual debut: exposure to porn films, peer pressure, the degree of family control, financial constraints (especially for girls), alcohol consumption and chewing khat (in urban areas), early marriage (rural areas). Among upper class, youth also rent big houses to hold day parties where they chew chat, smoke, drink, watch porn films and participate in sexual initiation activities. (Ali, 2006)

The majority of young people suggested the right age for marriage for women should be 18 – 22 and for men it should be 25 and above. The latter age was seen as desirable because this is the age where a young person would have finished University and have become economically independent (Ali, 2006).

Sexual behavior

Many recent studies have shown that young people have become more knowledgeable about ‘ABC’ as methods of HIV prevention; however, safe sexual behavior has not necessarily increased comparatively. Results from the 2005 BSS shows that ISY and OSY participants claimed that among their age group, inconsistent practice of all three prevention methods was the norm (BSS, 2005).

Furthermore, a nationally representative study using data from the 2000 DHS concluded that sexually active young people in Ethiopia exhibit highly risky sexual behavior evidenced by the proportions of multiple sexual partners, low condom use, and low contraceptive use. For example, the study highlighted that 65.8% of young males and 24.6% of young females who ever had sexual intercourse had two or more sexual partners in the last 12 months (Maria, 2007).

Nevertheless, virginity for boys and girls is perceived to be of benefit both in rural and in urban areas. In a cross sectional survey of 3,743 young people, a large percentage of rural and urban males and their female counterparts viewed the benefits of virginity to be a pre-condition for marriage and protection from HIV/STIs (for partners) (Berhane, et. al, 2008).

Regardless of the perceived benefits of virginity, young people between the ages of 20 – 24 are five times as likely to be sexually active than those aged 15 – 19. A quantitative study conducted in Addis Ababa, Dire

Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs – AIDS Resource Center 6 Dawa and Amhara regions found that 64% of respondents between the ages of 20-24 were sexually active versus the 14% of 15 – 19 year olds who reported they were sexually active (BBC, 2007).

In a quantitative study of 758 high school students (most of whom were aged 15 - 19), 31% stated they were sexually active. Ninety percent of these respondents were aged 15 – 19 of which 58.6% were male and 32.2% were female (G/Mariam, 2007). This data is interesting considering that results from the 2005 BSS show that 9% of ISY stated they were sexually active.

Similar to other trends in Africa, OSY in Ethiopia are more sexually active than ISY. Thirty three percent of OSY surveyed stated they were sexually active. OSY females were 2.9 times more likely than males to have had sex and more females reported sexual activity in 12 months preceding the survey, suggesting that transactional or survival sex associated with young women in low-income settings could explain this larger percentage (BSS, 2005).

Results from a qualitative study showed that high school students perceive that most of their peers are in relationships and/or having sex. Reasons for having sex included: peer pressure, hopelessness, inability to control sexual drive, sex for money (particularly females), and rape (G/Mariam, 2007).

Types of sexual intercourse practiced among young people are varied. Vaginal sex is still the most commonly practiced type of sex by young people. Sixty-two point five percent of sexually active respondents from the G/Mariam study practiced vaginal sex, followed by 19.1% for oral sex, and 11.6% for anal sex. More anal sex is practiced between male and female high school students, Males reported higher practice of anal and oral sex than females followed by men having anal sex with either gender and then male-to-male anal sex.

Interestingly, the same study found that condoms are used only for vaginal sex; and of those had vaginal sex, only 19.7% reported condom use (G/Mariam, 2007).

The study also showed that about two-thirds of high school students agree that oral sex is a common practice among their peers and 25% of them see anal sex as a common practice. Students also regard the occurrence of anal and oral sex as a foreign practice that has made its way into Ethiopian society via “illegal” films from Europe and the Middle East (G/Mariam, 2007).

In a comparison of government high schools to non-government schools, the amount of individuals reporting practicing vaginal sex was practically equal. However, anal and oral sex was more prevalent in government schools. (G/Mariam, 2007)

Misconceptions about sexual modes of transmission prevail among young people. High school students engaged in anal and oral sex because of the following reasons: to keep their virginity, avoid unwanted pregnancy, prevent HIV transmission, to experience extra satisfaction/pleasure, and as foreplay before vaginal sex. (G/Mariam, 2007)

Young people use a number of slang words to refer to anal, oral or group sex, and masturbation. For example oral sex was referred to as ‘wiredlign’ (meaning “to get down to my private part for sucking or licking”), “armonica,” “zifenlign” mean to sing for me; “yedama”, “skinkut” referring to group sex; and “sega,” and “amist band” to refer to masturbation (G/Mariam, 2007).

Multiple sexual partners

Sexually active young people (those who engage in any type of sex – anal, oral or vaginal) in Ethiopia often have had more than one sexual partner. This trend is more statistically visible among young men then young women. The trend is also more apparent in Addis and certain regions where having multiple partners is socially condoned for some groups. For example, 25% of sexually active ISY in Addis reported having more than one partner in the 12 months preceding the 2005 BSS. Similarly, among sexually active ISY respondents from all regions, 22.7% had had more than one partner in the last 12 months and males were 12 times more likely to have had more than one sexual partner than females.

Additionally, three regions where having two or more sexual partners was most common was Somali (38.6), Harar (28) and Gambella (27.9) (BSS 2005).

More recent data from a qualitative study of government and non-government high schools estimates a higher proportion of sexually active young people. The study found that 63.9% of sexually active high school Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs – AIDS Resource Center 7 students reported having sex with regular partners, 6% reported having sex with strangers and 2.8% with CSWs (G/Mariam, 2007). Risk perception among high school students is somewhat low; 48.2% of ISY who had had more than one sexual partner in the past year or who had risky sex felt that they were at no or low risk of HIV infection. Eighty-five percent of OSY felt that they were at no or low risk of HIV infection because of low exposure to sexual activity, no exposure to needle use and trust in partner (BSS, 2005).

Sexually active young people also seem to have different partners for different sexual activities. Fifty percent of sexually active students from the G/Mariam study who reported they had 2+ partners in their lifetime reported that they had 2+ partners for vaginal sex, 64.2% had 2+ partners for oral sex and 53.1% had 2+ partners for anal sex.

The study also found that government school students have more vaginal sex partners than non-government school students, however the latter had more anal and oral sex partners (G/Mariam, 2007).

Generally, young people agree that their many of their peers are in multiple sexual partnerships. Young people stated that is common for youth (boys and girls) to have an average of three partners – one for school, one located on the road from school to home and one who resides in their community (G/Mariam, 2007).

Many young people also assert that having multiple partners is considered adventurous among many male youth. Young men in the 20 – 24 age group in Addis, Dire Dawa and Awassa also felt that it was becoming more common for young girls to have 2 sexual partners - one for love (younger/boyfriend) and the other for money (much older /sugar daddy) (Ali, 2006).

Younger youth are having more significantly more sexual partners than older youth. In 2007, a quantitative study showed that respondents aged 15 – 19 had had 2.2 partners over the preceding 12 months versus the 1.2 partners had by 20-24 year olds (BBC 2007).

Masturbation

As in other societies around the world, discussing and practicing masturbation is a taboo subject in Ethiopian culture. However, similar to other trends around the world, many young men and women do masturbate. Among students surveyed in the G/Mariam study, the average age for first masturbation was 13.9 years. Additionally, the study found that:

. Among sexually active and non-sexually active high school students, 32.8% had masturbated at least once in their lives; more males (23.4%) than females (8.8%). . More sexually active students (59%) were found to have masturbated than non-sexually active respondents (42.2%). . 52.4% of respondents said they masturbated more than twice a week and 50.4% reported once a week.

Many high school students participating in FGDs believed that masturbation was practiced mostly by boys but others argued that it was common among females as well. Others reported that two “close friends” would practice group masturbation while they were fully clothed (G/Mariam, 2007).

These students also maintained that their peers masturbate for the following reasons: because there is a taboo of females asking males for sex; lack of self confidence to ask one’s partner for sex; it is seen as a performance test for vaginal sex; and it is a way to control sexual urges (G/Mariam, 2007).

In Dire Dawa, young people identified female masturbation (referring to incidents where girls inserted foreign objects into their vaginas) as dangerous sexual practices. Some of these incidents led to visits to physicians to help remove lodged objects (Ali, 2006).

Marriage

A quantitative survey conducted in 2007 found that the average age of first marriage for youth was 16 years. Overall, 43% of respondents were first married at 16 to 18 years of age, 25% were first married between 13 and 15 and 10% before 12 years of age and 21% after 19 years. Both males and females from the rural areas were more likely than urban respondents to get married before 18 years of age (BBC, 2007).

Pregnancy and Contraception

Among young people, misconceptions about how and when pregnancy occurs are high, both in both urban and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs – AIDS Resource Center 8 rural areas. Approximately 40% of respondents from the above study reported that they do not know if or do not believe that pregnancy can occur at first sex intercourse encounter. This percentage increases among the 15 – 19 age group (BBC, 2007).

Findings from the same study showed that 95% of respondents have heard of a family planning method; birth control pills, injectibles and condoms were mentioned in that order by all these respondents. However, a lesser proportion of younger people and rural respondents reported ever or current use of contraceptive methods (BBC, 2007).

On average, the majority of participants could mention five types of contraceptive methods, however 15 – 18 year olds did not have comprehensive knowledge of the methods, how to use them or where to access them (Ali, 2006).

The majority of female discussants in regional sites noted that a married woman can’t decide for herself what contraceptives to use. If she does so and her husband finds out, he feel disrespected, he may suspect her of having extra marital affairs and conflict would ensue (Ali, 2006).

Sexual equality

A qualitative study highlights the dichotomy associated with gender equality with respect to sexual rights and consent. Although the majority of participants felt that women are entitled to the right of making their own choices and making decisions about their sexual life and actions, the majority also felt that women shouldn’t have the right to refuse sex whenever asked by her sexual partner (Ali, 2006).

A quantitative baseline study among respondents from Addis Ababa, Dire Dawa and Amhara regions supported these findings. Approximately 23% of respondents felt that, even if they are unwilling, it is acceptable for a man to have sex with a commercial sex worker or his wife (BBC, 2007). (Participants were asked if it was completely acceptable, acceptable or acceptable under certain circumstances)

The same study found that 6% of respondents believed that, if she is unwilling, it is acceptable for a man to have sex with a woman he doesn’t know or with a virgin (BBC, 2007).

The 2006 qualitative study found that this was the case especially within marriage where participants indicated that women should have special and convincing reasons for not want sex and even then she would need to discuss this with her partner before refusing outright. Participants also said that those reasons would need to be discussed with her partner before she can refuse outright (Ali, 2006).

In the rural context, sexual responsibility seems to be attributed to women only with respect to the issue of sexual rights. Some rural male youth participants were not in favor of women’s sexual rights and argued that it would contribute to unrestricted sex and therefore an increase in HIV. Many of these male participants also felt that women should not have the right to practice premarital sex (Ali, 2006). Research on current urban attitudes about sexual responsibility is warranted to ascertain the level of societal approval of women’s sexual rights.

Participants justified these views by stating that refusal of sex by a partner may cause a man to go satisfy his sexual desire elsewhere and this can lead to HIV infection, divorce and conflict (Ali, 2006).

Sexual abuse and harassment

Sexual abuse and harassment is a sizeable social problem in Ethiopia. In addition to varying harmful beliefs about sexual consent, young people must contend with sexual abuse and especially harassment from varying arenas. A large percentage (41.1%) of sexually active high school students reported sexual harassment at home (whether verbal or physical). Most of the abuse came from siblings, parents and other family – mainly cousins. Most of the harassment from parents was verbal as opposed to physical which for some respondents made them “think about sex and start it at an early age” (G/Mariam, 2007).

In the same study, of those who had been sexually abused physically at home, twice as many individuals reported that the abuse had been anal as opposed to vaginal. Abuse happens in school as well; 12.6% of respondents reported that they were harassed and abused at schools by teachers or students (teachers more than students, a .8% difference) (G/Mariam, 2007).

Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs – AIDS Resource Center 9 Although the majority of sexual abuse and harassment (among youth) is committed against young women, sexual abuse of young boys occurs often. A qualitative study of sexual abuse of young men in Addis Ababa found that 22% of sexual abuse cases reported to the police were regarding sexual abuse of boys. The majority of sexually abused boys are school children aged 10 to 18 years Eighty percent of the perpetrators of this abuse are children between 10 and 18 years old and 98% of the perpetrators are male (Hagos, 2006).

Additional research needs to be done on young women and men’s understanding of sexual harassment and their self efficacy and skills associated with dealing with sexual abuse and harassment.

Forced sex/rape

Deep rooted inequitable male and female gender norms fuel harmful attitudes with respect to sexual and gender based violence among many young people in Ethiopia.

Among a study’s urban sites, rape was considered a despised act and was condemned, however in some of the study’s rural sites, rape is considered shameful and despicable if it involves a child. However, if the female victim is above 16, it is considered resolvable between the victim/perpetrator’s families (Ali, 2006).

Women many feel unable to say no to sex due to cultural pressures, potential violence by their partners, economic dependence, fear of losing her partner, rape or forced sex, forced marriage, lack of self confidence, awareness and assertiveness (Ali, 2006).

Male participants in Chuko indicated that a woman who has had premarital sex has no right to refuse sex and ISY in Awassa maintained that women should not refuse sex in either marital or premarital relationships (Ali, 2006).

Although many young people were aware of the adverse psychological, physical, and physiological effects of rape and were aware that it is a violation of women’s rights and punishable by law; there were reports of youth, particularly between 15 and 18 who believed that forced sex could only be rape if the victim is a virgin (Ali, 2006).

Participants provided a number of major factors that contributed to rape or forced sex. These included: “lenience of the law and law-enforcement bodies, low reporting of rape cases to police, addiction, girls’ negligence to avoid being in potentially dangerous places at unseemly times, peer pressure, uncontrolled sexual lust of rapists, mental disorder, cultural traits that condone rape of divorcees or girls assumed to be not virgin, lack of knowledge about human rights, and absence of free discussion about sexual issues in the community.” Moreover, some male groups argued that women invite rape by dressing indecently (Ali, 2006).

Harmful sexual practices

In the previous study, the majority of youth from urban areas identified the following as dangerous sexual practices: rape/forced sex, having multiple sexual partners, uncontrolled sex, sex after drug and alcohol use, homosexual exercises (?), anal and oral sex, sex at an early age, sexual incompatibility (men reaching orgasm before women do which could lead to unfaithfulness on the part of either person), having sex while menstruating, and imitating acts from porn films (Ali, 2006).

In rural areas, early marriage, female circumcision and open air sex (believed to lead to epilepsy in Amhara) were identified as dangerous sexual practices (Ali, 2006).

Early marriage was found to be unacceptable to 90% of respondents in a qualitative study conducted in AA, DD and Amhara. Approximately 85% mentioned school drop out and early pregnancy as risks of early marriage (BBC, 2007).

Abstinence

Both qualitative and quantitative research supports that young people are aware that abstaining from sex is one of the ways of limiting HIV transmission. In a qualitative study, most participants aged 15 -18 felt that abstinence is possible and that they could and should practice it. Female respondents felt that it was necessary to reach life and future goals. Rural male participants agreed (much more than their urban counterparts) that

Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs – AIDS Resource Center 10 abstinence was possible (Ali, 2006).

However there is a significant difference between belief and action. Urban male participants in 20 – 24 age group maintained that abstinence was difficult because: they needed to practice before marriage to make sure they are sexually fit and because denying themselves sex is a denial of their right to experience sexual pleasure at a time when they should enjoy it the most (Ali, 2006).

Young women and men aged 15 – 19 who reported they were abstaining defined abstinence as not having sex; delaying sex until the right time, or until marriage; helps with achieving one’s goals; requires an individual or joint decision1 between partners; requires self and emotional control. Some young men also attributed the absence of a girlfriend to being abstinent and others felt that abstinence was either undoable or difficult but important. Some young women felt that abstinence also meant avoiding activities that could motivate one to have sex such as chewing khat, drinking alcohol and watching pornographic films (CCP/ARC, 2007).

In the same study, randomly picked older young people aged 18 -21 held similar to attitudes to their younger counterparts. However, older women mentioned that abstinence meant avoiding oral, anal and group sex, kissing, and close body contact with a partner. Abstaining also meant one didn’t have to worry about STDs, pregnancy and related issues. Young men reported that secondary abstinence is possible. Interestingly, some young men also believed that abstinence meant being honest to only one partner or having only one sexual partner, thereby suggesting that some young men believe abstinence is related to avoiding socially unacceptable sexual partnering (two or more, adultery, etc.) rather than sex at all (CCP/ARC, 2007). Additional exploration into this belief is warranted.

Both females and males aged 15 – 19 in this study, although reported to be abstaining, generally maintained that abstinence was very difficult. Both young men and women indicated that the difficulty stemmed from loss of self and emotional control, environmental factors such as porn films, khat, alcohol and no open discussion about sex within families. Both men and women also felt that abstaining would be difficult since sex is used to express love (CCP/ARC, 2007).

Young males reluctantly believed that young people in Ethiopia even do abstain. They also attributed the difficulty of abstaining to current trends in women’s dress. Young females focused more on less abstract reasons why abstinence is difficult for youth. For example, females mentioned transactional and commercial sex, rape and abduction of rural females, peer pressure, and excessive familial control which, in turn, leads to youth abusing any semblance of freedom (CCP/ARC, 2007).

The same study found that young people perceive that incentives to avoiding sex include open communication with parents, familial values, advice from family members and close friends, keeping active and staying focused on school, work or goals. Additionally, young males stated that convincing one’s self to abstain and self emotional control could be incentives. Contrastingly, young females stated that group education from clubs, avoiding STI/HIV/pregnancy, learning from others’ mistakes, staying healthy and the benefits of virginity (taking pride in virgin status, husband/family will be proud) were incentives to abstain. This marked contrast (young women providing more less abstract answers) may be a result of the quality, dose, and frequency of interventions targeted at young people (CCP/ARC, 2007).

Young women and men also differ in their perception of the right time to have sex. Both gender groups responded that they should delay sex until they get married, get a girlfriend/boyfriend or until they reach their goals. However, young males were more inclined than females to shorten the time between abstinence and sexual activity. For examples, male felt that the right time to have sex was at the present time given the chance, between the ages 18 and 21, when one is independent (has a job/lives alone), and once one is physically fit and has enough knowledge and understanding about sex. Young females tended to respond in the longer term – once one finishes school, finds a job, lives well, forms a relationship and then gets married (CCP/ARC, 2007).

Although abstinence is perceived to be difficult by 15 -19 years for various reason, young people also provided ways they believed would convince their peers to delay sexual debut. Many young people advised

1 Note: although both men and women emphasized the importance of partners making a joint decision to be abstinence, one could raise the issue here that making a joint decision about abstaining affects a persons individual right to decide not have sex. For example, a young man could believe that his partner’s decision to abstain should have been agreed upon by both of them, thereby using gendered power differentials in this relationship to achieve his own agenda. Thus, an examination of the reasons behind why young people (especially men) emphasize joint decision making should be conducted. Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs – AIDS Resource Center 11 that their peers avoid pornographic films, alcohol and drugs and places that offer these items. They also suggested that their peers be informed about the disadvantages of early and unplanned sex and that there is a right time, place, and way to counsel and advise young people such as using real life testimonies/stories from people who had sex too early (CCP/ARC, 2007).

Similar to the trends above, young women identified more concrete ways of convincing youth to abstain. Their examples included: peer discussion; including abstinence issues in drama, school curriculum, school mini-media and sexual education sessions; and abstinence education for kids in elementary school. Young men tended to provide answers relating to the physical and emotional aspects of abstinence. Examples include, advising youth to visit church, staying away from body contact with women, pairing with a girlfriend who believes in delaying sex until marriage and providing youth with scientific facts about the destructive effects of alcohol, drugs, and khat on the body (CCP/ARC, 2007).

Young people still hold misconceptions about the types of sex and abstinence. Among total respondents in a baseline quantitative study, only 38.7% reported that abstinence from vaginal sex was a possible method to protect oneself from HIV, 55.6% reported this for oral sex, and 24.1% for anal sex. The trend was similar among sexually active respondents – 40%, 59%, and 21.3% for vaginal, oral and anal sex respectively (G/Mariam, 2007).

Young men also hold misconceptions about the physical affect of abstinence. Abstaining youth were seen as having psychological and mental problems. Additionally, sex was believed to facilitate an active body metabolism (CCP/ARC, 2007).

Major barriers that made it difficult for youth to abstain were: peer pressure, economic dependence (for girls), lack of vision in life due to poverty and hopelessness, uncontrolled sexual lust, lack of open communication within the family, exposure to pornographic films and drug abuse (particularly for the urban youth), stereotyping of girls who stay virgin as unwanted (unattractive), and boys as feminine, etc (Ali, 2006).

Other challenges included partner pressure (girls and boys), being considered backwards, falling in love, believing that a relationship lacking sex is boring, sugar daddies, believing that not having sex will make your partner leave you, hearing about older youth’s sexual activities, and spending time with a partner in a quiet place (CCP/ARC, 2007).

Faithfulness

Participants maintained that faithfulness is one of the most important ways of preventing STIs and HIV/AIDS. However, many youth claimed that faithfulness is a rare practice among youth and young married couples in their respective communities (Ali, 2006).

Participants in the two different age groups had different opinions about the reliability and dependability of faithfulness as a preventive mechanism. Youth aged 15-18 maintained that if two people really love each other, infidelity shouldn’t happen. However, the 19 – 24 age group felt that you could only be sure about your own thoughts and feelings and that it’s difficult to rely on faithfulness as a dependable method of prevention (Ali, 2006).

Some participants asserted that faithfulness is often practiced more by women than men due to social and cultural factors (Ali, 2006).

Youth asserted that the following factors influence the ability to be faithful: peer pressure, poverty (looking for money), doubtfulness, sexual incompatibility, competition, uncontrolled lust, addictions, jealousy, and perceived or actual infidelity of one’s partner (Ali, 2006).

Condoms

Although youth are knowledgeable about condoms as a means of preventing HIV, practical application of this knowledge is low. Reasons for this include: inconsistent use, improper use, discontinuing use based on the assumption of partner fidelity, lack of self-control due to alcohol, chat and drug use, distrust of condoms (Hiwot brand) (Ali, 2006). Other reasons young people give for not using condoms are young people’s

Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs – AIDS Resource Center 12 personal weakness and being driven overly by emotional desires (Taffa, 2002).

A large majority of ISY has heard about male condoms (98.7) and a significantly smaller amount (67.5) has heard of female condoms. At the time of the BSS 2005, a much lesser percentage of ISY (than other regions) in Benishangul-Gumuz (44.2) and Gambella (48.1) had heard about the female condom (BSS 2005).

Among both sexually active and non-sexually active respondents from the G/Mariam study, 37.1% reported that condom use during vaginal sex was a possible method to protect oneself from HIV, 28% for condom use during anal sex, and 72% for oral sex. The trend was similar among sexually active respondents – 42.7%, 31.1%, and 78.4% for vaginal, anal and oral sex, respectively (G/Mariam, 2007).

Consistent condom use among both ISY and OSY is not pervasive. Sixty one point five percent of ISY surveyed in the 2005 BSS and 58.7% of OSY reported that they were consistently using condoms. Males reported a significantly higher percentage of consistent use than females (BSS, 2005).

Twenty-five point two percent of sexually active high school students surveyed in the G/Mariam study reported that they don’t use condoms because they don’t like it, 13.8% didn’t use them because they trust their partner and 11% don’t use condoms because their partner objected (G/Mariam, 2007).

Among ISY surveyed in the 2005 BSS, 88.3% knew places of person from which they could get male condoms. Ninety-four percent of males and 82% of females knew of sources for males condoms. Shops, hospitals and health centers, pharmacies and private clinics were sources of male condoms mentioned by 92.8%, 44%, 41% and 33.4% of respondents respectively (BSS, 2005).

FGD results showed that many ISY agreed that high school students use condoms to avoid unwanted pregnancy, STIs (such as HIV/AIDS) and that condom are easily accessible in Addis Ababa. However a similar amount of students maintained that high school youth don’t use condoms because of various misconceptions, stigma, and the nature of the sex they practice (casual, unplanned, anal, and oral) (G/Mariam, 2007).

Some young people in Tigray and SNNPR disliked the way condoms are promoted in the media. They claim that it encourages promiscuity and therefore increases the likelihood of HIV infection (Ali, 2006).

Youth also expressed that condoms reduce sexual pleasure and gratification since it bars the contact of sexual organs and diminishes the intimacy and “natural warmth” experienced during sex (Ali, 2006).

Men and young people aged 20 – 24 have higher self efficacy with respect to discussing condom use with their partners than women and 15 – 19 year olds. A survey of 2410 young people in 3 urban centers showed that 72% of male and 74% of 20-24 year old respondents were more likely to report they feel able to discuss condom use with their partner versus 64% of both female and 15-19 year old respondents (BBC, 2007).

Both male and female youth in Addis Ababa reported that they talk to friends and peers about condoms. However, some female respondents acknowledged that a young woman may agree to have sex without a condom out of fear of losing her boyfriend (Ali, 2006).

Communication about sex

Talking about sex is generally considered taboo and unacceptable in society. Open discussions about sex between the opposite sexes and/or couples is, unfortunately, still not common (Ali, 2006). However, open discussion about sex is becoming more common among peers in the 15 – 24 age group and among those in this group from urban settings (Ali, 2006). This trend is supported by results from a quantitative study which found that 69% of respondents discussed or sought advice from friends as opposed to parents (22%), a partner (17%), or the media (17%) (BBC, 2007).

The quantitative study also found that communication about sexual and reproductive health issues was less likely between partners and married couples in rural regions. Females and respondents in the 15 – 19 age group were also less likely to discuss SRH issues with anyone (BBC, 2007).

Similar to trends in other countries, constructive communication between parents and young people about sexuality is almost non-existent. Many parents feel that discussion of sexual issues with their children will

Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs – AIDS Resource Center 13 lead to children having sexual experiences early (Ali, 2006).

Young people also feel that issues concerning sex and sexuality are always discussed within the context of HIV and AIDS. Young people feel that sex and sexuality should be discussed as a separate issue and that information should be provided to them on how to have healthy and happy sexual lives (Ali, 2006).

Substance Abuse

Alcohol use by ISY and OSY is significantly different. The 2005 BSS found that 29.4% of OSY males and 21.3% of OSY females had consumed alcoholic drinks in the month preceding the survey. Contrastingly, 10.9% of ISY males and 9% of ISY females had consumed alcoholic drinks in the month preceding the survey. In the same period, 4.9% of OSY and 3.3% of ISY consumed alcohol at least once a week. Frequent alcohol drinking was the most common in the Amhara region (for OSY) and in Benishangul-Gumuz (for ISY) (BSS, 2005).

Alcohol, chat and cigarette use is higher among government schools than non-government schools. However non-government respondents chewed more chat in the last 12 months than government respondents. (G/Mariam, 2007)

Gender norms

The study reported that prevalent gender norms give men power over women’s sexuality and allow men to satisfy their sexual desires at the cost of women, while they are expected to be submissive (Ali, 2006).

Access and Exposure

Access to the media is somewhat limited among young Ethiopians. Print, radio and TV media in this order were reported as the most frequent forms of media ISY and OSY are exposed to. In the 2005 BSS, 59.8% of ISY and more than 65% of OSY had used the radio more than once per week in the month before the survey and more than 41% of OSY had been exposed to TV. Interestingly, almost all ISY had read printed media daily vs. the more than 17% of OSY who had regularly read printed media in the same period. ISY and OSY also reported that they were received to relatively clear HIV/AIDS messages by radio, print and TV media in this order in the last 12 months (BSS, 2005).

An earlier study found that more than 80% of young people 15-24 have no regular exposure to newspapers, radio, or television. In general, men have more exposure to the media than do women, and exposure increases with age for both sexes (Govindasamy, 2002).

However, in certain areas, such as Addis Ababa, Dire Dawa and Amhara regions, young people have access to media. Eighty four percent of respondents from a baseline study of 2410 youth reported having a functional transistor radio at home. Most of these respondents listened to the radio at home and a majority reported being able to decide what to listen to themselves (BBC, 2007).

Consumption

Young people who had access to non-satellite dish TV are dissatisfied with local TV stations. Young people feel that ETV is boring, not entertaining, and untrustworthy. However, young people found Ethiopian Idol, Sink lewotatoch and talk shows like Shay Buna relatively appealing. Above all, young people feel that they need to be selective when watching ETV (Ali, 2006).

Similar attitudes to the above were expressed about Radio Ethiopia (RE) although young people considered more programs on RE as relatively more attractive than those on ETV. Interesting and educational programs mentioned where Population Media Council’s Yeken Kignit (SRH, youth focus), Mestawet, Kemestahift Alem and sports (Ali, 2006).

Young people in Addis consider Radio Ethiopia to be government propaganda, one-sided, monotonous, full of lies and untrustworthy. Their counterparts in Tigray were more sympathetic to RE, yet they also preferred to

Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs – AIDS Resource Center 14 listen to Dimsti Woyane since it covered local issues and transmits programs in Tigre (Ali, 2006).

Radio listening trends

Young people aged 15 – 24 (a larger percentage of females and 20 – 24 year olds then their counterparts) reported that their preferred radio listening times are 8:30a – 12:00p and 8:00p – 12:00a (most likely males and 15 – 19 year olds). For weekends, 62% of respondents preferred to listen to the radio between 1:30p and 5:30p (BBC, 2007). Contrastingly, most young people in a qualitative study indicated that their preferred radio listening times was between 2 and 6 in the afternoon. However, respondents also indicated that time was important as long as the broadcasts were entertaining (Ali, 2006).

Overall, young people in Addis Ababa, Dire Dawa and Amhara regions listen to Radio Ethiopia but would much rather listen to regional FM radio stations (BBC, 2007). For example, FGD participants in Addis preferred to listen to FM 97.1 and FM 96.3 (the former more than the latter – especially when it comes to entertainment education). Young people in Dire Dawa, Awassa and Bahir Dar also prefer local FM radio than Radio Ethiopia (Ali, 2006).

Health messages/ programs in the media

Young people are more likely to hear sexual and reproductive health messages on the radio in urban areas versus rural radio. A baseline study found that 76% of Addis Ababa respondents and 75% of Dire Dawa respondents reported hearing sexual and reproductive health messages on the radio as opposed to 55% in the Amhara region (BBC, 2007).

Many young people feel that most mass media lacked creativity in addressing HIV/AIDS issues in a way that would contribute to behavior change (BSS, 2005). Advertisements and spots in the media are seen by youth as unattractive, unrealistic, unclear and full of wording errors. Youth also feel that there is a lot of repetition and imitation (Ali, 2006).

Young people did listen to health/education programs on the radio such as Yibekal, Yeke’en K’ignit, Behiwot zuria, T’enachen that focused on HIV/AIDS. These programs where however seen as lacking in entertainment elements or repetitive. Programs that contained real life elements were most liked and health programs broadcast on the local FM stations were seen as more educational and interesting (Ali, 2006).

Compared to rural areas, health workers and health institutions are a more trusted source of information than radio and TV for young people living in urban areas such as Addis Ababa and Dire Dawa (BBC, 2007).

Media literacy

The level of media literacy among young people has not been researched in Ethiopia. However, from anecdotal evidence and secondary data, it is evident that young people possess some level of media literacy (although not much). For example, young people aged 20 – 24 have a lower likelihood to trust information received from radio/TV versus the 15 – 19 age group (BBC, 2007).

Young people also need to be provided with skills to sift through the messages they receive from mass media. Some young people, street children and teachers felt that messages in the media were contradictory. On one hand health messages encourage healthy sexual behavior, but other messages such as those transmitted through music videos, commercials, etc. “arouse sexual feelings” in young people (BSS, 2005).

Life goals/aspirations and role models

There is a clear distinction between ISY and OSY regarding setting life goals. The former were generally optimistic and the later were pessimistic and in Addis, displayed bitterness about the future (Ali, 2006).

Among 15 – 24 youth set, there is a general consensus among youth that education is the only way out of poverty (Ali, 2006).

Young people in urban and rural areas consider the following people as role models: 1) self made people who began with nothing but overcame life obstacles and succeeded in their lives; 2) politicians from opposition parties; and 3) renowned scholars. Most role models were Ethiopian and only one participant identified a

Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs – AIDS Resource Center 15 fictitious character from Yeken Kignit serial drama as her role model (Ali, 2006).

Leisure

Youth expressed that there is severe limitation in choices of leisure activities. Young people’s interests/choices included listening to music, visiting friends, and sports (mostly soccer either playing it or watching it on TV). Only a few mentioned reading (Ali, 2006).

Most male participants feel they have enough time for leisure, while females (especially in the 19 – 24 age group say they hardly have any time due to household chores. This difference was also observed between urban and rural young people. Urban youth seemed to have more time for leisure activities while those in the rural areas had to spend most of their time making ends meet (Ali, 2006).

Desired activities for leisure among young women aged 19 – 25 in an urban area were watching films, listening to music at home, visiting recreational sites in/out of the country, sports, and reading novels (Ali, 2006).

Conclusions

1. Knowledge is high but it does not translate into behavior 2. Misconceptions about sex abound among young people. Misconceptions about the types of sex, definitions of sex and the risks associated with these types of sex thrive among young people. 3. Young people also have misconceptions about abstinence ands its supposed negative health effects. 4. Abstinence is seen as impractical, unrealistic, impossible for certain groups of young people. 5. Definitions of relationships vary; young people who do engage in sexual acts also engage in high risk behavior such as multiple partnerships for different types of sexual acts 6. Transactional sex and cross generational sexual relationships among sexually active young people are not the norm, but are common. 7. Definitions of sexual consent vary among young women and men 8. Risk perception is low among young people 9. Peer-to-peer communication about sexuality is the norm although not necessarily beneficial in passing on healthy sexuality; parent/youth communication is low

Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs – AIDS Resource Center 16 References

Ali, Kelklachew. Formative Research on Sexual and Reproductive Health Among The Youth in Ethiopia: A Synthesis Report. BBC World Service Trust, Addis Ababa, September 2006.

BBC World Service Trust. Baseline Survey Conducted in Amhara Region, Addis Ababa and Dire Dawa Administrative Cities. January – March 2007. BBC World Service Trust, Addis Ababa, March 2007.

HIV/AIDS Behavioral Surveillance Survey (BSS) Ethiopia 2005 Round Two. Ethiopia Ministry of Health, HIV/AIDS Prevention and Control Office, Addis Ababa University, Ethiopian Public Health Association, Ministry of Defense, Tulane University, 2005.

G/Moges, Mariam. Sexual Orientation, Practices and HIV Risk Behavior of Young People in Addis Ababa High Schools. School of Graduate Studies, Addis Ababa University, Addis Ababa, July 2007.

Hagos, B. Sexual Abuse and Exploitation of Male Children in Addis Ababa. Bright for Children Voluntary Association, Save the Children Denmark, Addis Ababa, August 2006.

Health Communication Partnership. HIV/AIDS and Youth in Ethiopia: An Overview of Current Research, HCP, September 2004.

Maria, Wouhabe. Sexual Behavior, Knowledge and Awareness of Related Reproductive Health Issues among Single Youth in Ethiopia. African Journal of Reproductive Health, Vol 11, No.1, April 2007, pp. 14-21.

Taffa, N. Psychosocial Determinants of Sexual Activity and Condom Use Intention among Youth in Addis Ababa, Ethiopia. International Journal of STD and AIDS, Vol 13, 2002, pp. 714 – 719.

Suzuki, C., et al. Recent Trends in HIV-Related Knowledge and Behaviors in Ethiopia, 2000-2005. Calverton, Maryland, Macro International, MEASURE DHS, 2008.

Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs – AIDS Resource Center 17